There was a breakdown of communication between doctors following an operation on a two-year-old haemophiliac boy who later died from complications of the surgery at Our Lady's Hospital for Sick Children in Crumlin, Dublin, an inquest has heard.
Dublin city coroner Dr Brian Farrell recorded a verdict of death by medical misadventure yesterday.
Pierce Nowlan, of Carrigmore Green, Saggart, Co Dublin, had an artery punctured during the procedure and died three days later from brain damage due to lack of oxygen on October 14th, 2004.
Since Pierce's death, the hospital has changed the procedure for carrying out the operation that resulted in Pierce having an artery punctured.
The operation to fit a device to stop clotting is now attached to a vein in the neck, rather than the chest, as was attempted with Pierce.
Addressing Dublin City Coroner's Court yesterday, Dr Patrick Doherty, chairman of the medical board at the hospital, said an internal review of procedure had been carried out following Pierce's death.
He said it is now standard that all children will have a chest X-ray in the operating suite; all operations involving children will take place before noon; the most senior medical clinician will make all final decisions about their patients; and the hospital is re-examining its parental consent procedure.
The court heard that Pierce did not have a chest X-ray in the operating theatre; his operation took place in the afternoon and his father, Stephen Nowlan, previously said in court: "We were not made aware of any risk with the procedure."
Dr Farrell said there was "a breakdown in communication between senior medical surgical staff. This has been demonstrated in the direct evidence of consultants."
Dr Farrell added there was also a concern over the matter of parental consent. While he accepted the evidence of Farhan Tareen, who took the parental consent, it was clear the family did not feel the operation was clearly explained to them.
Emily Egan, barrister for the hospital, said she agreed with the Nowlan family's solicitor that a change in hospital procedure meant, "out of this tragedy some good could come".
Dr Farrell said he endorsed the hospital's review of procedure and would write to the Irish Haemophilia Society outlining the recommendations.
During the procedure, Pierce's subclavian artery was punctured in the left side of his chest, causing a bleed. As operating doctors were unable to fit the device to his subclavian vein, they managed to successfully attach it to a vein in his neck.
Dr Martina Healy told the inquest yesterday that after she punctured the artery, "There was nothing there to tell me that Pierce was bleeding into the chest."
Last Thursday Dr Alan Mortell, who undertook the operation with Dr Healy, said he did not recall if he had told Prof Martin Corbally, the most senior consultant involved in Pierce's care, that the artery had been punctured.
In the hours following the procedure, an X-ray confirmed that Pierce sustained a significant amount of internal bleeding in his chest.
Dr Healy asked the advice of consultant surgeon Freddie Wood, who advised an immediate chest drain.