Inquest welcomes changes at St John of God school since boy’s death

The coroner at the inquest into the death of six-year-old Tristan Neiland has returned a narrative verdict.

The child, from Cabinteely, Dublin, had a number of health issues and was in weekend respite care when he was found unresponsive by staff.

Tristan, who suffered from epilepsy, asthma and global development delay, was staying at the St John of God Carmona Respite Service* in Dún Laoghaire at the time. He was a pupil at Carmona Special National School in Dún Laoghaire.

His mother Angela Neiland told Dublin Coroner's Court that her son suffered from seizures, mostly at night and in the early morning. She said her son could not breathe during a seizure and needed oxygen at the onset.

She understood her son would be “constantly monitored” using a monitor that measures oxygen saturation levels, she said. She brought the sats monitor to the Carmona centre and left clear instructions for its use. She told staff the sats monitor should only be attached once her son was “deeply asleep” as it could otherwise disturb him.

“My understanding was he would be constantly monitored. His seizures generally last from three to five minutes. If any longer than seven minutes it becomes a medical emergency and an ambulance must be called,” Mrs Neiland said.

Found unresponsive

Staff at the facility put Tristan to bed at 8.30pm on January 5th, 2013. He was due to be checked every 15 minutes. Tristan was checked about five times between 9pm and about 11pm. There was a baby monitor in his room and the door was left slightly open. There was no sats monitor attached to him because staff were of the opinion Tristan was not deeply asleep, the inquest heard.

When a staff member checked on Tristan shortly before 11pm he was found unresponsive.

A nurse immediately began cardio-pulmonary resuscitation and an ambulance was called.

Tristan was rushed to Our Lady's Children's Hospital in Crumlin, where he was pronounced dead the following day.

Pathologist Dr Maureen O’Sullivan gave the cause of death as sudden, unexplained death in epilepsy.

St John of God apologised to the Neiland family for the shortcomings in Tristan’s care and outlined a number of changes made at the facility since the child’s death.

Following a full systems review, the centre no longer accepts children with “high medical needs”, and individual care plans with risk assessments for each child are now conducted, along with more stringent staff training.

Returning a narrative verdict, Coroner Dr Myra Cullinane endorsed the changes that have been implemented at the Carmona centre since Tristan's death.

Speaking after the inquest, Tristan’s mother welcomed the verdict.

“We note that Tristan’s death and the circumstances surrounding it has resulted in changes being made in the Carmona Services. In that context Tristan’s death has not been in vain,” she said.

“I miss him. Every single day,” Mrs Neiland said.

*This article was amended on December 6th, 2017.