Death by medical misadventure ruling in Baby Luke's case
County Coroner makes a number of recommendations to prevent against another 'terrible catastrophe'
A verdict of death by medical misadventure has been returned at the inquest into the death of an infant at Cavan General Hospital more than two years ago.
Baby Luke Kelly passed away at the local hospital facility on July 5, 2023, having developed pneumonia and despite having overcome open heart surgery weeks earlier. He was just weeks shy of his first birthday.
The County Coroner, Dr Mary Flanagan, said the “only option available” was to return a verdict of medical misadventure in the case.
The inquest was heard over two days - Wednesday and Thursday - at Cavan Courthouse.
Dr Mary Flanagan also made a series of recommendations for communications between super hospitals like Crumlin Children's Hospital in Dublin and “country” hospitals like Cavan General Hospital to ensure a similar “terrible catastrophe” that led to the death of the 11 month old from Shantemon never happens again.
Through their legal representative, Luke’s parents - Helena Lyons and Barry Kelly - said they are “very grateful” for the letter of apology they received from the management of Cavan General Hospital at the start of the two-day inquest yesterday (Wednesday).
In it they admitted “shortcomings in the care” given to Baby Luke in the days leading up to his death.
In his summary to the inquest, solicitor for Luke’s family, Roger Murray, said there was no dispute that the medical cause of Luke’s death was pneumonia but an act or omission of act transpired to be the real cause of death.
“System failures led to Luke’s death," Roger Murray said.
“The verdict here today is not to punish anyone or establish civil or criminal liability," he added.
Over the two-day proceedings the inquest heard depositions and evidence from six nurses and various doctors from Cavan General Hospital involved in the care of Luke Kelly over three days until his death in July 5, 2023.
* More to follow *
At the outset of the inquest, the management and staff at Cavan General Hospital have apologised for "shortcomings in the care" received by Luke, who was born with a congenital heart defect.
The apology was read into the record on behalf of the hospital.
It reads as follows:
"On behalf of management and staff at Cavan General Hospital, I wish to offer my deepest condolences to you both and to your extended family following the death of your dear son Luke.
"I would like to extend my sincere apologies for the shortcomings in the care that your son received in Cavan General Hospital. We acknowledge that the experience was devastating for you and understand that this apology cannot negate the deep effect the loss of your son has had on your lives or in any way make up for this tragic loss.
"I wish to reassure your family that the hospital strives at all times to optimise patient care and that we will continue to ensure the best practice is at the forefront of our clinical service to all patients."
The apology was issued in the name of Laura Waters, Acting General Manager for the Cavan and Monaghan Hospital Group.
On Tuesday, prior to the inquest, Luke's parents also issued a statement in which they thanked their family, friends and colleagues who had supported them over the past few years since Luke's death.
"This is any parent’s worst nightmare and we live in the depths of heart break and pain every day since we lost our warrior son, Luke," said Helena and Barry.
"Our son Luke was born with a congenital heart defect and from his very first day he showed strength, courage and resilience. Luke was the most placid, smiley child whom we all adored from the day he was born."
The parents said that Luke needed a lot of medical interventions in care but the doctors in Crumlin were "very hopeful for his future".
"We were so happy that he had overcome everything that was thrown at him," his parents said.
They described Luke as "incredibly strong and brave".
"He had such a gentle personality and nature about him. He never complained. He barely ever cried and was so, so strong. Every operation and virus and hospital stay was so hard on him, but he made his way back to us at home in Cavan every time. His siblings and family adored him and we all looked forward to our future together," said Helena and Barry.
They say they have been in the "depths of grief" since his passing on July 5, 2023.
"We feel extremely let down about Luke’s care and death and we feel angry because we trusted the medical professionals," said the family.
They say that, six weeks after open heart surgery, they were not informed that Luke had pneumonia.
"We feel that Luke’s death could have been prevented, and we will never be the same family ever again. We miss him every single minute of every day. We are angry that this has happened to our very precious little warrior who fought, time and time again, to come home to us. We are so proud of him."
Helena and Barry have noted the apology from the hospital but believe this should never have happened.
"We expect and hope that they have learned from this tragedy. There needs to be continuous improvement in children’s care in Cavan General Hospital and that should be Luke Kelly’s legacy. We want this to never happen to another family.
"Luke’s death, we say, could have been prevented - he deserved so much more."
Helena Lyons and Barry Kelly also thanked their solicitor Roger Murray and the staff at Callan & Tansey for all their "advice, direction and professionalism".
* More to follow *