Baby girl was transferred between hospitals three times before her death

A baby born at Limerick Regional Hospital was transferred between three hospitals before she died at Our Lady's Hospital Crumlin, a Coroner's Court was told has been told.

The baby was delivered by emergency Caesarean section in Limerick Regional Hospital on February 21st, 2013, after doctors detected potentially severe problems with the pregnancy. The problems detected included a “non-reassuring foetal heart rate” as well as restricted growth while in the uterus.

At birth Amanda weighed just 1.13 kilograms and required oxygen for five minutes before being taken to the hospital’s neo-natal intensive care unit. She was diagnosed with a heart murmur two days later, on February 23rd, 2013 and on March 12th she was transferred to Our Lady’s Children’s Hospital in Dublin, for cardiac assessment.

She was later transferred to the Coombe hospital in a successful attempt to improve her general condition and get her weight up around two kilograms, which would facilitate further cardiac investigation. Doctors then decided it was necessary to send her back to Crumlin to have a line inserted through a large vein into her heart.

Prof Martin White, a consultant with both Our Lady's Hospital and the Coombe, said Amanda was suffering from a complex form of congenital heart disease as well as chronic lung disease which may have been linked to premature birth, among other issues.

He said she was progressing reasonably well, despite a set back in early April, and another on April 16th, when her condition weakened. Prof White said she was stable when she was taken by ambulance on the four minute journey, from the Coombe back to Crumlin on on April 17th.

Dr Cathy McMahon told the court that Amanda had a medical episode in the ambulance in which a tube going to her airways became blocked while in the ambulance.

Pathologist Dr Michael McDermott said “given the gravity of Amanda’s condition prior to transfer, it would not be reasonable to assume that this short episode alone led to the tragic outcome, but clearly this short episode was an additional challenge that contributed to the the tragic outcome that was Amanda’s death”.

He said proposals to co-locate services under a national paediatric hospital would reduce the necessity for inter-hospital transfers “which can be a risk factor”. It would be wrong to assume that “stable for transfer” could mean “stable and well”, he added.

City Coroner Brian Farrell said he was bringing in a verdict of medical misadventure which was a result of multiple organ failure due to necrotising enterocolitis, but he said he wanted to make it plain that "medical misadventure" in no way cast any blame on the medical professionals involved in Amanda's care.

The expression meant simply an unintended outcome of an intended procedure, and was, he said “entirely neutral”.

He said there had been a number of “internal risk factors” including Amanda’s prematurity at birth, a complex congenital heart heart defect, chronic lung disease and “ external risk factors” which included a medical episode on the final transfer. “I am accepting the transfer was an issue so I am leaving it in” he said.