A haemophiliac lost three-quarters of his blood following surgery on his second birthday, an inquest heard.
Pierce Nowlan had 600 millilitres of fluid drained from his chest after medics punctured an artery while trying to insert a line. Dublin City Coroners Court heard a child of that age carries just 800 millilitres.
Pierce was admitted to Our Lady's Hospital for Sick Children, Crumlin, on October 11th, 2004, to have a device fitted into a vein that would have allowed the regular injection of a blood-clotting agent.
During the procedure an artery on the left side of his chest was punctured, causing internal bleeding. He suffered brain damage from a lack of oxygen to his brain and died three days later.
Paediatric surgeon Dr Alan Mortell had no concerns over the child's welfare during surgery, the inquest heard. He said he had no evidence that the toddler was in difficulty during or after the procedure and that he was not made aware that the youngster's blood pressure or gas levels were causing concern.
Dr Mortell told Coroner Dr Brian Farrell that six to eight attempts were made on the vein in the child's chest but were unsuccessful.
He said he was aware at least one hit had punctured the chest's vein but that pressure had been applied to it for five minutes. A line was instead entered into his neck.
Anaesthetist records taken during the procedure were referred to at the hearing and revealed changes in Pierce's vitals, which Dr Mortell said he had no knowledge of. They also referred to a small bleeding that had occurred on the first vein.
"I didn't have any indication he was in serious difficulty at the time I left," said Dr Mortell. "The procedure in my mind had gone according to plan apart from one artery hit. I was not aware of him being in any serious condition when I left the theatre."
Surgical registrar Feilim Murphy was called to the recovery room to care for Pierce where he drained 600 millilitres of blood from the left side of the youngster's chest. Internal cardiac massage and resuscitation were also carried out on the child, who he described as being "obviously unwell".
The inquest is being held in full after Pierce's parents, Stephen and Jean Nowlan, of Carrigmore Green, Saggart, Co Dublin, called on Justice Minister Michael McDowell to change legislation that restricted the coroner to call in just two medical witnesses in any one case, including a pathologist.
An amendment to the Coroner's Act followed last December, allowing for more than two medical practitioners to give evidence at an inquest.
PA