The medical records of patients should be available at all times to staff at Cavan General Hospital, an inquest jury recommended last night. The jury made its recommendation after finding that nine-year-old Frances Sheridan, of Cootehill, Co Cavan, died of medical misadventure.
The verdict of medical misadventure was welcomed by the Sheridan family. Speaking through their solicitor, they said it confirmed their belief that Frances's death was avoidable and should not have happened.
At an earlier inquest into the child's death in December a different jury returned a verdict of death by natural causes.
The Sheridan family was extremely unhappy with this result and appealed to the Attorney General to direct that a new inquest be heard. In a rare move he granted the request, resulting in the second inquest being heard yesterday.
Video evidence of Frances's time in the A&E unit in Cavan hospital with her mother on January 30th was shown at yesterday's inquest. It had not been shown at the first inquest and indicated that she spent 38 minutes in the unit before being seen.
However, once assessed by nurse Olive O'Reilly she was seen within 10 minutes by a doctor as she was in severe pain and the nurse regarded her condition as urgent.
Yesterday the six-person jury took 42 minutes to arrive at its verdict at Cavan Coroner's Court.
The jury also recommended that surgical teams should review patients post-operatively.
Frances died in 2004 three weeks after an appendix operation in Cavan hospital.
The jury heard the child presented with abdominal pain at the hospital A&E unit on Friday, January 30th, 2004, having had her appendix out on January 7th. Two junior doctors, who qualified in 2001, examined her. There was no A&E consultant on duty.
Dr Liezl Du Plessis gave evidence that the child's medical records were not available to her on the day. This was a usual occurrence. She knew, however, that the child had had an operation. She read a letter from the child's GP, Dr Michael O'Hea, which queried if the child might have a twisted bowel post-operatively.
She examined the child and found her bowel sound to be normal. She ordered an X-ray to rule out a bowel obstruction. The X-ray was normal.
She agreed that the GP's letter was addressed to the surgical team on call at the hospital but the child was not referred to them.
She said the practice at the hospital was that the doctors in A&E would only refer somebody to the surgical team if they felt this was necessary after examining a patient. She did not feel it was necessary on this occasion.
Dr Du Plessis asked the other junior doctor in the A&E department, Dr Martin Brand, to look at the X-rays and to examine Frances. He also found nothing abnormal and agreed she could be discharged.
The child's mother, Rosemary Sheridan, said her daughter vomited as she left the hospital. Dr Du Plessis said she was not informed of this.
Mrs Sheridan said she took Frances home, and as she still had pain she stayed up with her that night. The next day, Saturday, she was a bit better. She stayed up with her again on Saturday night, and some time after 5am on Sunday morning Frances woke looking for a drink of 7Up. As soon as she drank it she vomited black material and collapsed in her mother's arms. She was rushed to Cavan hospital and pronounced dead on arrival.
Earlier the State Pathologist, Dr Marie Cassidy, gave evidence that the child died from complications from recent surgery. Adhesions or scar tissue developed at the site from where her appendix was removed, which was a normal part of the healing process. However in this case the adhesions formed a loop through which the bowel could slip in and out. It got trapped in this case and ultimately led to the child's death. She said further surgery could have remedied the problem.