A verdict of "medical misadventure" was returned by the Dublin City Coroner yesterday in the case of a 15-month-old girl who died following a medical procedure at Our Lady's Hospital for Sick Children, Crumlin, Dublin.
Dr Brian Farrell said it seemed that a feeding tube, which was re-inserted into Megan Neary, of Leinster Avenue, North Strand, Dublin, at the hospital on January 10th last "was not in the correct position".
When feeding recommenced after re-insertion, the feed went into an abdominal cavity, causing acute peritonitis.
He expressed his sympathy to the child's parents, Anthony and Paula Neary, and family. He also expressed sympathy to the hospital, saying he believed the child's death was a cause of great sorrow to them.
Mr John Gleeson, a solicitor for the hospital, said he wished to express the hospital's regret over the death of Megan and its "sincere sympathy" to her family.
In his verdict, Dr Farrell found Megan died of acute peritonitis on January 11th last, arising from the leaking of the feeding tube into an abdominal cavity.
The tube had been re-inserted the previous day, January 10th, by Dr Felim Murphy, senior registrar at Our Lady's Hospital, after it had fallen out at home some hours earlier.
Dr Farrell said Dr Murphy had told the inquest he believed the re-insertion of the tube went smoothly. However, the coroner said: "It seems, on the pathologist's evidence, that the tube was not in the correct position."
In evidence at the inquest, Dr Deirdre Devaney, a pathologist who conducted an autopsy into the child's death, said the last section of the tract into which the feeding tube was to be placed appeared to have bounced off the stomach wall and veered off slightly in another direction. "We are talking about millimetres," she said.
The inquest heard Megan was born with Down's Syndrome and had spent long periods in hospital for treatment of congenital heart disease. However, Dr Devaney said the child's coronary features were functioning normally at the time of her death.
The inquest had opened on September 4th and was adjourned to yesterday to hear evidence from Ms Anthea Bryce Smith, a clinical nurse specialist in nutrition support.
Ms Bryce Smith said she received a phone call from Megan's parents on the morning of January 10th and was told the button at the top of the child's tube had fallen out overnight and they were unable to replace it. She advised them to bring the child to hospital where she tried to insert a new button.
Ms Bryce Smith said she could not do so as the child's stoma (surface opening) had partially closed and she had instead inserted a narrower tube for the purpose of preventing the stoma closing further. She had then referred the child to the Accident and Emergency Department and said she required a surgical review.
Under cross-examination by a solicitor for Mr and Ms Neary, Ms Bryce Smith said she would change such tubes 10-15 times a week and also trained other nurses and parents to do so. She said she was not surprised Dr Murphy was able to insert a tube. She would always ask a surgeon to intervene if she could not do it.
In his evidence at the earlier hearing, Dr Murphy said he had taken extensive care to ensure the tube was correctly fitted by checking it rotated freely after insertion. If the stoma was closed, he could not have inserted it in any fashion, he said.
Dr Murphy also said that most children who experienced such a leakage generally felt abdominal pain after three to four days. He had never known one to have had such an effect as in Megan's case, he said.
Mr Anthony Neary told the coroner Megan had been somewhat unsettled after she was discharged into her parents' care following the re-insertion procedure on January 10th. He believed this was because she didn't like being handled. They gave her a feed about 2.45 p.m. that day. That night, the child's heart monitor went off between 11.30 p.m. and 11.40 p.m. "I could see by her she had no life in her," he said. "I tried to revive her but couldn't." The child was rushed to Temple Street Children's Hospital and pronounced dead soon afterwards.
Mr Neary said he wanted to say that while Megan had had "an awful history of illness", she was thriving after November 2002.
Ms Paula Neary wept as the verdict was delivered. Afterwards, the parents, who have two other children and are expecting another soon, declined to comment.
