One of the country’s main children’s hospitals has admitted changing how it carries out a biopsy and the related aftercare of patients after a baby boy suffered a fatal bleeding in his liver following such a procedure.
Legal representatives of Children’s Health Ireland at Crumlin issued an apology to the parents of the two-month-old baby at a sitting of Dublin District Coroner’s Court on Friday about the failings in its care of the infant.
The baby, Mason Taaffe, died at the hospital on January 15th, 2019 just 24 hours after undergoing a liver biopsy at the hospital.
A post-mortem revealed he had suffered “catastrophic bleeding” as a result of the procedure.
Counsel for CHI Crumlin, Conor Halpin SC, apologised for the pain, distress and loss suffered by the baby’s parents, Maria Roche and Jamie Taaffe, during their son’s five-day admission to the hospital.
Mr Halpin told the inquest that the hospital had introduced several changes as a result of a review of the baby’s death which were designed “to improve safety for all patients.”
The inquest also heard a conflict of evidence between hospital staff over whether Mason’s care had been escalated following a deterioration in his condition at around 3am on January 15th, 2019.
A staff nurse, Rejitha Revi, said she had bleeped a senior house officer three times over a period of around 90 minutes to review baby Mason as she had growing concern about his condition.
In a statement, however, the SHO, Siobhán Pennycook, maintained she had been given no indication that there was any urgency with the situation.
Dr Pennycook said she was busy attending other patients including another urgent case and said she would review Mason as soon as possible.
The inquest heard that the little boy had been born three-months prematurely at the Rotunda Hospital in Dublin on November 20th 2019.
His mother told the hearing that her son had a number of health complications resulting from his premature birth and needed to be on a ventilator.
Ms Roche, who comes from Killinarden, Tallaght, explained her son had been transferred to CHI for a biopsy because of concerns about the functioning of his liver.
She outlined several concerns about the care provided to her son during his short stay in Crumlin including being left without oxygen for over an hour and a half and having a rash on his face because it was not cleaned.
Ms Roche also claimed she had seen her son’s blood pressure only being checked once after the biopsy was carried out on January 14th 2019, although it was meant to be checked at regular intervals.
She said she was also worried when Mason started to scream in pain several hours after the procedure which she knew was unusual, although a nurse had tried to reassure her there was nothing to be concerned about.
Ms Roche said she and her partner were called back to the hospital and were informed that their son’s heartbeat had recovered after it had stopped first for 7 minutes and then again for 36 minutes.
However, she said his face was blue and swollen and his condition continued to deteriorate until he was pronounced dead at 12.51pm.
A consultant paediatric gastroenterologist, Billy Bourke, informed the inquest that the baby did not have the suspected biliary atresia – a blockage of the bile ducts around the liver – for which the biopsy was ordered to confirm.
While there was no particular risk of bleeding with the procedure, Prof Bourke said the risk would always be somewhat elevated with premature babies.
He said it was the first time in his professional career that he had experienced a baby dying from a liver biopsy.
However, Prof Bourke said it was unlikely that a major blood vessel had been ruptured by the needle used to perform the biopsy as it would have been detected almost immediately.
The consultant said all biopsies were now carried out using ultrasound by radiologists rather than anatomically as it had been in baby Mason’s case.
Prof Bourke admitted that the reason they had not been carried out by ultrasound beforehand was due to “resources”.
He also accepted that post-operative monitoring guidelines for the patient had been followed initially but not after six hours after which the baby’s condition deteriorated.
The inquest heard post-operative observations of patients who undergo a biopsy are now carried out at greater frequencies.
A consultant neonatologist, Eleanor Molloy, told the coroner, Cróna Gallagher, that medical staff were “definitely” more aware about the complications of a biopsy following baby Mason’s death.
Returning a verdict of medical misadventure, Dr Gallagher said she was not required to resolve the conflict of evidence that had emerged during the hearing.
The coroner said the verdict reflected the fact that baby Mason’s death was the unintended consequence of an action and/or omission but did not imply any blame or exoneration of any party.
Dr Gallagher said she also endorsed the changes already introduced at CHI Crumlin following the baby’s death.
While she had considered making a recommendation about staffing levels at the hospital, the coroner said the evidence did not indicate having any extra nurses or doctors would have prevented his death.
Offering her condolences to the baby’s parents, Dr Gallagher said they had suffered a great loss during a “deeply traumatic” experience.
“There is no tragedy greater than the loss of a child,” she remarked.