Looking for truth in tragedy

The report on Róisín Ruddle’s death offers answers but is overshadowed by the failures of a system that turned a critically-ill child away, says Catherine Shanahan

ALL things being equal, it is against the natural order for parents to outlive their child. All things being equal, seriously ill patients expect and deserve to be cared for by the health service most pay to provide.

There was little equality in the world Róisín Ruddle arrived into on May 16, 2001, or in the health service she was forced to depend on.

Róisín died, aged two, on July 1, 2003, one day after surgery for a congenital heart defect was deferred at Our Lady's Hospital for Sick Children, Crumlin, Dublin. She had been sent home to Ballingarry, Co Limerick, because of a shortage of paediatric intensive care nurses.

Her distraught parents Helen and Gerard, unhappy with an earlier report into her death by the Eastern Regional Health Authority (ERHA) sought further explanation for their child's death.

Yesterday, more than 18 months after their daughter was buried, an independent panel published its review of the events surrounding her death.

It dismissed the majority of Róisín's parents' concerns.

Why did Róisín not undergo a physical examination prior to discharge? Because, the panel said, "her cardiothoracic surgeon (Mr Freddie Wood) was satisfied that she was fit for discharge, and so discharged her." The panel said Mr Wood informed them Róisín had been admitted in a stable medical condition. Her pre-operative tests, performed on June 25/26, were satisfactory. No new medical problem had arisen after her re-admission on June 29 and it was not considered necessary to carry out any further checks before discharging her home. On this basis, Mr Wood discharged Róisín home on June 30 "as there was no medical reason to keep her in hospital."

Why were the Ruddles not given an alternative date for her surgery, contrary to the ERHA report claim that a date of July 7 had been given?

The panel found a confirmed alternative date for surgery was not given to Mrs Quain-Ruddle before she and her family left the hospital on June 30. However, Mr Wood said he mentioned July 7 to them and the liaison nurse would contact them to confirm. The nurse didn't, because, she said, she heard Róisín had passed away.

In a meeting with the panel on October 14, 2003, the Ruddles asked why they had not been told the night before Róisín was due to undergo surgery that the operation was likely to be cancelled. They said the father of a child who was first on the list for surgery was told on June 29 it was unlikely his child would be operated on because emergencies had come in. Róisín's parents asked if it was apparent on Sunday night, June 29, that Róisín would not be operated on the next day, and if so, was it appropriate that she be prepared for the operation, including being put on an intravenous drip?

The panel said following discussions with medical and surgical staff that it was not until approximately 10.30am on Monday, June 30, that Mr Wood was in a position to decide Róisín's surgery would have to be deferred.

The Ruddles asked if, as Róisín had fasted from the evening of June 29, she or her family ought to have been offered food for her, particularly as she was about to undertake a long car journey home?

The nurse who was particularly responsible for Róisín's care on June 30 told the panel she did offer food two yoghurts for Róisín to Róisín's mother. Mrs Quain-Ruddle told the panel she had to request food for Róisín, as none was offered. The panel said it was not in a position to make a finding as to whether she was or was not offered food.

The Ruddles asked was it appropriate that Róisín undertook a long car journey home after her discharge on June 30?

The panel discussed this with the relevant medical staff, who were of the view that the journey home would not have affected Róisín's physical condition. They told the panel Róisín had undertaken similar journeys to and from the hospital on several occasions without difficulty.

However, the report concluded it was possible that undertaking several car journeys between Our Lady's Hospital and her home may have been detrimental to Róisín's health. It said, however, there was no medical evidence to support this possibility.

The Ruddles asked if the stress associated with Róisín's pre-operative treatment, the cancellation of her operation and two lengthy car journeys had contributed to her death by cardiac arrhythmia.

The medical staff with whom the panel discussed these issues considered it very unlikely that the deferral of Róisín's surgery, her pre-operative treatment or her journey home by car precipitated a cardiac arrhythmia. They believe it is likely Róisín's death was due to an unexpected fatal cardiac arrhythmia associated with her congenital heart defect.

THE family also asked why only Mondays are set aside for elective surgery for children with heart defects.

The panel said the scheduling of the service was necessary as other surgical specialties also require planned access to the intensive care unit.

They asked why seven other cardiac surgical postponements took place in 2003, how late were these postponements and were the patients involved treated any differently from Róisín?

Mr Wood told the panel all seven of the cardiac surgery cases were deferred on the day of the scheduled operation. The operations were rescheduled within the following one to five weeks without any harmful effects. The cases in question were not dealt with any differently to Róisín's case. The panel accepted this response.

Mr Ruddle and Mrs Quain-Ruddle said Dr Paul Oslizlok (consultant cardiologist), speaking to them after Róisín's death, stated that "there won't be any changes, we will continue as before." They took this to mean that Róisín's death would not have an effect on hospital management or procedure.

Dr Oslizlok told the panel his comment was made in response to Róisín's parents saying they hoped the review would have the effect of ensuring that what happened to Róisín would not be allowed to happen again. Dr Oslizlok took this to mean that procedures would be put in place to ensure that a child's cardiac surgery would never again be deferred. He believes he told the Ruddle family that surgical cancellations, although hopefully rare, would always arise and that, given the nature of congenital heart disease, unfortunately there would always be cases of tragic unpredictable sudden death and that the two events may occasionally coincide. Dr Oslizlok said he felt it was necessary to be realistic about what medicine and society could and could not achieve.

There were many other questions, and the answers relating to Róisín's treatment path seem to show her case was one of high priority among staff at Our Lady's Hospital. There was detailed and thoughtful discussion and analysis of what could be done to improve her medical condition and quality of life. If that had been followed through in the surgery proposed, you might not be reading this report today. Whether Róisín would have died anyway is overshadowed by the failures of a system which turned away a critically-ill child.

Main findings

Róisín Ruddle: died after operation deferred because of staff shortage.

Róisín Ruddle was due to undergo a heart operation on June 30, 2003, which was part of a staged strategy in the management of Róisín's cardiac condition.

She underwent the normal pre-operative investigations on June 25/26, 2003, and was discharged, to be re-admitted on June 29 for planned surgery the following day. On June 30, however, her surgery was deferred because there was no staffed intensive care bed available for her post-operatively. Róisín was discharged from the hospital on June 30 and she returned home with her parents. Róisín died at home in the early hours of Tuesday July 1, 2003.

An autopsy indicated that Róisín's death was due to acute cardio-respiratory failure associated with the presumed development of a cardiac arrhythmia.

The report found that, if the procedure had gone ahead as planned on June 30, the likelihood of Róisín's survival would have been greater.

Róisín's parents said the ERHA Report contained some inaccuracies. They also raised a number of questions relating to the clinical care Róisín received in Our Lady's Hospital.

The reason for the deferral of Róisín's surgery on June 30 was that there was no staffed intensive care bed available in the Intensive Care Unit to accommodate her post-operatively.

Our Lady's Hospital has not been in a position to utilise the full complement of beds in ICU because of a shortage of appropriately trained nursing staff

There is, and has been for some time, a worldwide shortage of paediatric ICU nursing staff.

Given the centrality of the ICU to the operation of the hospital as a whole, the report found the shortage of nurses to staff does not appear to have been seen by hospital management at the time as a priority issue.

Although aware of the problems, there is no evidence that hospital management or the Committee of Management gave any active support, other than the approval of financial resources, to help the Director of Nursing to address the recruitment issues

Insufficient focus was placed by Our Lady's Hospital management and the committee of management on the resolution of the staff shortage. As a consequence, there was a lack of urgency in applying and distributing available resources to resolving the problem or at least trying to do so.

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