Medical misadventure Verdict Recorded in Death of Lily Daly at Temple Street Hospital

Dublin – A Dublin District Coroner’s Court has returned a verdict of medical misadventure in the death of seven-year-old Lily Daly, who died at Children’s Health ireland (CHI) at Temple Street on Feb. 9, 2019. The inquest revealed critical delays in treating Lily, who suffered from a known brain condition and experienced severe headaches for several hours before her death. the court heard that a swift procedure to drain fluid from Lily’s brain could have potentially saved her life. Lily’s parents, Olivea Maguire and Brian Daly, had previously settled a legal action against the hospital for €168,000.

The inquest into Lily Daly’s death has brought to light a series of events that culminated in a tragic outcome, highlighting the critical importance of timely and appropriate medical intervention, especially in cases involving known pre-existing conditions. The case underscores the challenges faced by medical professionals in balancing diagnostic procedures with immediate treatment needs.

The Events Leading to Lily’s death

Lily Daly, from Ben Edair Road, Stoneybatter, Dublin, had a medical history of hydrocephalus, a condition characterized by an abnormal accumulation of fluid in the brain. This condition made her notably vulnerable to complications arising from increased intracranial pressure.

On the morning of Feb. 8, 2019, Lily was brought to Temple Street Hospital after complaining of headaches and a sore throat as 1 a.m. According to her mother, olivea Maguire, Lily’s condition rapidly deteriorated at the hospital. Ms. Maguire testified that her daughter began vomiting and was “screaming in pain.” Despite informing medical staff about Lily’s history of hydrocephalus, Ms. Maguire stated that this information was not adequately considered by the examining doctors, and the family was not informed about the necessity of an MRI scan.

Ms. Maguire recounted a particularly distressing moment when Lily’s eyes moved in opposite directions, a memory she described as unforgettable. The family experienced further delays when they were initially directed to the wrong entrance for the MRI scan. The scan was eventually carried out approximately 20 minutes later.

During the MRI scan, Ms. Maguire noticed that Lily had stopped breathing. She described the chaotic scene as they “fumbled” to remove her from the equipment. Lily was then rushed to the operating room for emergency surgery to drain the fluid from her brain. Though,the damage was irreparable,and she was pronounced dead the following day.

Despite the tragedy, Ms. Maguire shared a poignant detail: Lily’s kidneys and heart valves were donated to save other lives, a testament to the family’s resilience and generosity in the face of immense grief.

Testimonies and Admissions

Consultant neurosurgeon Darach Crimmins, who had been treating Lily since she was a baby, testified that her death might have been prevented with immediate surgery instead of an MRI scan. On the day Lily was admitted to Temple Street, Prof. Crimmins was performing surgery at Beaumont Hospital but was being briefed on Lily’s condition by his registrar, Ellen O’Brien.

Prof. Crimmins took “full and sole responsibility” for the events that transpired. He expressed deep regret for not instructing Dr. O’Brien to arrange an immediate procedure to drain the fluid from Lily’s brain, especially after Dr. O’Brien called him a second time at 4 p.m.to report that Lily was very sick. He acknowledged that he had not personally seen Lily and had not fully appreciated the concerns raised by his registrar.

I remain deeply sorry that I didn’t make a different decision.
Darach Crimmins, Consultant Neurosurgeon

Prof. Crimmins, visibly emotional during his testimony, stated that he has since ceased all adult practice to focus exclusively on treating children, ensuring that a pediatric neurosurgeon is always available at Temple Street. He further admitted:

I made entirely the wrong decision. I should have had the common sense to say ‘things are not stable.’
Darach Crimmins, Consultant Neurosurgeon

The inquest also heard that Lily was initially classified as a Category 2 patient upon arrival at 11:19 a.m., indicating she should have been seen within 15 minutes. Dr. Ike Okafor, a consultant in emergency medicine, examined Lily 20 minutes later and ordered several tests, including a CT scan. The CT scan, performed at 12:23 p.m., revealed a marginal increase in the ventricles in Lily’s brain compared to a scan from 2011. though, Dr. Okafor stated that he did not consider it an emergency, as there were “no extreme findings.”

Dr. Okafor noted that Lily’s vital signs were “reassuringly close to normal given the severity of the headaches,” which he described as a “mismatch.” He also acknowledged that it would have been preferable if medical notes had accurately reflected the severity of Lily’s headaches.

Dr.O’Brien testified that any patient with hydrocephalus is a cause for concern. She examined lily at 2:25 p.m. and noted that she appeared stable and that the earlier CT scan showed no signs of acute hydrocephalus. Following a consultation with Prof. Crimmins, the plan was to order an MRI scan, even though Dr. O’Brien anticipated that Lily would require surgery later that day due to her condition. she stated that she was certain she was dealing with a sick child who would require intervention.

Dr. O’Brien also mentioned that she could not recall being informed of potential “red flag” signs displayed by Lily, such as vision problems and involuntary urination, but stated that she likely would have noted them if she had been informed.

The Coroner’s Findings and Hospital’s Response

Coroner Myra Cullinane recorded a verdict of medical misadventure, stating that there was evidence that medical staff had not acted in a timely manner to intervene “with the least clinical course.” She noted that a more junior decision-maker was present at Temple Street, while the consultant neurosurgeon was working at Beaumont Hospital. Dr. Cullinane also observed a lack of thorough information sharing among decision-makers regarding Lily’s condition, factors that contributed to her untimely death.

The coroner acknowledged and welcomed a series of changes implemented at the hospital, including the addition of consultants and nursing staff in the emergency department, as well as MRI scanners. Other measures include training on medical record keeping, communications, and the management of increased pressure on the brain in patients.

A representative of Children’s Health Ireland at Temple Street issued an apology and expressed “profound regret” to the Daly family for the “tragic consequences” that occurred while Lily was under the hospital’s care six years ago.

Roger Murray SC, counsel for Lily’s family, stated that they greatly appreciated the hospital’s apology and found some solace in the fact that lessons had been learned, potentially preventing similar fatalities in the future.

Remembering Lily

Olivea Maguire fondly remembered Lily as “an amazing young girl who was very luminous and very sociable.” Her legacy continues through the lives she saved through organ donation, and the changes implemented at temple Street Hospital in response to the circumstances surrounding her death.

Conclusion

The inquest into Lily Daly’s death serves as a stark reminder of the critical importance of timely and coordinated medical care, particularly for patients with pre-existing conditions.The verdict of medical misadventure underscores the need for continuous improvement in communication, decision-making, and resource allocation within healthcare institutions to prevent similar tragedies from occurring in the future. The changes implemented at Temple Street Hospital represent a step forward in ensuring that lessons are learned and that patient safety remains the top priority.