External pressure, “system failures” and “human factors” contributed to the death of a 10-year-old Temple Street patient who underwent repeat surgeries at the hospital – according to a “private and confidential” Children’s Health Ireland (CHI) internal report.
The review into the death of Dollceanna Carter, who lived with spina bifida and who died in September 2022, concluded there were “major” issues with Dollceana’s care – with external pressure to clear hospital waiting lists being a factor in her death.
The review also found that Dollceana’s parents maintained “they were not fully aware of the potential for complications and adverse outcomes” and that there was “no indication in the medical record” they’d had been appropriately informed of risks.
The report concluded a different approach in care would’ve probably resulted in a different outcome for Dollceana.
“A different plan and/or delivery of care would, on the balance of probability, have been expected to result in a more favourable outcome, for example systemic factors were considered to have an adverse and causal influence on the outcome.”
The Ditch first reported the use of unlicensed, non-medical implants on patients, including Dollceanna, at Temple Street in September 2023. Though the CHI review into her death was supposed to be completed in February 2023 the report was only delivered to staff last summer.
The Ditch followed its reporting on unlicensed implants with a series of stories on unnecessary surgeries at a CHI hospital. Late last year, after multiple resignations at CHI, government agreed to a statutory inquiry into child spinal care.
'They were not fully aware of the potential for complications and adverse outcomes'
Dollceanna Carter died at Temple Street on September 29, 2022 after suffering multi-organ failure caused by sepsis. She had been receiving intensive treatment at the hospital for spina bifida and in the last months of her life had faced repeat surgeries because of care failures and complications.
In October 2022 then Children’s Health Ireland chief executive Eilísh Hardiman commissioned a report on Dollceanna’s death. The report was delivered to staff on 27 May last year.
Though the report panel apologised to the Carter family for the two-year delay, it isn’t clear if CHI has made progress implementing the report's recommendations – which had an eight-week deadline.
Many senior staff members only got access to the report within the last week.
The Ditch obtained a copy.
“It is the opinion of the review panel that a number of system failures in conjunction with human factors contributed to the adverse outcome in the present case,” reads the report.
One of these failures was “external pressures” placed on Temple Street to clear a backlog of cases.
“This complex surgery, which is very resource intensive and prone to complications, was carried out in an environment where there was a backlog of numerous similar cases,” the report reads.
“There was significant pressure on surgeon X to do these cases because of the external pressures placed on the hospital. This surgery is even more risky when there is an open wound initially,” it reads.
The report also questioned whether Dollceana’s parents gave their full consent. “Feedback from Dollceanna’s parents indicates they did not request the surgery and felt under pressure to agree to the surgery,” reads the report.
“Consultant X”, according to the report, “outlined multiple meetings with the family to discuss the surgery with consent being signed on the day of the surgery.”
“Dollceanna’s parents”, however, “maintain that they were not fully aware of the potential for complications and adverse outcomes,” it reads.
Though “it is possible that long discussions were had with the parents regarding the significant risks of such major surgery,” the report found, “there is no indication in the medical record that this was the case.”
The report recommended, “CHI conduct an audit in relation to compliance with the HSE National Consent Policy (2022 updated 2024) and put in place a plan to address any deficits identified”.
Among other “major system of care/service issues” was the failure to put together a multidisciplinary team of medical practitioners.
This would’ve included plastic surgeons and infectious disease specialists who could have managed the complications that ultimately led to Dollceanna’s death,
The review panel didn’t find evidence of such a team meeting or “the use of standardised clinical protocol for decision making in relation to pre-operative care requirements”.
Concern had previously been expressed within the hospital about the failure to involve plastic surgeons in Dollceanna’s care despite the persistence of open wounds. “There was no evidence of efforts to involve the plastic surgery team at any time in her care,” reads the report.
The review panel found that the involvement of such a team would “likely have helped to minimise the difficulties with wounds closure which occurred at each surgery”.
'Dollceanna’s care was not of the standard that they would have expected'
Dollceanna required multiple returns to theatre for revision of metal work in the lead up to her death because of what the review described as “inadequate surgical stabilisation of the spine”.
Dollceanna twice underwent operations on her ward which may have increased the risk of persistent infection.
The review panel “confirmed in meetings with staff that access to theatre for procedures such as this could always be accommodated in theatre in discussion with the surgical team but that surgical teams members may themselves decide to do them at ward level.”
Dollceana’s parents had questions for CHI, including a query about theatre availability. “When she had plates taken out of her back,” they asked, ”It took one week to get Dollceanna into emergency surgery. Why was her case not treated as an emergency?”
The report answered that “attempts” had been made to get theatre access. “Complex cases are ideally managed on planned elective lists in order for all experienced staff, appropriate instrumentation is available. It is also not ideal to undertake emergency surgery out of hours. Attempts were made to get timely access to theatre facilities.”
The report concluded Dollceana did not receive the care her family expected.
“The review panel acknowledge that, in multiple regards, Dollceanna’s care was not of the standard that they would have expected.”
A senior CHI staff member said it’s “incredible” it took so long to share the May 2025 report.
“There were clear systemic problems with CHI’s operative governance that allowed substandard procedures to be performed and then encouraged to continue to clear waiting lists.”
The Ditch has previously reported how six months after Dollceanna’s death, Temple Street management suggested resuming spinal operations that had been suspended because of serious concerns about complication rates.
“The delay in providing this report to those who would benefit most from reading it, never mind in publishing it, demonstrates that management at CHI is not committed to learning from past mistakes,” the senior CHI staff member said.
CHI has been contacted for comment.
