Baby's death exposed 'systemic failure' of HSE - IPA

The Irish Patients' Association (IPA) has said the inquest into the death of baby Luke Kelly has exposed not just individual shortcomings in the health service but "a deeper systemic failure".

It comes after a verdict of medical misadventure was returned by the coroner for Co Cavan, Dr Mary Flanagan, after hearing two days of evidence.

Dr Flanagan said this evidence was reflective of the "admitted and acknowledged" deficiencies in management that had been identified at Cavan General Hospital.

The inquest into the death of the 12-month-old boy, who was in the care of Cavan General Hospital at the time, had heard that he went 18 hours without a physical examination by a consultant despite his condition deteriorating.

The IPA has said the courage of Luke's parents, Barry Kelly and Helena Lyons from Shantemon, Co Cavan, "in speaking publicly, even in the face of profound loss, must now become the catalyst for change".

The IPA also said the absence of a formal afternoon handover in a paediatric unit caring for medically complex children contravenes HSE clinical guidelines.

It also said that HIQA's National Standards for Safer Better Healthcare demand safe transitions of care and effective communication at every point.

IPA chairperson Stephen McMahon said: "These are not optional extras; they are basic safeguards."

He said: "Luke went 18 hours without consultant review as his condition deteriorated - a gap that coincided with a missing handover.

"This is precisely the kind of preventable risk these standards were designed to eliminate. International studies repeatedly show that informal or inconsistent handovers, interruptions, and weak escalation processes contribute to avoidable harm."

Mr McMahon added: "Every patient in Ireland has the right to continuous, coordinated care.

"We call on the Minister for Health, HIQA and the HSE to urgently investigate how this governance gap persisted, audit handover compliance nationally, and ensure every transfer of responsibility is subject to scrutiny.

"Only then can Luke's death drive the change his family deserves as his grieving family have said: We expect and hope that they have learned from their mistakes. We want this to never happen to another family," he added.

Meanwhile, in an updated statement, a spokesperson for Cavan and Monaghan Hospital said: "A review was undertaken in relation to this matter, and all recommendations arising from that review have been fully implemented by the hospital."

The spokesperson also said: "Cavan and Monaghan Hospital extends its deepest sympathies and sincere condolences to the family on the passing of Luke.

"We recognise that this has been an immensely painful and devastating experience for them, and we understand that no words or apology can lessen the profound grief and loss they have endured."

The hospital continues to be available to offer support to the family, the spokesperson added.