A coroner has returned a verdict of \u201cmedical misadventure\u201d in the death of a 16-year-old girl at University Hospital Limerick (UHL).<\/p>\n
The inquest into the death of Niamh McNally, Ardykeohane, Bruff, Co Limerick, on January 29th, 2024, heard there were \u201cso many missed opportunities\u201d in her care at UHL.<\/p>\n
Niamh died of \u201casphyxiation\u201d, after suffering cardiac arrest, having suffered a \u201cpulmonary haemorrhage which most likely resulted from an erosion of a collateral artery into the respiratory tract\u201d, a post-mortem found.<\/p>\n
Niamh attended UHL on January 9th gasping for breath and coughing up blood. The hospital was aware she had a history of congenital heart disease.<\/p>\n
A battery of tests followed, but her family argued these were not focused enough on her cardiac history, and, although her condition improved and she was discharged from UHL 14 days later on January 23, Niamh was still coughing up blood.<\/p>\n
Six days later, on January 29th, with her symptoms persisting, Niamh was readmitted to UHL, where she was pronounced dead later that day.<\/p>\n
Damian Tansey, senior counsel for the McNally family, told the inquest that Niamh had been continuously coughing up \u201ca massive amount of blood, her bedsheets were soaked with blood\u201d.<\/p>\n
Heart defect<\/p>\n
Despite UHL\u2019s awareness that Niamh had been born with scoliosis and a congenital heart defect, for which she had undergone three surgeries in the years prior to attending UHL that January, her treatment at the Limerick hospital had not been focused enough on her heart, Mr Tansey said.<\/p>\n
\u201cThere were numerous missed opportunities, and had they not been missed, we wouldn\u2019t be here \u2014 and a letter of apology (from the HSE) confirms that,\u201d Mr Tansey told Limerick Coroner\u2019s Court.<\/p>\n
Niamh\u2019s mother, Carolyn O\u2019Neill, said prior to her daughter\u2019s death, blood was spilling out of her mouth, but she said her concerns for her daughter were not heard: \u201cNobody listened to me in UHL, and that is heartbreaking.\u201d<\/p>\n
Breaking down while giving her evidence to the court, Ms O\u2019Neill told how moments before Niamh went into cardiac arrest, her ailing daughter looked at her and said: \u201cMammy, I can\u2019t breathe\u201d.<\/p>\n
Apology<\/p>\n
A letter unreserved apology from the HSE was read out at the opening of the two-day inquest, which concluded on Thursday.<\/p>\n
The HSE letter, to Ms O\u2019Neill, stated: \u201cWe acknowledge the devastating consequences that this has had on both you and your extended family.\u201d<\/p>\n
\u201cWe sincerely regret the opportunities that were missed to intervene.\u201d<\/p>\n
\u201cWe accept that these failings, which ultimately led to Niamh’s tragic death, should not have happened.\u201d<\/p>\n
\u201cOn behalf of the management and staff of the University Hospital Limerick, we wish to apologise unreservedly for these failings,\u201d the letter added.<\/p>\n
The HSE letter commented that it was \u201ccommitted to learning from this tragedy and to implementing any necessary changes to prevent similar incidents in the future\u201d.<\/p>\n
However, Mr Tansey, citing several inquests into patient deaths at UHL in recent times, for which he had acted for families, said it appeared lessons were not learned by the hospital.<\/p>\n
Lessons not learned<\/p>\n
Mr Tansey said: \u201cThis is like a Shakespearean tragedy, and to quote Hamlet – \u2018Something is rotten in the state of Denmark\u2019 \u2014 Something is very wrong in UHL\u201d.<\/p>\n
\u201cThis is the third time in a little over a year that I have appeared before this court in relation to UHL, and it seems that no lessons have been learned,\u201d Mr Tansey said.<\/p>\n
Speaking afterwards, Carolyn O\u2019Neill said: \u201cI wish no other family will have to go through what Niamh experienced inside UHL. The inquest findings were horrendous.\u201d<\/p>\n
\u201cThere were missed opportunities, and if they had actually acted upon and done a proper cardiology check-up on Niamh, she would be alive today.\u201d<\/p>\n
Ms O\u2019Neill, whose husband died prior to her daughter\u2019s death, said she hoped the HSE would take on board fifteen recommendations arising out of an independent review of Niamh\u2019s case, which the coroner, John McNamara, attached as a rider to the verdict.<\/p>\n
Paying a tearful tribute to her only daughter, Niamh, she said: \u201cNiamh was a lovely girl, she was just coming into her own, she was turning into a beautiful woman, and she was so stable until (in UHL).\u201d<\/p>\n
\u201cShe loved everything, she was such a fighter, she was fantastic, she had such a beautiful group of friends, and while it was hard, she never let her disability get in the way.\u201d<\/p>\n
Mr Tansey told the inquest that when Niamh was first admitted to UHL on January 9th, her admissions team recommended that she be referred to the hospital\u2019s cardiology department, but, he said, \u201cthe first time there is any cardiology involved is on the 18th of January – a full nine days later\u201d.<\/p>\n
When cardiology checks were eventually conducted, they were \u201cso narrow\u201d that they were \u201cutterly ineffective\u201d.<\/p>\n
An \u201cecho\u201d scan of Niamh\u2019s heart took place on January 11th; it did not include her medical history, but it also did not indicate a cause for her condition. The patient\u2019s medical history was included in a report of the scan.<\/p>\n
A \u201cBNP blood test\u201d, used to diagnose heart failure, was conducted, but it too did not indicate the cause of Niamh coughing up blood.<\/p>\n
A bronchoscopy and chest x-ray, used to examine the airways and lungs, also did not provide answers.<\/p>\n
\u201cThere was still no change in her treatment plan on discharge; there was no reassessment in respect of Niamh, none whatsoever,\u201d added Mr Tansey.<\/p>\n
Mr Tansey called on Coroner John McNamara to return a verdict of medical misadventure. He said it was \u201cclear\u201d that UHL \u201cdidn’t intend for Niamh to die, but she did die\u201d.<\/p>\n
Simon Mills, senior counsel for the HSE, told the coroner that, in determining his verdict, he could not consider the outcomes of previous inquests he had adjudicated, in respect of other patient deaths at UHL: \u201cThey must be put far from your mind\u201d.<\/p>\n
Mr Mills suggested the threshold for \u2018medical misadventure\u2019 had not been reached, and that the correct verdict was a \u201cnarrative verdict\u201d.<\/p>\n
Mr Mills argued that it was clear from the evidence that Niamh McNally had received a multidisciplinary care plan, including an echo, a BNP, and a CT Thorax, which included a scan of her heart, and that her \u201cunderlying condition\u201d went \u201cundetected\u201d.<\/p>\n
He said Niamh\u2019s symptoms and markers for infection had reduced when she was discharged from UHL on January 23, six days prior to her being readmitted and dying there.<\/p>\n
Returning a verdict of medical misadventure, the coroner extended his \u201cdeepest condolences\u201d to Ms McNally\u2019s mother, grandfather, uncle, and friend, who were in attendance.<\/p>\n
Mr McNamara said Niamh\u2019s death was a \u201cprofound tragedy\u201d and he paid tribute to her family\u2019s \u201cdignity\u201d throughout the inquest.<\/p>\n
He said the inquest did not assign blame nor did it apportion liability, and that Niamh\u2019s death was \u201cclearly unintended\u201d.<\/p>\n
\u201cLosing a child is obviously the deepest of tragedies. I am sure Niamh\u2019s memory will live on through her family.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"A coroner has returned a verdict of \u201cmedical misadventure\u201d in the death of a 16-year-old girl at University…\n","protected":false},"author":2,"featured_media":163571,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3],"tags":[42,43,40,38,41,39],"class_list":{"0":"post-163570","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-headlines","8":"tag-headlines","9":"tag-news","10":"tag-top-news","11":"tag-top-stories","12":"tag-topnews","13":"tag-topstories"},"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/posts\/163570","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/comments?post=163570"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/posts\/163570\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/media\/163571"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/media?parent=163570"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/categories?post=163570"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/tags?post=163570"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}