A three month old baby died from complications after getting eye surgery at University Hospital Galway and inquest has heard.
Jonathan Borges Gonclaves was born prematurely at 25 weeks in February 2016.
At birth he was diagnosed with an eye condition known as retinopathy of prematurity, which can cause visual impairment.
The condition is treatable with laser eye surgery, which is what happened here.
But during the procedure Jonathan Borges Gonclaves suffered oxygen deprivation, causing permanent brain damage.
He died one week after the procedure was carried out.
According to RTÉ, the inquest was told that one of the machines to monitor his oxygen levels had been inadvertently left off before the surgery.
While the procedure was taking place, it was not noticed that he was suffering a drop in oxygen levels.
An MRI carried out the next day found irreparable damage to Jonathan’s brain.
The HSE has apologised for Jonathan’s death to his parents, who had nothing to say as they left the court.
The surgery
Dr Donough O’Donovan, Consultant Neonatologist at UHG, detailed for the inquest how the surgery was carried out.
Jonathan had been sedated beforehand and fitted with a nasal tube to give him oxygen if he needed it.
In the theatre were the eye surgeon Dr Eamon O’Donoghue, neonatal nurse Maureen Sweeney, and theatre nurse Philomen Laurence.
Dr O’Donovan told Galway West Coroner Dr Kieran McLoughlin that concerns were raised when the baby remained unresponsive for hours after the surgery.
It was only when the MRI was carried out the following day that the extent of the problem became clear, he said.
Concerns were raised in the inquest about staffing and the workload placed on nurses.
Dr O’Donovan admitted it could have helped to have more people in the theatre monitoring the baby’s vitals.
Nurse Sweeney gave evidence that she was preparing the room, and administering eye drops to baby Jonathan before they began.
She said she forgot to turn on the ‘Nellcor’ oxygen monitor because she became distracted when the baby’s eyes weren’t dilating properly.
If something went wrong, the ‘Nellcor’ monitor is the one she would rely on, she said.
According to Nurse Sweeney, the alarm on the connected monitor was sounding continuously during the surgery.
But she said she only became concerned afterwards when the theatre lights were turned back on.
Dr O’Donoghue and Nurse Philomen both contested her evidence of a persistent alarm, saying they had no recollection of one.
Giving evidence, Dr O’Donoghue said he asked Nurse Sweeney if the baby was alright at least 30 times, and each time she said he was.
The doctor said he would have stopped working immediately if there was a continual alarm going off, but left the theatre thinking things had gone well.
An external review of the death was carried out for the HSE, parts of which was contested by the hospital.
Dr O’Donovan disputed claims in the review that a head cooling technique would have been beneficial, or that there was a treatment that could have changed what happened.
The HSE refused to give the Coroner Dr McLoughlin a copy of the external when he asked, saying they did not provide this material to coroners.
Counsel for the HSE Oonagh McCrann said it was the state’s position that reviews should not form part of a coroner’s inquest in certain cases.
She added that the review was highly contentious and numerous part of it were being contested.
Dr McLoughlin said he was surprised at the HSE’s decision, but was glad that the family’s legal team were able to get a copy of the review.
Since the time of this incident University Hospital Galway has implemented changes to improve the monitoring of vitals.
It has also stopped carrying out laser eye surgery on infants.
