Witnesses only contacted last week about Temple Street death

A report on the death of a child at Temple Street Children’s Hospital that was supposed to be finished this February is yet to be completed, with hospital staff who cared for the child only asked last week to submit witness statements.

Though the report was commissioned a year ago, staff were asked to submit “personal recollections” just more than a month after media reports on Dollceanna Carter’s family’s struggles to get answers about their daughter’s death.

The Ditch first reported in September this year that unlicensed non-medical grade springs were implanted in child patients at Temple Street, which led to the announcement of several internal and external reviews into patient care at the hospital.

Only contacted last Thursday

Dollceanna Carter from county Meath died on 29 September, 2022, following complications from spinal surgery she underwent at Temple Street.

Less than a week after The Ditch published details of the unlicensed implant scandal at Temple Street, RTÉ reported that Dolceanna’s parents were still seeking answers from Children’s Health Ireland (CHI), which runs the hospital, more than one year after her death.

“We know now she didn’t need the operation and if she didn’t have it she would be outside now playing away with her friends. We also want to know if our child… had the springs put in. There is so much we haven’t been told. We want all the answers. We want 100 percent transparency,” said Dollceanna’s father Michael Carter in an interview with the Irish Mirror.

Medical staff, including senior doctors, who cared for Dollceanna were contacted by a CHI internal review team last Thursday.

Internal documents obtained by The Ditch show that they were each asked to give a “personal recollection” of their involvement in her care.

In letters sent last week, CHI told these staff members that a review of Dollceanna’s death was commissioned on 18 October, 2022.

“As part of the review process,” reads the letter from CHI incident management dated 26 October, “I am writing to invite you to provide the review team with a written personal recollection of your involvement in patient Dollceanna’s care. Personal recollections are records relating to what you did and how you felt at the time and should not include subjective information in relation to other people.”

Staff have been instructed to return their personal recollection statement by 9 November or “it will be taken that no response will be shared with the review panel,” according to the correspondence.

Though the document setting out the terms of reference into Dollceanna’s treatment at Temple Street states that the review was “commissioned by the chief executive officer '' on “18 October 2022”, it appears to have only been finalised last month.

The bottom left of the three-page document titled “SIRG Terms of Reference SIRG TS.10.22” contains the text “Version 2 October 2023”, even though the CEO had ordered the review a year earlier.

“These are the terms of reference for a comprehensive review into the death of Patient X following a prolonged hospital stay on 29 September, 2022,” it is stated in the introduction section of the document.

CHI also sets out the scope of the investigation and the timeframe for its completion.

“The scope of the review will include the timeframe from the time of the multi-disciplinary team pre-assessment meeting 6-8 weeks prior to the surgery, to the time of death,” according to the terms of reference.

It is also claimed in the document that “the review will commence on 30 November, 2022 and will be expected to last for a period no longer than 90 calendar days”.

Despite suggesting the report would conclude by the end of February this year, it remains unclear why staff are only being asked in recent days to give statements to the review panel.

The review team is being chaired by Crumlin Children’s Hospital surgeon David Moore, head of orthopaedics at CHI. The review team’s other five members all work at CHI hospitals, including two consultants based at Temple Street.

CHI declined to comment.