The jury at an inquest into the death of a toddler who fell from an upstairs window has urged the HSE to immediately publish the findings of an external review into the handling of the 999 call after the accident.
The jury also urged all families to review the safety of windows in their homes after hearing how two-year-old Vakaris Martinaitis fell to his death in Midleton, Co Cork, last May from a bedroom window with no locking mechanism.
They returned a verdict of accidental death after hearing a second day of evidence at Cork City Coroner’s Court in relation to the toddler’s death at Cork University Hospital on May 8 last, two days after his fall at the family home in The Paddocks, Castleredmond.
Assistant state pathologist Dr Margot Bolster said Vakaris died from a combination of the brain injuries, brain swelling, and catastrophic haemorrhaging.
The inquest previously heard that Vakaris’ father, Vidas, was in the sitting room around 1pm as his son and daughter, Agneta, 8, played upstairs.
The inquest heard yesterday that in an interview with two specialist Garda interviewers, Agneta said she saw her brother fall out the window.
Neighbour Kevin Hennessy dialled 999. The inquest previously heard that based on the information passed to him by Mr Hennessy, ambulance controller Richard Walsh “genuinely thought the child had suffered a simple fall” and did not think it was life-threatening.
An available ambulance in Cork City, 18 minutes away, was assigned to respond. But it was not dispatched once the controller, acting on the information he had, advised Mr Hennessy to take the child to the SouthDoc GP service in Midleton.
There was no direct communication link between ambulance control and SouthDoc and the GP service was not expecting the injured child.
Mr Hennessy subsequently had to rush the child in his own car, under Garda escort, to CUH, where he died on May 8.
HSE solicitor Diarmuid Cunningham said a comprehensive review has been undertaken by a team of experts in pre-hospital emergency care and primary care from both Ireland and Britain. It includes recommendations which he said are in the process of being implemented.
It has not been published because of the coronial process, he added.
However, it is expected to deal with issues around language barriers during 999 calls and the referral relationship between the ambulance service and the out-of-hours GP service.
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