A verdict of medical misadventure has been returned at the inquest into the death of a 12-month-old child who died while in the care of Cavan General Hospital.
Delivering the verdict this afternoon, the coroner for Co Cavan, Dr Mary Flanagan said this was the only option available to her based on the evidence heard.
Dr Flanagan said the evidence was reflective of the admitted and acknowledged deficiencies in management that had been identified at Cavan General.
The coroner also attached a number of recommendations to her verdict, including that an overarching national policy be introduced to ensure that intubation difficulties in patients be highlighted by super hospitals to feeder hospitals. The coroner also said that such feeder hospitals should introduce their own policies for highlighting this amongst their own staff.
The coroner also accepted the medical evidence of the pathologist that the cause of death was severe acute double pneumonia. The second day of the inquest today was told that the outcome for baby Luke Kelly could have been different had he been in a tertiary hospital when his condition deteriorated. The inquest heard that Luke went 18 hours without a physical examination by a consultant at the hospital despite his condition deteriorating.
The coroner was also told that the Cavan General Hospital had no formal afternoon handover process in place at the time. The inquest at Cavan Courthouse heard from a total of 17 witnesses over a two days period.
Statement from Luke's parents
"We would like to thank our family /relatives/friends and colleagues who have supported us for the last 2 years. We would also like to thank Roger Murray our solicitor and the staff at Callan and Tansey for all their advice, direction, and professionalism. This is any parent’s worst nightmare and we live in the depths of heart break and pain every day since we lost our warrior son, Luke.
"Our son Luke was born with a congenital heart defect and from his very first day he showed strength, courage and resilience. Luke was the most placid, smiley child whom we all adored from the day he was born.
"Luke needed to have a lot of medical interventions and care , but the doctors in Crumlin hospital were very hopeful for his future and we were so happy that he had overcome everything that was thrown at him. Luke was incredibly strong, brave and had such a gentle personality and nature about him. He never complained. He barely ever cried and was so, so strong. Every operation and virus and hospital stay was so hard on him, but he made his way back to us at home in Cavan every time. His siblings and family adored him and we all looked forward to our future together.
"But sadly, we are in the depths of grief since the 5th of July, 2023. We feel extremely let down about Luke’s care and death and we feel angry because we trusted the medical professionals who did not inform us that a medically complex child 6 weeks post open- heart surgery had pneumonia. We feel that Luke’s death could have been prevented, and we will never be the same family ever again.
"We miss him every single minute of every day. We are angry that this has happened to our very precious little warrior who fought time and time again to come home to us We are so proud of him. We feel that poor Luke was let down on so many levels. We note the apology from the hospital ,but this should never have happened and we should not be standing here today.
"We expect and hope that they have learned from this tragedy. There needs to be continuous improvement in children’s care in Cavan general hospital and that should be Luke Kelly’s legacy We want this to never happen to another family .Luke’s death, we say, could have been prevented he deserved so much more."
