A CORONER has identified a number of “areas of concern” at an inquest into the death of a two-year-old girl at a Dublin children’s hospital, including the fact that the on-call paediatric consultant was not asked to see her.
The child, Emma Jane Doyle-Blake of Village Green, Kilbreck, Stamullen, Co Meath, was brought to the AE department of Our Lady’s Hospital for Sick Children, Crumlin on the afternoon of August 25th, 2007, with a rash on her body and a history of vomiting.
The little girl, who had Down syndrome, died at the hospital the following day from inflammation of the heart muscle known as myocarditis, which was probably of viral origin. Consultant paediatrician Dr Rosemary Manning, who was in the hospital for seven hours on August 25th, expressed surprise at an inquest at Dublin City Coroner’s Court yesterday that she was not asked to see the little girl, who has a “significant diagnosis” of septicaemia with a rash and a slow heart rate, on admission.
Emma Jane, who was two years and eight months, had been categorised by the triage nurse in the AE department as “orange”, which means “semi-urgent” and indicates the person needs to be seen by a doctor within 10 minutes, the inquest heard.
“She was categorised as orange. I think I should have been called to see her then. I was in the hospital,” said Dr Manning. “I can’t understand it. I was in the hospital for five hours on the Saturday and I was called in again at 7pm [in the] evening and I was in the hospital for another two hours,” said the doctor.
When Dr Patricia Glavin was called at 5.10am to review the baby’s fast heart rate she was critically ill and was in respiratory distress. Emma Jane was pronounced dead at 7.40am on August 26th.
Coroner Dr Brian Farrell yesterday pinpointed a number of “significant risk factors” which arose with regard to the care of the baby including the assessment of a patient on admission with very significant diagnosis, the assessment of the ECG, the ongoing clinical assessment and monitoring of the patient and the issue of non-consultation with the paediatric consultant. “Dr Manning said she would have been expected to be informed,” he said.
He recorded a verdict of death by misadventure.
“I believe the issues of concern are relevant to the death at that time in those particular circumstances.”
“A number of areas of concern have been identified. I’m not making a causative link between the risk factors and the death,” said the coroner.
Solicitor for the hospital, John Gleeson, said they accept there were “deficiencies in the management”. But he said there was no evidence of a link between the risk factors and the final outcome.