Analysis: Report paints a picture of a hospital in a state of chaos, writes Eithne Donnellan.
Deaths are always difficult to cope with, none more so than the death of a child. The fact then that such a death might have been prevented is worse than disturbing.
Thus the internal Cavan Hospital report on the death of nine-year-old Frances Sheridan, the Cavan girl who collapsed and died at her home in Cootehill on February 1st last, just 36 hours after she was sent home from her local hospital, makes for distressing reading.
It paints a picture of a hospital in chaos. Not unusually for a busy hospital, it had an overcrowded accident and emergency department with 19 patients. Nurses were run off their feet - there were four in the department, and two were busy preparing a deceased body and another was on a rostered break - and it fell to a member of the public to direct the girl and her mother to a trolley where she could lie down.
Her medical records could not be found, and the referral letter given her by her GP was addressed to the surgical team, who were on call, but it was not delivered to them.
An absence of guidelines has been blamed by the North Eastern Health Board, which runs the hospital, for what happened. But surely no guidelines were needed to deliver a letter to people it was addressed to.
Frances was with her mother in the waiting area for 34 minutes before she was assessed by a senior nurse. The report said it was unacceptable for a child to wait this long without being assessed by a professional.
When she was seen by a medic, it was a junior doctor "inexperienced in general surgery" who examined her. An X-ray was ordered, another junior doctor consulted, and she was sent home, apparently with nothing more than a tummy bug diagnosed. The doctors, according to the health board, acted in good faith, and there was no evidence of "gross negligence, complete carelessness or indifference".
Frances had been suffering from abdominal pain and had had her appendix out at the hospital three weeks earlier. Her mother, Rosemary, asked why they were being sent home again so quickly. Her GP had dispatched them to the hospital in a taxi and told her to bring an overnight bag for Frances. She was told, however, there was nothing major wrong and to take her daughter home.
As we all now know, however, something major was wrong, and an obstructed bowel went undiagnosed. Frances even vomited as she left the hospital.
That night, Friday, January 30th, Frances had a bad night. Her mother was up with her all night. But by the next day she seemed to have improved and had stopped vomiting.
She went to bed on Saturday night at 10.30 p.m. and slept until about 5 a.m. when she woke up vomiting. She called her parents. She complained of being thirsty and said she couldn't see. She collapsed shortly afterwards and died.
So the obvious question is: should she have been kept in hospital? One of the authors of the report, Dr Brian McDonagh, said hindsight was a great thing. "We would feel that had the surgical team been consulted that would have been the appropriate thing to do," he said.
Knowing now that the hospital failed adequately to assess and manage her when she was in the A&E unit 36 hours earlier is devastating for a family who did everything they could to try and help their child. But their hospital let them down. The Irish healthcare system let them down.
It is well known that A&E units are grossly overcrowded, patients are being treated on trolleys every day of the week and nothing is being done to change things. So presumably other catastrophes are waiting to happen.
But if lessons are to be learned from this episode in Cavan, it is that junior doctors should not be left to make choices, tragically shown later to be life-and-death decisions, on their own. Nor should they be afraid to contact senior colleagues if they need a second opinion.
There has long been conflict in the surgery department of Cavan Hospital, and interpersonal difficulties resulted in two consultant surgeons at the unit being suspended last August.
It would appear from the report on Frances Sheridan's death that there are still difficulties in the unit, and that doctors in A&E at the time the girl presented had reservations about contacting the surgical team, which they should have done, because they viewed them as unco-operative.
"There is a difficulty still in and around the surgery department. It's an area we are moving to correct," the health board's CEO, Mr Paul Robinson, said yesterday. The report recommends that a good working relationship should be established between all acute specialities at the hospital.