A grief-stricken father has told how he and his wife only had their newborn baby daughter for 42 hours and 27 minutes before she died, when her heart was pierced as she underwent a hospital procedure.
Coilin O Scolai and Irene Kavanagh said they have been left "shattered and broken" following the death of baby Laoise who, along with her twin brother Cuan, was born premature at 28 weeks on January 22, 2015, at Dublin's Coombe Hospital.
Both babies were diagnosed as suffering from respiratory distress syndrome and Cuan was the first to undergo a chest drain procedure to remove air trapped in his chest cavity.
The same procedure, where a needle is inserted into the chest and air is released, was later performed on Laoise after an X-ray revealed she too was suffering from a tension pneumothorax.
However, during the procedure on January 24, Laoise's heart was pierced.
She was transferred to Our Lady's Hospital for Sick Children, Crumlin, where she was pronounced dead.
A post-mortem revealed her death was due to a rupture of the heart due to a penetrating injury by a catheter. A contributing factor was her prematurity.
An inquest into her death at Dublin Coroner's Court yesterday returned a verdict of medical misadventure, with coroner Dr Myra Cullinane recommending that guidelines for chest drain procedures, which had changed between 12 and 18 months before Laoise's death, be drawn to the attention of staff at the Coombe.
Speaking to reporters following the inquest, Mr O Scolai said: "As a family we have been left devastated and broken.
"We only had 42 hours and 27 minutes with her. We want to ensure this never happens to another family. Her siblings have lost us for the last two-and-a-half years because we have been devastated by this."
Ms Kavanagh added: "She was a twin so we have her brother that we watch every day. We look at him and we wonder what would she look like, every milestone he's taken, we can just never get away from it."
Her husband continued: "[Cuan] is thriving, he's so strong, so beautiful. She should be playing there beside him and she's not. We're empty."
They had never been told the procedure "could have life or death consequences for Laoise".
Pathologist Professor John O'Leary, who performed the post-mortem, said he could not be definitive as to whether the injury was due to the needle being inserted too far, or the heart shifting back following the air being released.
He said he would not "minimise" the explanation given by medics that, when the pneumothorax was relieved, "the heart could have flipped back".
Asked by Richard Keane SC, for the family, if the injury could just as likely have been caused by the needle being inserted too far, he replied: "There are various possibilities."
Neonatal registrar Dr Muhammed Islam said the drain was "high-risk". He inserted the needle two to three centimetres into the baby's chest in line with the guidelines he was aware of.
Mr Keane put it to Dr Islam that the correct depth, given Laoise's size, was 1.5cm.
There were no written protocols in relation to the method of drain insertion used at the hospital, the inquest heard. New guidelines had been introduced for the technique.