On Valentine’s Day 2019, ten year old, Vivienne Murphy from Mill Street, Cork complained of a sore throat, raised temperature, rash, aches and pains. Her parents were told to alternate between giving Calpol and Nurofen on the advice of South Doc, but they failed to spot that she was suffering from Streptococcus – a bacterial infection that has experienced a recent surge in Ireland.
Vivienne’s parents, Elizabeth and Dermot Murphy, brought her to South Doc, an out of hours surgery, and then to her family GP three times between 14 February and 18 February with deteriorating symptoms. They were sent home with their sick daughter on each occasion without a prescription for antibiotics or a referral to hospital. On 18 February 2019, Vivienne was carried to the doctor’s surgery by her mother as she was in too much pain to walk.
Vivienne’s parents advocated strongly for their young daughter but despite expressing the deepest concerns about the persistence and progression of her symptoms they were reassured by doctors that their daughter was suffering with nothing more than a virus.
Vivienne’s parents took it upon themselves to go with their gut and bring her to A&E at Cork University Hospital around midnight on 19/20 February 2019 where it was recognised that their daughter had signs of sepsis. They believe that valuable time was also lost in administering treatment in CUH.
The Coroner’s court heard evidence that there is no paediatric ICU in Cork and a decision was made by a consultant surgeon to transfer Vivienne to Temple Street Children’s Hospital, Dublin.
Ultimately, following extensive debridement surgery and subsequent complications Vivienne tragically died nine days later surrounded by her family.
The Coroner’s Court heard that Strep A can prove fatal when left untreated.
The Murphy family were emotional and stoic as they listened to and gave evidence over two days at the Dublin District Coroner’s Court in Store Street.
The court heard that their daughter was a happy and healthy little girl who had no other relevant health issues of note. On 14th February 2019 Vivienne went to school as normal but unbeknownst to her and her family and classmates it would be her last day at school.
What Vivienne’s family now know is that Vivenne was suffering from Group A Streptococcus infection which would fail to resolve without antibiotics.
Recording a verdict of death by medical misadventure, coroner Dr Crona Gallagher noted that this was an extremely complex medical case of sepsis and welcomed any efforts to increase awareness in relation to Strep A. She promised to send the findings to the relevant group of medical bodies and to draw their attention to the need for a paediatric ICU in Cork and to the transport issues involved in travelling to Dublin for ICU care.
The Coroner considered the submissions made by Abdulla Morgan Kamber BL instructed by Rachael O’Shaughnessy, Partner with HOMS Assist, who represented the Murphy family in reaching her verdict of medical misadventure.
Rachael O’Shaughnessy, Partner with HOMS Assist, said that “lessons must be learned in relation to the identification and treatment of Strep A and highlighted the need for a paediatric ICU outside of Dublin”.
“Elizabeth and Dermot Murphy and their eldest daughter, Caroline, and son, Steven, do not want any other family to live the nightmare that they have been living and with which they will have to live with for the rest of their lives. The Murphy family wish to thank the Coroner’s Court for its time and welcome the Coroner’s findings but are also aware there is no assurance that the recommendations will be implemented. The Murphy family have suffered immeasurable grief and heartbreak from the loss of their beautiful daughter Vivienne and hope that today’s recommendations could prevent this unnecessary tragedy from happening to another family.”
Inquest Proceedings at Dublin Coroner’s Court
The inquest into the death of Vivienne Murphy was held at the Dublin District Coroner’s Court, located at Store Street, Dublin. This court is one of the busiest in the country, known for its thorough and compassionate handling of cases. Presiding over the inquest was Dr. Cróna Gallagher, a highly respected coroner with extensive experience in such matters. The court’s facilities are designed to provide a comfortable and respectful environment for families and witnesses, ensuring that those attending inquests receive the support they need during these difficult times.
Investigation and Recommendations
The inquest heard evidence from over a dozen witnesses, including medical staff from Beaumont Hospital and the Midland Regional Hospital in Mullingar. The investigation revealed a series of failures and shortcomings in the care of Vivienne Murphy, including a fundamental breakdown in communication between staff at the two hospitals. Dr. Gallagher recommended that the Midland Regional Hospital carry out a review of its on-call arrangements to ensure that staff know who to contact in emergency situations. Additionally, she emphasized the importance of listening to nurses and specialists to prevent similar incidents in the future. These recommendations are crucial steps towards improving patient care and preventing such tragedies from recurring.
Family’s Response and Next Steps
Vivienne’s family welcomed the verdict, acknowledging the long and arduous process they endured to get answers about their daughter’s death. They called for the hospital to review its on-call arrangements to prevent similar incidents in the future. Vivienne’s father also advocated for additional on-call staff to be made available in hospitals over weekends. The family expressed their intention to take further action regarding the circumstances of their daughter’s death, including lodging complaints with the Medical Council. Their hope is that these steps will lead to meaningful changes in the healthcare system, ensuring that no other family has to endure the same heartbreak.
Conclusion
The inquest into the death of Vivienne Murphy underscores the critical importance of effective communication and collaboration among medical staff in emergency situations. The coroner’s recommendations for a review of on-call arrangements and improved communication between staff are essential measures to prevent similar incidents in the future. The Dublin District Coroner’s Court, led by Senior Coroner Dr. Myra Cullinane, plays a vital role in investigating deaths and providing support to families. The court’s expansion, including the opening of new courts at the Richmond Education Centre, will enable the Coroner’s Service to hold more inquests annually, thereby supporting the thorough investigation of deaths in Dublin.