A report into the death of a nine-year-old girl less than 48 hours after being discharged from Cavan General Hospital has identified eight high-priority issues in a scathing assessment of the tragedy.
Frances Sheridan from Cootehill, Co Cavan, underwent an appendectomy at Cavan General on January 7th this year but three weeks later returned to the hospital suffering from stomach pains.
She was sent home where she died two days later. A post-mortem blamed complications in relation to recent surgery.
Procedures at the hospital were strongly criticised in an independent report into the incident, published today and a strong emphasis was placed on inadequate facilities, funding and staffing.
"The nursing and medical staff work closely as a team and good leadership is demonstrated within both disciplines," the report says. However at the time Frances presented at the hospital, there was only one nurse on duty who was " de factoin sole charge of the A&E department".
The report also noted that two of the three doctors on duty that evening had not completed their induction at the hospital.
"The staffing levels, skill mix and shift patterns on 30/01/04 did appear to have an adverse effect on this particular incident," the report said.
The North Eastern Health Board (NEHB) which commissioned the inquiry again extended their sympathies to Frances's family today.
The review team conducted a wide range of interviews, reviewed relevant documentation and prepared a detailed chronology of events in relation to the death.
The report identified "a failure to adequately assess and manage the patient on 30th January, 2004" - the day Frances arrived at Cavan General A&E suffering from stomach pains. The failure of the hospital to ensure Frances was treated by the team that originally performed the surgery was criticised in the report.
It also identified "inadequacies in systems, an absence of guidelines, a need for more nursing and clerical staff and structural changes in the Accident and Emergency department.
"The staffing levels, skill mix and shift patterns on 30/01/04 did appear to have an adverse effect on this particular incident," the report says. It makes 22 recommendations, eight "high priority" and 14 "medium priority".
The North Eastern Health Board said today some of the recommendations have "resource implications in relation to both staffing and funding".