A verdict of medical misadventure has been recorded at the inquest into the death of 16-year-old Jemma Gardiner, who suffered fatal brain injuries following surgery to relieve a build-up of fluid on her brain. The coroner heard that a pressure monitor attached to Jemma provided "falsely reassuring" readings during a critical period.
Jemma, from Ratheskin, Kincon, Ballina, Co Mayo, died at Beaumont Hospital in Dublin on 18 February 2019. The inquest at Dublin District Coroner's Court heard that her condition deteriorated sharply in the early hours of 12 February after she underwent an endoscopic third ventriculostomy (ETV), a procedure designed to create a natural drain for excess fluid on the brain.
The surgery followed the failure of a shunt implanted a month earlier, which had replaced her original shunt that functioned without issue for 16 years since shortly after her birth. Jemma, born with congenital hydrocephalus, had been in good health for most of her life, according to her mother, Gillian Gardiner. She was non-verbal and used a wheelchair but had experienced no complications with her annual shunt check-ups.
Ms Gardiner recalled how Jemma returned to school a few weeks after her second shunt surgery in January 2019 but had to be readmitted on 8 February when she became unwell. During the ETV, both existing shunts were removed, two external drains were fitted, and a pressure monitor was attached.
After surgery, Jemma became agitated and repeatedly tried to remove a bandage around her head. Ms Gardiner said she constantly monitored the pressure readings and, when concerned about Jemma’s breathing, alerted the nurses. A doctor immediately drained fluid using the external drains before transferring her to intensive care. An MRI later revealed significant brain damage, and tests confirmed brain stem death. Ms Gardiner said, “Jemma grew her angel wings” when she passed away at 3.20pm on 18 February.
Jemma’s family described her as a very special child who “loved fashion and having her nails painted.” Her sister, Clara, who represented Mayo in last year’s Rose of Tralee festival, spoke about her sister’s death during the contest.
Consultant neurosurgeon Darach Crimmins, who performed the ETV, told the inquest he was “devastated by the outcome” and admitted Jemma had experienced severe brain pressure for 60 to 90 minutes before fluid was drained. Consultant John Caird said the ETV was “the appropriate next step” following shunt failure but acknowledged the monitor had given false low readings.
Dr Keane, who delivered the verdict, noted that the early ETV failure, despite being “technically successful,” was compounded by a displaced pressure monitor. She endorsed the hospital’s change to monitors providing waveform readings for easier patient assessment and offered her condolences to the family.
Following the inquest, Ms Gardiner welcomed the verdict and information revealed during the proceedings, while calling for improved communication between medical staff and families, particularly regarding vulnerable patients. Her daughter Chloe said, “Jemma wasn’t going anywhere without a fight. She fought so hard and we’re just happy we got some answers for her and ourselves.”
