Report into Cork toddler's death finds ambulance staff deviated from procedure

The review team which was set up following the death of Vakaris Martinaitis in East Cork earlier this year also found that while ambulance control staff acted in good faith by standing down an available ambulance, they deviated from ambulance control procedure.

It resulted in failure to appropriately assess the child's condition at the scene of an accident, and failure to provide post-dispatch advice to the 999 caller.

Another deviation from dispatch standards resulted in a decision not to dispatch an ambulance that was not based on correct and complete information.

Vakaris fell to his death in Midleton, Co Cork, last May from a first-storey bedroom window which had no locking mechanism.

He died at Cork University Hospital on May 8 last, two days after the fall at the family home in The Paddocks, Castleredmond.

He suffered devastating brain injuries and died from a combination of the brain injuries, brain swelling and catastrophic haemorrhaging.

When it emerged that an available ambulance was not sent to help the child, the HSE established an independent review team to examine the handling of the 999 call.

It published its findings this morning just over a week after an inquest returned a verdict of accidental death in the case, and the jury recommended that the findings be published immediately.

The 54-page report contains 12 recommendations around improvements or changes to various policies and procedures governing the operation of ambulance control centres, and on continued training and education for national ambulance service staff.

The key recommendation is that ambulance control procedures should be amended to give higher priority to a 999 call where there is limited information available or when the person involved in the incident does not speak English.

The team recommended that the practice of combined roles for ambulance control call takers and call dispatchers should cease in all ambulance control centres.

It also said ambulance control room staff should not routinely refer 999 callers to a GP out of hours service without prior consultation with the GP service.

"Everyone we have spoken to during this review has been deeply affected by this tragic incident," the chair of the review team, Dr David McManus said.

"I would, once again, extend our sincerest condolences and sympathy to the family at this very difficult time."

He said nobody expects or anticipates a medical emergency but knowing urgent medical care is available when and where we need it provides both comfort and reassurance.

"Therefore the public deserve a response that is appropriate, effective, efficient and reliable," he said.

"It is our responsibility as a review team to ensure we learn from the experience of this family and continue to improve services."