Overview
- The HSE issued an unreserved apology, accepting failings that it said ultimately led to Niamh McNally’s death.
- The inquest recorded death as asphyxiation from a pulmonary haemorrhage likely caused by erosion of collateral arteries.
- Evidence detailed repeated missed opportunities and delayed cardiology involvement despite her complex congenital heart history.
- Seven medical witnesses acknowledged shortcomings, including a failure to implement a cardiology treatment plan during her January admissions.
- The coroner emphasized that the finding does not assign blame or liability, and the family urged the HSE to adopt the review’s recommendations.