THE CORONER AT the inquest into the death of six-year-old Tristan Neiland has returned a narrative verdict.
The child from Cabinteely, Dublin 18, had a number of health issues and was in weekend respite care when he was found unresponsive by staff.
Speaking after the inquest, Tristan’s mother Angela Neiland welcomed the verdict.
“We note that Tristan’s death and the circumstances surrounding it has resulted in changes being made in the Carmona Services. In that context Tristan’s death has not been in vain,” she said.
“I miss him. Every single day,” she said.
A narrative verdict is one which records the factual circumstances of a death. The Coroner will set out the circumstances of the death in a detailed way based on the evidence he/she has heard. This verdict gives more of a detailed conclusion of events leading to the death is provided by way of the shorter inquest verdicts.
Tristan, who suffered from epilepsy, asthma and global development delay, went to Carmona Special National School in Dún Laoghaire which caters for pupils with special needs. Separately, he had been staying at the St John of God Carmona Respite Service. He was in respite there on 5 January 2013.*
His mother told Dublin Coroner’s Court that her son suffered from seizures, mostly at night and in the early morning. Neiland said her son could not breathe during a seizure and needed oxygen at the onset, she said.
The mother said she understood her son would be constantly monitored using a sats monitor, which measures oxygen saturation levels. She brought the sats monitor to the Carmona centre and left clear instructions for its use. She told staff the sats monitor should only be attached once her son was deeply asleep as it could otherwise disturb him.
“My understanding was he would be constantly monitored. His seizures generally last from three to five minutes. If any longer than seven minutes it becomes a medical emergency and an ambulance must be called,” Neiland said.
Staff at the facility put Tristan to bed at 8.30pm on 5 January 2013. He was due to be checked every 15 minutes. Tristan was checked approximately five times between 9pm and approximately 11pm. There was a baby monitor in his room and the door was left slightly open. There was no sats monitor attached to him because staff were of the opinion Tristan was not deeply asleep, the inquest heard.
When a staff member checked on Tristan shortly before 11pm he was found unresponsive.
A nurse immediately began cardio-pulmonary resuscitation and an ambulance was called.
Tristan was rushed Our Lady’s Children’s Hospital in Crumlin where he was pronounced dead the following day.
Pathologist Dr Maureen O’Sullivan gave the cause of death as sudden, unexplained death in epilepsy.
St John of God community services apologised to the Neiland family for the shortcomings in Tristan’s care and outlined a number of changes made at the facility since the child’s death.
Following a full systems review, the centre no longer accepts children with “high medical needs” and individual care plans with risk assessments for each child are now conducted, along with more stringent staff training.
Returning a narrative verdict, Coroner Dr Myra Cullinane endorsed the changes that have been implemented at the Carmona centre since Tristan’s death.
*This article was amended for clarity. The Carmona Special National School in Dún Laoghaire is funded by the Department of Education & Skills.
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