The purpose of an inquest is to establish the cause of a death, not to apportion blame.
Nobody was blamed at yesterday's inquest into the death of schoolgirl Frances Sheridan for what all parties agreed was her "tragic death" at the age of nine.
However, several practices at Cavan General Hospital, which she had attended prior to her death, were highlighted at the inquest which give serious cause for concern.
The child's file could not be found when she presented at the hospital's A&E unit on January 30th last year, three weeks after she had undergone an appendix operation at the hospital.
The coroner, Dr Mary Flanagan, asked the junior doctor who examined her in A&E, Dr Liezl Du Plessis, if she had inquired why the file could not be found. Her answer was telling. She said she hadn't as this "was a frequent thing". It was often the case that files could not be found.
She also said she and another junior doctor, Dr Martin Brand, were the only two doctors on duty in A&E at the time and it was very busy. She was of senior house officer grade and Dr Brand was the same. There was no supervision of their work by a hospital consultant, she said. An A&E consultant had recently been appointed to the hospital but was not on call at the time.
She admitted she was "scared" she would send somebody home having missed something so she sought a second opinion. It was from her junior doctor colleague. This issue of non-supervision of junior hospital doctors is a major one at many hospitals, particularly smaller hospitals, across the State. It has got to change in the interests of patient safety.
Several reports, including Hanly, have recommended the appointment of large numbers of extra hospital consultants so they are available around the clock to see patients and supervise doctors in training. The sooner this happens the better, but it will take time.
This inquest also touched on the language skills of foreign doctors. Dr Du Plessis is from South Africa and when Ken Connolly, for the Sheridan family, put it to her that in notes she had taken on examining Frances Sheridan she had written "now severe abdominal pain".
He suggested to her that in simple English this meant the child had pain during her examination. Dr Du Plessis responded that English was not her first language. She then said what she meant by the note was that the girl had severe pain earlier that day. She did not have severe pain when she examined her. An X-ray was clear and she sent the child home. The child was dead 36 hours later.
The child's GP also wanted her to be seen by the surgical on-call team, given her surgical history. His letter was read by Dr Du Plessis but not passed to the surgical on-call team.
Dr Du Plessis said doctors in A&E were told they themselves had to see such patients first and then decide whether to call the surgical team. But she said patients coming in with letters from their GPs to the medical team in the hospital went directly to the medical team.
It seems a strange anomaly that all letters are not treated the same way and an effort made to ensure they got to the people to whom they were addressed.