Baby deteriorated during four-minute transfer between hospitals

A baby who deteriorated during a four-minute transfer between Dublin hospitals died two days later, an inquest heard.

Nine-week-old Amanda Glazer of Corbally, Co Limerick, was considered stable for transfer when she left the Coombe Hospital on April 17 last year to go to Our Lady’s Children’s Hospital, Crumlin (OLCHC), but was in a critical condition on arrival. As doctors resuscitated her, they found the endotracheal tube through which she was being ventilated had become blocked.

She died two days later as a result of necrotising enterocolitis (NEC), a condition where portions of the bowel suffer tissue death.

Pathologist Dr Michael McDermott told Dublin Coroner’s Court she had predisposing factors for NEC but the collapse during transfer was a “significant additional challenge” that “likely contributed” to the condition’s evolution.

When born, Amanda was underweight, had chronic lung disease, and had a congenital heart defect which meant doctors had to maintain her circulation using Prostin. On March 12, she was transferred from Mid-Western Regional Hospital, Limerick, to OLCHC for cardiac assessment. Eight days later, she was moved to the Coombe with a view to increasing her weight. The Prostin was being delivered via a peripherally inserted central catheter (PICC).

The inquest heard from Prof Martin White of the Coombe that the line was removed on April 14 and transfer to OLCHC for the insertion of a central line was requested. No beds were available on April 15 and the transfer was delayed until April 17 due to the baby’s condition.

Upon arrival at OLCHC she had unrecordable oxygen levels. Her endotracheal tube was changed and she was ventilated. However, she developed multi-organ failure and later died.

Dr McDermott said Prof White and his team had demonstrated that the transfer was necessary.

Coroner Dr Brian Farrell said risk factors in the death included the condition at birth, problems with the PICC line, and the collapse on transfer. He returned a verdict of medical misadventure, emphasising that it carried no connotations of blame or wrongdoing.


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