'The critical tests were not performed' - Verdict of medical misadventure returned at inquest into death of little Aibhe Conroy (6)
A coroner returned a verdict of medical misadventure in the case of a six year old girl who died four days after she was admitted to hospital suffering from hypoglycaemia.
Aibhe Conroy, from Gowla, Connemara, Co Galway died at Temple Street Children's Hospital in Dublin on December 14 2011.
In a statement, Aibhe’s family said they feel ‘vindicated in their campaign for answers regarding Aibhe’s care and treatment during her short life.’
Coroner Dr Brian Farrell said the verdict of medical misadventure takes into account risk factors that arose in evidence during the inquest into the child's death.
The coroner identified the lack of critical blood samples to determine whether Aibha had an underlying metabolic or endocrinal issue as a risk factor and noted that the results of a cortisol test shortly before she died could not be relied upon.
“It is clear, in my interpretation of evidence, there were a number of potential risk factors bearing on what happened. Those factors would constitute a potential or actual risk that would have a bearing on the verdict,” Dr Farrell said.
The verdict contains ‘no connotation of blame or exoneration’ the coroner said.
“It is a neutral verdict, reflecting only the facts and issues that have been ascertained in evidence,” Dr Farrell said.
Aibhe’s mother, Kathleen Conroy shed tears as the long running inquest drew to a conclusion.
“Those (four years since Aibhe’s death) were characterised for the most part by obstacles being put in the way of an enquiry. They had tried getting answers through the Medical Council, but for technical reasons that process couldn’t go ahead,” a statement released on behalf of the Conroy family said.
Four days before her death, Aibhe had been admitted to Galway University Hospital suffering from hypoglycaemia, or low blood sugar, and weakness. She was also vomiting.
She initially responded to treatment when first admitted to GUH on December 11, but within 90 minutes she suffered a respiratory arrest and had to be resuscitated.
Aibhe was subsequently transferred to the intensive care unit at GUH and then to Temple Street Children’s Hospital where she died four days later.
She was pronounced dead on December 14 at 3.55pm. The cause of death was cerebral oedema following a prolonged episode of hypoglycaemia. The coroner said there were only two verdict options open to him, that of medical misadventure and a narrative verdict.
“At inquest we are not concerned with what might have happened, we are concerned with what happened. The (critical) tests were not performed. In my view that is an issue in the evidence,” the coroner said.
The family’s solicitor, Damien Tansey, thanked the coroner for his ‘painstaking approach’ on behalf of Aibhe’s parents John and Kathleen Conroy.
“Their ambition was that no stone would be left unturned, to extract some answers for the tragic and untimely loss of their daughter. It’s an unspeakable loss,” he said.
The Conroy's faced a challenge akin to climbing Mount Everest, Mr Tansey said.
“But they were the measure of that climb.” The Conroy’s bear no ‘ill-will’ to any medics, Mr Tansey said.
“They know that none of doctors or nurses intended this to happen,” he said.