Children’s Health Ireland (CHI) has apologised after a teenager with severe and poorly controlled asthma died following a severe attack while waiting years to see a specialist.
Killian Burnett (15), from Finglas, Dublin, had four cancelled appointments between his first referral to see a respiratory medicine consultant in December 2017 and his death on March 22nd, 2022, at Connolly Hospital, Blanchardstown.
At an inquest at Dublin Coroner’s Court on Wednesday, coroner Clare Keane recorded a verdict of death due to medical misadventure.
Dr Keane said there had been “missed opportunities” to treat his “unstable, severe asthma”.
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Welcoming improvements already made by CHI, she recommended consideration should be given to making it mandatory for any children presenting with a history of respiratory arrest due to asthma to be discussed with a senior clinician, with a referral made, or the patient’s care escalated, if clinical conditions warranted it.
The inquest heard how Killian and his parents had attended CHI at Temple Street, Dublin, to see a specialist a month before his death without realising that, due to miscommunication, the appointment had been cancelled a short time previously.
Evidence was also heard how the teenager, a student at New Cross College, Finglas, had been discharged home after a few hours on five occasions he had been brought by ambulance to Temple Street over the space of two months shortly before his death, including two occasions when he had lost consciousness.
On the day of Killian’s death, his father David Burnett recalled being alerted at 4am how his son was struggling to breathe and his face went pale and his lips went purple.
He told the inquest his son had said: “Dad, please help me.”
“This is something I relive every single day,” Mr Burnett said.
At the coroner’s court CHI’s clinical director for medical specialities, Michael Riordan, offered an “unreserved apology” to the family for “acknowledged shortcomings” in the care of the teenager’s condition.
Dr Riordan told the inquest how a serious incident report on Killian’s death had been circulated to all respiratory consultants, while waiting lists for such patients had been merged across all CHI hospitals to ensure “equity of access” based on clinical priority and time spent on waiting list.
“No patients are currently waiting for more than two years on the respiratory waiting list,” he said.
Dr Riordan said various referral pathways for children with asthma had been reviewed with reminders on how referrals could be updated if there was a change in their clinical status.
The inquest heard Killian had been categorised as a “routine” case following his first referral – a status that never changed before his death.
Dr Riordan said patients categorised as “semi-urgent” still faced “a significant wait” at the time to be seen by a specialist.
He also said CHI had reviewed its management of waiting lists for respiratory patients, while the HSE had also commissioned a similar independent review.
Dr Riordan said Killian’s multiple attendances at the emergency department in Temple Street was a striking feature of the case.
He outlined how CHI was working to see if its IT systems could trigger a warning for children who have multiple hospital attendances with asthma and other potentially serious recurrent illnesses.
Conor Halpin SC, for CHI, issued an apology on behalf of CHI’s chief executive, Lucy Nugent, and acknowledged, to the Burnett family, that “the experience was devastating for you”.
A postmortem found Killian had died as a result of respiratory failure due to a severe exacerbation of chronic asthma.
The coroner said focal pneumonia was among the contributory factors.
Following the hearing, Killian’s eldest brother, Jordan, paid tribute to him and said the inquest was an important step to understanding everything that led up to his death.
“For years we tried our best to support him and to get him the help he needed. As his brother I saw him struggle in ways no child should ever have to and those memories will stay with me for the rest of my life,” he said.
“Killian was never just a case number or a file. He was a bright, funny, loving boy who deserved to grow up and experience all the things life had to offer. He deserved a chance.”
