A report on how a Cavan girl died 36 hours after being sent home from hospital has blamed system inadequacies for the staff's failure to identify and treat her life-threatening condition, writes Eithne Donnellan, Health Correspondent, in Kells
The report, published yesterday by the North Eastern Health Board, which runs Cavan General Hospital, found that when Frances Sheridan (9), from Cootehill, presented at the A&E unit on January 30th suffering from severe abdominal pain, she was assessed only by two junior doctors.
She was not seen by the surgery team, although she had had an appendix operation there three weeks earlier, and her file could not be found.
She was sent home, despite a recommendation from her family doctor that she stay at the hospital, and despite her mother's efforts to persuade hospital staff to keep her overnight.
She died 36 hours later, and a post-mortem showed her bowel had become obstructed as a consequence of her operation. A second operation could have rectified the problem.
The report says that when she went to the A&E unit, the first doctor to assess her "was inexperienced in general surgery" but ordered an X-ray. After the X-ray was obtained, this doctor consulted with a colleague who had "slightly more surgical experience but was of a similar grade".
They told the girl's mother no abnormality was found and they were satisfied to let her go home.
"The mother queried his decision but was assured by the doctor and accepted his decision," the report said. "She had taken nightclothes with her to the hospital, expecting Frances to be admitted, as was advised by the GP."
The report found a catalogue of systems failures. They included the fact that the child's GP had written a referral note to the surgical on-call team via the A&E department, suggesting a diagnosis of "volvulus" (twisting of the gut).
However, the receiving doctor did not alert the surgical team. The child's GP was not informed that the child was being discharged. Medical notes from her appendix operation were not available as they were "passing through the secretarial hospital system".
The chief executive of the health board, Mr Paul Robinson, said an absence of guidelines on how such cases should be dealt with contributed to what happened.
However, he said it was "impossible to say" whether or not, if the surgical team had been contacted, the child's life could have been saved. Her chances would have been "improved enormously". Mr Robinson said the task now was to ensure the report's 22 recommendations were implemented.
The family of Frances Sheridan said it was a source of great distress to them to learn that there was a failure on the part of the hospital to manage their daughter's care.
The Minister for Health has asked his chief medical officer, Dr Jim Kiely, to examine the report.