Inquiry finds serious failings in treatment of baby Adam

ADAM O’Connor was born a healthy nine pounds six ounces at Cork University Maternity Hospital on November 10, 2008.

When the Mallow infant became ill that Christmas, doctors told his anxious parents, Tom and Julie, that the little boy was suffering from colic and constipation.

Within weeks he was dead from leukaemia.

An investigation into baby Adam’s care has uncovered a number of unacceptable factors in the little boy’s treatment.

Senior doctors who might have picked up on key signs did not see him, important symptoms were missed and there was poor communication between the various health bodies that took part in his care.

Adam’s problems first became clear to his parents five weeks after his birth as he was constantly issuing piercing cries.

After visits and phone calls with a number of health providers, they were still being given the impression colic and constipation were causing the distressing symptoms.

He even attended the emergency department in CUH on January 4, 2009.

By February 14, it was clear to his parents he was very sick. They contacted the emergency department and were put through to the paediatric unit where nurses and the paediatric registrar advised them to bring him in to hospital.

Once there they asked to see the registrar, but his admission was recorded as a self-referral and he was seen by an emergency department Senior House Officer. The more senior doctor did not see the patient and the little boy was discharged.

The following day, his parents brought Adam to Mallow General Hospital who referred him back to the paediatricians at CUH. He was rushed there by ambulance. Two days later he was dead.

A review was ordered by CUH chief executive Tony McNamara following media coverage of the parents’ concerns about Adam’s treatment. The expert review team identified a variety of deficiencies in the care.

On February 14, 2009, Adam had an abnormal heart rate that “required further assessment, yet that did not happen. He should also have been physically seen by a senior doctor not just an SHO.

“It would have been reasonable for Baby Adam to be reviewed by a member of the paediatric team as he was re-presenting to CUH with an unresolving problem, his heart rate was elevated and the registrar had advised the family to attend the hospital,” the team said in its report that was obtained by TV3.

In spite of being rushed back to CUH the next day with Mallow General Hospital requesting he be seen by the paediatric team, there was a delay in that team seeing him.

Finally, in spite of being seen by various health bodies, the review team found that his overall care was “fragmented between the services” and communications between all the services was “unstructured”.

Adam’s mother Julie said yesterday that they were treated like they were “just another number”.

“The fact that Adam was lying in our arms, he was half-limp, he wasn’t responding, it didn’t even make them blink.”

She told how she had witnessed blood in the little boy’s vomit but still the problem was not being taken seriously enough. “The HSE, when we met the representatives, they said there was a catalogue of errors and they failed him at every turn from the moment we had contact with the HSE to the moment of diagnosis.”