Family Left with "More Questions Than Answers" After Teenager's Unexpected Death Following Routine Procedures

 Dublin, Ireland - The family of 14-year-old Cillian Gorman, who passed away suddenly and unexpectedly at Children’s Health Ireland (CHI) at Crumlin four years ago following routine surgical procedures, have stated they are left with "more questions than answers" after an inquest into his death concluded.

The Dublin District Coroners Court heard on Tuesday how medical professionals at CHI at Crumlin remain perplexed by the "vanishingly rare" blood clotting condition that afflicted the Carlow student in a sudden and catastrophic manner.

Cillian Gorman, from Tullow, Co Carlow, was admitted to the Dublin hospital on March 14, 2021. The following day, he underwent an endoscopy of his upper and lower gastrointestinal tract and a liver biopsy as part of investigations into a suspected development of inflammatory bowel disease.

The inquest heard that Cillian's condition deteriorated rapidly in the hours following the procedures. He became unresponsive while recovering from the surgery and was subsequently confirmed to have suffered brain stem death on March 20, 2021.

Following the testimony of several medical witnesses, the family’s counsel, David Roberts BL, called for a verdict of death due to medical misadventure, prompting a large applause from Cillian’s relatives and friends present at the hearing. Mr. Roberts asserted that Cillian was a healthy boy who experienced a "catastrophic event resulting in his death while under the care of the hospital." He further stated that Cillian’s parents "did not accept the medical evidence they had heard at the inquest."

However, Conor Halpin SC, representing CHI at Crumlin, argued that a narrative verdict was the appropriate finding, citing a lack of evidence directly linking the hospital's care to Cillian’s death to support a verdict of medical misadventure.

Coroner Clare Keane recorded the cause of death as a lack of oxygen to the brain due to acute intracranial bleeding secondary to thrombophilia, a condition that causes blood to clot. Dr. Keane acknowledged significant pre-existing health factors, including auto-immune hepatitis and inflammatory bowel disease, but stressed that these were "not directly contributory to his death."

Dr. Keane explained that she would record a narrative verdict to reflect the "complexity of the case and how it had been impossible to establish what caused the blood clotting."

The inquest revealed that extensive specialist DNA testing had yielded inconclusive results. A pathologist who conducted the post-mortem examination described the case as "so rare, so unusual and so complicated."

Dr. Emer Fitzpatrick, a consultant gastroenterologist and hepatologist at CHI at Crumlin, stated that the finding of thrombotic microangiopathy (TMA), a rare and serious condition causing blood clots, was unprecedented in her experience in Dublin. "I’ve never seen a child like that," she said, describing TMA as "vanishingly rare."

Dr. David Rea, a paediatric radiologist who performed the liver biopsy, testified that pre-surgery tests indicated a slightly elevated risk of bleeding but that proceeding with the procedure was deemed safe. He added that there were "no concerns" during the surgery and Cillian remained in a stable condition afterwards. The inquest heard Cillian was transferred to a recovery ward at 2.30 pm.

Dr. Fitzpatrick recalled reviewing Cillian at 6.15 pm, noting he appeared "in good form and smiling" after eating. She highlighted that he was under enhanced observation following the biopsy and there were no concerns regarding his vital signs at that time.

The inquest further heard that Cillian subsequently complained of a headache and vomiting later that evening. His mother raised the alarm at 8.40 pm when he suddenly became unresponsive after a few deep breaths. He was moved to the intensive care unit, where doctors discovered massive internal pressure on his brain. A planned transfer to CHI at Temple Street was deemed impossible due to his unstable condition.

Consultant paediatrician Dr. Michelle Dillon provided evidence regarding Cillian’s treatment at St Luke’s Hospital in Kilkenny in June 2020 for worsening dizziness. He was diagnosed with anaemia and prescribed iron. Dr. Dillon also expressed concerns about potential inflammatory bowel disease, leading to his referral to CHI at Crumlin.

Neuropathologist Prof. Michael Farrell, who examined Cillian’s brain post-mortem, found it to be "massively swollen" with multiple areas of bleeding that he believed occurred in a "hyper acute" manner. However, he admitted he "could not explain why it had happened."

Paediatric pathologist Prof. Maureen O’Sullivan, who also conducted a post-mortem, stated she had "never seen anything like this before." She identified the most significant finding as "very abnormal clotting" throughout Cillian’s blood vessels, noting that while TMA was unusual in patients with inflammatory bowel disease, Cillian presented with multiple clotting sites in organs including his lung, liver, and heart. Prof. O’Sullivan acknowledged her inability to determine the trigger for this clotting.

Addressing Cillian’s parents, Deirdre and Declan Gorman, at the inquest's conclusion, Dr. Keane described the loss of their son as "unbearable." While expressing hope that the inquest had clarified some issues, she acknowledged, "you still may have more questions than answers."

Speaking on behalf of the family after the hearing, their solicitor, Simon McElwee, stated that they did not agree with the narrative verdict but accepted the coroner’s handling of the inquest. "Cillian was a robust, normal child when he went into hospital. He was dead when he came out. After hearing all the evidence of the doctors today, my clients learned nothing new and have more questions than answers. They have no trust in the CHI," said Mr. McElwee.