The Dublin City Coroner has urged the Department of Justice to bring forward amending legislation to remove the restriction that only one medical doctor can give evidence at an inquest.
Dr Brian Farrell made the comments at the inquest into the death of 16-year-old Richard Callan, who was admitted to the A&E of the Beaumont Hospital, Dublin, after falling from a skate board. He died after his condition deteriorated following surgery to remove his spleen.
A verdict of death from misadventure was recorded by the coroner. However, he said it could not be explained why the boy did not respond to medical and surgical treatment.
Dr Farrell said he had to secure seven medical reports in order to get the full picture of the sequence of events once the boy was taken to hospital.
"The difficulty is the present restriction in law when only one medical practitioner can give medical evidence. It means I have to choose one out of a number of teams, the A&E team, the surgical team, and anaesthetic team. It is extremely difficult," he said.
He said it was hugely difficult for coroners who had to hold public inquiries into deaths. In this case, they had one doctor to give evidence but had to obtain medical reports from others and had five doctors present in court.
"It is extremely difficult for the coroner's office, for the families who do not have the benefit of hearing all the doctors give a coherent account of what happened and the doctors themselves who are anxious to give evidence," he said.
Dr Farrell said he did know that the Department of Justice had indicated it was bringing in a Bill that would amend the existing Coroners Act in various ways.
"It would delete this unjustified restriction of law and I urge that the Department may bring this forward," he said.
Prof Denis Cusack, representing the family, said that the restriction placed on coroners was very pertinent to the case.
"The family is entitled to a full inquiry and doctors are entitled to give a full version of events. The inquiry is limited by the lack of amending legislation," he said.
The inquest heard that Mr Callan was taken to hospital by his mother, Mrs Noeleen Callan, after a skate-boarding accident on December 31st, 2002. He was brought to the A&E of Beaumont Hospital at 6.30 p.m. He was in pain but there was no fracture and no bleeding or head injury.
Tests were taken and he was sent for an ultra-sound which showed there could be a laceration of the spleen.
However, at about 11 p.m., when he was being moved from the trolley to the table for a CT scan, his condition deteriorated rapidly. It was decided to operate and his spleen was removed. He deteriorated further and did not respond to resuscitation measures. He died at 1.10 a.m. on January 1st, 2003.
The doctor chosen to give evidence was Dr Louise Kelly, a registrar, who saw Richard at 9.45 p.m. and was at the operation until his death.
She said when Richard was taken from the trolley for the CT scan, there was a very dramatic deterioration. They abandoned the scan and took him to surgery. The operation was performed at once but he deteriorated. They tried resuscitation measures for over an hour.
Dr Farrell said there was nothing in the autopsy report which would help them with the cause of death.