THE Health Service Executive (HSE) apologised to a Lithuanian family whose son died in a window fall tragedy after admitting call centre staff failed to follow protocols.
Vidas and Aukse Martinaitis, who lost their son, Vakaris (2) last May, said they now wanted "learning and improvement" from the incident on May 6 last so no other family goes through their ordeal.
The grieving parents said they remain "devastated and broken-hearted" by the tragedy.
The toddler suffered catastrophic skull and brain injuries when he opened an upstairs bedroom window while playing at home and tumbled out onto a concrete footpath below.
His sister, Angeta (8), who had left the bedroom to collect a teddy, made a desperate bid to catch her brother as he fell.
"I loved my son very much. 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.
The family co-operated with the probe conducted by Northern Ireland Ambulance Service (NIAS) director, Dr David McManus.
They also accepted an apology tendered in person by National Ambulance Service (NAS) medical director, Dr Cathal O'Donnell.
Dr O'Donnell vowed that the NAS will never allow such a situation to happen again.
"That call was not handled appropriately. The long-standing existing procedures in that call centre were not followed. That should not have happened and it resulted in us not dispatching the ambulance," he said.
"The staff concerned were acting in good faith and thought they were doing the best with the information they had received. But, having said all that, they did not follow the procedures they should have."
Dr McManus, in making 12 recommendations for changes to NAS call centre operations, said the ambulance controversy would not have occurred had protocols been followed.
However, even if the ambulance had been dispatched it would not have changed the medical outcome for Vakaris.
Vakaris died in Cork University Hospital (CUH) two days after the accident with five children benefiting from organ donor transplants.
The McManus report, ordered by Health Minister James Reilly, confirmed two Cork-based call centre staff "deviated from procedures" in their handling of a desperate emergency call made on Vakaris' by former Cork hurling star, Kevin Hennessy.
Mr Hennessy lives in the same Castleredmond estate in Midleton as Vidas and Aukse and came upon the scene of the tragedy.
A Cork coroner's inquest already heard that Mr Hennessy and his daughter, Caoimhe, immediately rang for an ambulance.
But the first call centre official believed the toddler had not suffered life-threatening injuries and advised taking him to a GP.
A second call centre official recalled an ambulance racing to Midleton. Vakaris was taken to CUH, via a GP's surgery, in Mr Hennessy's car.