Full text of report's executive summary: Róisín Ruddle was born on the 16th May, 2001, at Limerick Regional Hospital...
She was transferred to Our Lady's Hospital, Crumlin, on the same day. She was diagnosed as having an extremely complex cyanotic congenital heart defect, this consisted of pulmonary atresia, multiple ventricular septal defects in unusual positions and a small hypoplastic right ventricle. This is a very unusual combination of defects.
Following initial investigative procedure, Róisín underwent an operation to invert a modified right Blalock-Taussig shunt on May 21st, 2001.
Roisin's condition continued to be managed by the consultant cardiologists at Our Lady's Hospital and she underwent a number of investigative procedures during the following months. The management of her condition was discussed at the hospital's joint cardiology/cardiothoracic conference on a number of occasions and the options for her treatment were considered. In March 2003, it was agreed that Róisín should undergo cardiac catheterisation with a view to a Glenn shunt procedure.
Róisín was due to undergo the Glenn shunt procedure on June 30th, 2003. This procedure was a palliative operation which was part of a staged strategy in the management of Róisín's condition. She underwent the normal pre-operative investigations on June 25th/26th, 2003, and was discharged to be readmitted on the June 29th for planned surgery the following day.
On June 30th, however, her surgery was deferred because there was no staffed intensive care bed available for her post-operatively. She was discharged from the hospital on June 30th and returned home with her parents. Róisín died at home in the early hours of July 1st, 2003.
The autopsy indicated that Róisín's death was due to acute cardio/respiratory failure associated with the presumed development of a cardio-arrhythmia.
This view was supported by the medical opinion presented in the course of the review and by the review panel's medical expert.
If the Glenn shunt procedure had gone ahead as planned on June 30th, it would most likely have improved Róisín's oxygen saturations, and this may have reduced the likelihood of an arrhythmia.
However, the reasons for the occurrence of arrhythmias in patients with congenital heart defects are complex and despite an improvement in oxygen saturations, fatal arrhythmias can occur.
Nevertheless, it is the view of the panel that if Róisín's operation had gone ahead as planned on June 30th, the likelihood of her survival would have been greater.
Róisín's parents told the panel it was their view that the Eastern Regional Health Authority's (ERHA) report contained some inaccuracies. Having examined these matters, the panel is satisfied that with one exception the ERHA report accurately reflects the facts relating to Róisín's care and treatment at Our Lady's Hospital.
Roisin's parents raised an number of questions relating to the clinical care she received in Our Lady's Hospital. Having examined Róisín's medical record and interviewed the clinical staff involved in her care, the panel is satisfied that the clinical care Róisín received while a patient in Our Lady's Hospital was appropriate.
The reason for the deferral of Róisín's surgery on June 30th was because there was no staffed intensive care bed available in the intensive care unit to accommodate her post-operatively. The intensive care unit (ICU) at Our Lady's Hospital comprises 21 fully-equipped beds. The beds are divided into two units: the main ICU and St Patrick's ICU. The hospital has not been in a position to utilise the full complement of beds in the ICU because of a shortage of appropriately-trained nursing staff. The main ICU, which caters for all cardiac patients, has eight fully-equipped beds but only has sufficient nursing staff to operate seven of these.
There is, and has been for some time, a worldwide shortage of paediatric ICU nursing staff. Our Lady's Hospital reported difficulties in recruiting such staff as far back as 1996 although it appears that the problem became more acute in or around 1998.
Given the centrality of the ICU to the operation of the hospital as a whole, the panel considers that the shortage of nurses to staff the unit does not appear to have been seen by hospital management at the time as a priority issue warranting significant management attention.
From the evidence presented, it is clear to the panel that the problems relating to recruitment and retention of specialist nursing staff were considered matters to be addressed solely by the director of nursing and her staff. Although aware of the problems, there is no evidence that hospital management or the Committee of Management gave any active support, other than the approval of financial resources, to helping the director of nursing with the problem-solving initiatives that were clearly needed to address the recruitment issues for this highly-critical area of the hospital's activities.
In the opinion of the panel, insufficient focus was placed by Our Lady's Hospital management and the Committee of Management on the resolution of the issue and, as a consequence, there was a lack of urgency in applying and distributing available resources to resolving the problem or at least trying to do so.
That said, the panel feels it is important to point out that despite significant efforts made by the hospital in more recent times, the hospital is still not in a position to staff its full complement of intensive care unit/high dependency unit beds.