A two-day-old baby died after a doctor attempting to insert a life-saving chest drain penetrated her heart with plastic tubing, an inquest has heard.
The procedure was carried out on baby Laoise Ní Scolai, a twin born premature at 28 weeks at the Coombe Hospital in Dublin.
“We are left broken as a family,” the infant’s father, Coílín Ó Scolai told the inquest.
The baby’s mother Irene Kavanagh said watching Laoise’s twin Cuán grow up left the family wondering about his sister.
“She was a twin so we have her brother that we watch everyday. We look at him and we wonder, what would she look like, every milestone he’s taken, we can just never get away from it,” she said.
Mr Ó Scolai said the family, from Comeragh Road in Drimnagh, Dublin 12 were told at the hospital that Laoise was the stronger baby.
“They said her twin was the weaker of the two...He’s thriving, so strong and so beautiful and she should be here, but she’s not.”
Baby Laoise and her twin brother Cuán were born by Cesarean-section on January 22nd 2015. Laoise weighed 1.25kg at birth.
Both newborns developed respiratory distress. They were diagnosed as having developed a build-up of air in the pleural cavity. A decision was made to insert a chest drain to relieve pressure on the infant’s heart and lungs.
Blood spots
Neonatal registrar Dr Muhammed Islam told the inquest he inserted the needle two to three centimetres into the baby’s chest in line with the guidelines of which he was aware. There were ‘a few spots of blood’ initially which he said he thought was a burst blood vessel. A nurse alerted him to the presence of blood in the tubing as the monitors attached to the baby began to alarm.
Senior Counsel for the family Richard Keane pointed out to Dr Islam that the correct depth to insert a needle in a baby of Laoise’s size was 1.5cm. There were no written protocols in relation to the method of drain insertion used at the hospital at that time, the inquest heard. New guidelines have been introduced at the Coombe in relation to the particular technique used for the insertion of the drain.
Baby Laoise deteriorated quickly. She was transferred to Our Lady’s Children’s Hospital in Crumlin where she was pronounced dead at 4.45pm on January 24th 2015.
The cause of death was a perforated injury of the left ventricle of the heart, following insertion of chest drain in a premature baby, according to pathologist Dr James John O’Leary.
Plastic tubing
The plastic tubing entered the left ventricle of the baby’s heart at a distance of 2.1cm from the chest wall.
Dr O’Leary said it was possible that the baby’s organs could have moved following the release of pressure with the insertion of the drain and noted that a premature baby’s internal organs are “very small”.
“We are talking about millimetres to centimetres... These are tiny distances,” he said.
Neonatal consultant at the Coombe Hospital Dr Pamela O’Connor said the twins were initially stable but baby Laoise was not responding to treatments administered to strengthen her breathing.
“Even in skilled hands, complications can occur when dealing with millimetres, in pre-term babies,” Dr O’Connor said. Coroner Dr Myra Cullinane returned a verdict of medical misadventure.
“It’s been an extremely difficult time for us. And all we were trying to do was uncover the truth of what happened to our little girl. We only had her for 42 hours and 27 minutes. And we want to ensure this never happens to another family,” Coílín Ó Scolai said, speaking after the inquest.