Tristan’s final hours as he lay 32 feet from nurses’ station
JANUARY 4, 2013
Tristan Neiland, aged six, arrives at Angels Quest respite centre for a twonight stay. His mother tells staff to use a SATS monitor to check his oxygen levels.
JANUARY 5, 2013
20.00 Night staff come on duty, Tristan is awake but some children are already asleep.
20.30 Tristan is put to bed in his room which is 32 feet from the nurses’ station. SATS monitor is not attached, instead a regular baby monitor is turned on.
20.45 Tristan is observed to be asleep, door is wedged open.
21.05/10 Tristan is checked and seen to be asleep in semi-prone position. Around the same time, he is checked again by another staff member.
21.25 Staff notice one of the five baby monitors in use is not working, and one person goes to replace this. Also at this time, Tristan is checked by a staff member, who stated she could hear him breathing.
21.28 Staff member checks the replacement monitor in the corridor outside Tristan’s room is working.
22.00 One staff member checks Tristan, but does not note his position or condition other than sleeping.
22.56 Staff member checks Tristan and calls for help as he is cyanotic – blue from lack of oxygen – and not breathing. 22.58
Ambulance called.
23.09 Paramedics arrive. 23.32 Tristan is transferred to Crumlin hospital but he is declared Dead On Arrival.