A HEALTH Service Executive (HSE) report into an ambulance recall from a toddler with fatal head injuries has made 12 recommendations for changes to '999' call handling procedures.
Vakaris Martinaitis (2) died from “devastating” brain injuries after he suffered a complex skull fracture when he fell and landed on a concrete path outside his Cork home on May 6 last.
The HSE report was ordered when it emerged an ambulance sent to Vakaris was recalled and he ultimately had to be taken to hospital in a family car.
An ambulance was dispatched to Vakaris' home but was recalled because a HSE dispatcher believed from the information he was given that the child's injuries were not life-threatening.
The report, which was ordered last May, has found that the HSE staff acted in good faith.
But it also found "the staff at the (ambulance) control centre failed to comply with organisational procedures and standards and underestimated the severity of the 112/999 call."
The report found there was a lack of clarity between the 999 call taker and the ambulance dispatcher.
"Had the (call) procedure been followed to conclusion this would have allowed the call taker to obtain further information about the incident."
The report, by Dr David McManus,Medical Director of the NI Ambulance Service, found that there was "a deviation from the procedure outlined in the ambulance control procedure for call taking."
"(There was also) a deviation from the EMS priority dispatch standard resulting in a decision not to dispatch an emergency resource that was not based on correct and complete information."
Vakaris' sister, Agneta (8), had made a desperate bid on May 6 to catch the toddler after he opened the window while playing in an upstairs bedroom and accidentally fell out.
Agneta was playing with Vakaris that lunchtime when she briefly left the room to collect a teddy.
Her father, Vidas, was downstairs cleaning their Castleredmond, Midleton home in preparation for Agneta's First Holy Communion the following weekend.
His wife Aukse was at work.
A Cork coroner's inquest earlier this month heard that when Agneta returned to the bedroom Vakaris, who was in his pyjamas, was sitting on the interior window ledge and had opened the sash.
“He opened the window and he fell out,” Agneta told specialist Garda interviewers.
“I tried to catch him but I didn't have time to catch him. I (ran downstairs) and told my dad what had happened,” she added.
There was no lock on the window and the two foot sash had an unrestricted opening arc.
A spare bed was directly underneath the window which allowed Vakaris to climb up.
An ambulance dispatched to the Lithuanian toddler was stood down because HSE call handlers understood the child had only sustained a simple bump to his head.
The HSE dispatcher who handled the emergency call made by former All-Ireland hurling star Kevin Hennessy and his daughter Caoimhe, neighbours of Vidas and his wife, Aukse, said he did not believe life-threatening injuries were involved.
“I genuinely thought that the child had suffered a simple fall. My thought at that stage was that the child had a simple fall and had just bumped his head,” the HSE official said.
A transcript of the 999 call made indicated that he queried whether Vakaris could have fallen from a height.
He was not told the child had fallen from a window.
But Mr Hennesy informed dispatchers that the child had suffered a nasty fall and was screaming in pain.
Mr Hennessy was concerned because he could see a swelling on the toddler's forehead.
He told dispatchers he had not witnessed the fall but had stopped his car to help the Lithuanian father who was screaming for help.
“I said to the dispatcher we need an ambulance here...(but he said) at the moment I have nothing in the area to send you, do you understand,” Mr Hennessy said.
A second HSE dispatcher had assigned the call to the Midleton-based ambulance which had just finished an assignment in Cork city and was returning to the east Cork town.
It could have been at the scene within 18 minutes.
But minutes later the ambulance was stood down because Vakaris' injuries were not believed to be life-threatening.
Mr Hennessy later drove the screaming child and his distressed father to Cork University Hospital (CUH).
Despite being initially conscious, Vakaris died two days later.
He suffered traumatic brain injuries and haemorrhage as a result of a complex fracture to the skull consistent with a fall from a height.
The toddler was the youngest child of Lithuanian nationals, Vidas and Aukse Martinaitis, who were “devastated and broken hearted” by the tragedy.
But they said they took some comfort from the fact their son's organs were donated and as a result four children benefitted from life-saving transplants.
“I loved my son very much. We had a great father and son relationship. Now I just have a lot of suffering and no life. I could not save my son. He was a beautiful little boy...he had a good heart,” Vidas said.
Vidas and Aukse paid tribute to Mr Hennessy for the kindness he had shown them that day.