The official report into the hospital treatment of a two-year-old girl who died after her heart operation was postponed criticises management at Our Lady's Hospital, Crumlin, for failing to properly tackle its shortage of paediatric intensive care nurses.
The report finds that Róisín Ruddle would have had a greater chance of survival had the surgery gone ahead.
Róisín, who was from Limerick, died on July 1st, 2003, the day after her operation was deferred because there was no staffed intensive care bed available.
The official report into her death, which was ordered by the former minister for health, Mr Martin, and is due to be published today, blames management at the hospital for failing to put measures in place to deal with an anticipated shortage of paediatric intensive care nurses.
It also indicates that the Department of Health was aware of the problem for several years.
The expert panel which investigated the case, found hospital management and its governing board (Committee of Management) had placed "insufficient focus" on the nursing shortage and showed a lack of urgency in dealing with the problem. The report says the medical care provided to Róisín was "appropriate", however.
The expert panel found Róisín Ruddle had been diagnosed with a congenital heart defect shortly after her birth in 2001.
As part of a staged strategy for dealing with her cardiac condition, she was scheduled to undergo a procedure known as a "Glenn shunt", which would provide an artificial channel in her heart, on June 30th, 2003. The surgery was deferred, however.
An autopsy found Róisín died as a result of acute respiratory failure associated with the presumed development of a cardiac arrhythmia. "If the Glenn shunt procedure had gone ahead as planned on June 30th it would most likely have improved Róisín's oxygen saturations and this may have reduced the likelihood of an arrhythmia," the report says.
"However the reasons for the occurrence of arrhythmias in patients with congenital heart defects are complex and despite an improvement in oxygen saturation, fatal arrhythmias can occur.
"Nevertheless it is the view of the panel that if Róisín's operation had gone ahead as planned on June 30th the likelihood of her survival would have been greater," it adds.
It says that following changes in nurse education in the mid 1990s it now takes seven years to qualify to work in a paediatric intensive care unit.
This protracted training, disincentives in salaries and allowances, stress and the cost of living in Dublin all contributed to the fall-off in the number of nurses working in the sector, it says. However, it maintains that given the changes in nurse education the "future staff shortages were predictable".
"The panel has seen copies of intra-hospital correspondence and minutes of a meeting between representatives of the hospital and the Department of Health in 1996 where the difficulty of recruiting ICU nurses was alluded to.
"The panel is of the view that the shortage of specialised nurses was predictable from the mid-1990s and that this does not appear to have been seen by management at the time as a priority issue warranting significant management attention.
"Although aware of the problems, there is no evidence that hospital management or the Committee of Management gave any active support, other than approval of financial resources, to helping the Director of Nursing with the problem-solving initiatives that were clearly needed..." the report says.
The report recommends the re-examination of the training period for paediatric intensive care nurses, the appointment of a clinical bed manager at the hospital and continued attempts to recruit such staff from abroad.
