Verdict of medical misadventure recorded in death of teen Niamh McNally at UHL

David Raleigh

A coroner has returned a verdict of “medical misadventure” in the death of a 16-year-old girl at University Hospital Limerick (UHL).

The inquest into the death of Niamh McNally, Ardykeohane, Bruff, Co Limerick, on January 29th, 2024, heard there were “so many missed opportunities” in her care at UHL.

Niamh died of “asphyxiation”, after suffering cardiac arrest, having suffered a “pulmonary haemorrhage which most likely resulted from an erosion of a collateral artery into the respiratory tract”, a post-mortem found.

Niamh attended UHL on January 9th gasping for breath and coughing up blood. The hospital was aware she had a history of congenital heart disease.

A battery of tests followed, but her family argued these were not focused enough on her cardiac history, and, although her condition improved and she was discharged from UHL 14 days later on January 23, Niamh was still coughing up blood.

Six days later, on January 29th, with her symptoms persisting, Niamh was readmitted to UHL, where she was pronounced dead later that day.

Damian Tansey, senior counsel for the McNally family, told the inquest that Niamh had been continuously coughing up “a massive amount of blood, her bedsheets were soaked with blood”.

Heart defect

Despite UHL’s awareness that Niamh had been born with scoliosis and a congenital heart defect, for which she had undergone three surgeries in the years prior to attending UHL that January, her treatment at the Limerick hospital had not been focused enough on her heart, Mr Tansey said.

“There were numerous missed opportunities, and had they not been missed, we wouldn’t be here — and a letter of apology (from the HSE) confirms that,” Mr Tansey told Limerick Coroner’s Court.

Niamh’s mother, Carolyn O’Neill, said prior to her daughter’s death, blood was spilling out of her mouth, but she said her concerns for her daughter were not heard: “Nobody listened to me in UHL, and that is heartbreaking.”

Breaking down while giving her evidence to the court, Ms O’Neill told how moments before Niamh went into cardiac arrest, her ailing daughter looked at her and said: “Mammy, I can’t breathe”.

Apology

A letter unreserved apology from the HSE was read out at the opening of the two-day inquest, which concluded on Thursday.

The HSE letter, to Ms O’Neill, stated: “We acknowledge the devastating consequences that this has had on both you and your extended family.”

“We sincerely regret the opportunities that were missed to intervene.”

“We accept that these failings, which ultimately led to Niamh's tragic death, should not have happened.”

“On behalf of the management and staff of the University Hospital Limerick, we wish to apologise unreservedly for these failings,” the letter added.

The HSE letter commented that it was “committed to learning from this tragedy and to implementing any necessary changes to prevent similar incidents in the future”.

However, Mr Tansey, citing several inquests into patient deaths at UHL in recent times, for which he had acted for families, said it appeared lessons were not learned by the hospital.

Lessons not learned

Mr Tansey said: “This is like a Shakespearean tragedy, and to quote Hamlet - ‘Something is rotten in the state of Denmark’ — Something is very wrong in UHL”.

“This is the third time in a little over a year that I have appeared before this court in relation to UHL, and it seems that no lessons have been learned,” Mr Tansey said.

Speaking afterwards, Carolyn O’Neill said: “I wish no other family will have to go through what Niamh experienced inside UHL. The inquest findings were horrendous.”

“There were missed opportunities, and if they had actually acted upon and done a proper cardiology check-up on Niamh, she would be alive today.”

Ms O’Neill, whose husband died prior to her daughter’s death, said she hoped the HSE would take on board fifteen recommendations arising out of an independent review of Niamh’s case, which the coroner, John McNamara, attached as a rider to the verdict.

Paying a tearful tribute to her only daughter, Niamh, she said: “Niamh was a lovely girl, she was just coming into her own, she was turning into a beautiful woman, and she was so stable until (in UHL).”

“She loved everything, she was such a fighter, she was fantastic, she had such a beautiful group of friends, and while it was hard, she never let her disability get in the way.”

Mr Tansey told the inquest that when Niamh was first admitted to UHL on January 9th, her admissions team recommended that she be referred to the hospital’s cardiology department, but, he said, “the first time there is any cardiology involved is on the 18th of January - a full nine days later”.

When cardiology checks were eventually conducted, they were “so narrow” that they were “utterly ineffective”.

An “echo” scan of Niamh’s heart took place on January 11th; it did not include her medical history, but it also did not indicate a cause for her condition. The patient’s medical history was included in a report of the scan.

A “BNP blood test”, used to diagnose heart failure, was conducted, but it too did not indicate the cause of Niamh coughing up blood.

A bronchoscopy and chest x-ray, used to examine the airways and lungs, also did not provide answers.

“There was still no change in her treatment plan on discharge; there was no reassessment in respect of Niamh, none whatsoever,” added Mr Tansey.

Mr Tansey called on Coroner John McNamara to return a verdict of medical misadventure. He said it was “clear” that UHL “didn't intend for Niamh to die, but she did die”.

Simon Mills, senior counsel for the HSE, told the coroner that, in determining his verdict, he could not consider the outcomes of previous inquests he had adjudicated, in respect of other patient deaths at UHL: “They must be put far from your mind”.

Mr Mills suggested the threshold for ‘medical misadventure’ had not been reached, and that the correct verdict was a “narrative verdict”.

Mr Mills argued that it was clear from the evidence that Niamh McNally had received a multidisciplinary care plan, including an echo, a BNP, and a CT Thorax, which included a scan of her heart, and that her “underlying condition” went “undetected”.

He said Niamh’s symptoms and markers for infection had reduced when she was discharged from UHL on January 23, six days prior to her being readmitted and dying there.

Returning a verdict of medical misadventure, the coroner extended his “deepest condolences” to Ms McNally’s mother, grandfather, uncle, and friend, who were in attendance.

Mr McNamara said Niamh’s death was a “profound tragedy” and he paid tribute to her family’s “dignity” throughout the inquest.

He said the inquest did not assign blame nor did it apportion liability, and that Niamh’s death was “clearly unintended”.

“Losing a child is obviously the deepest of tragedies. I am sure Niamh’s memory will live on through her family.”