Background: a tragic death and an inquest
The Health Service Executive (HSE) has publicly apologised to the family of Kate Colum, a five-year-old girl from Strokestown, Co Roscommon, who died following a severe Strep A infection linked to organ dysfunction and septic shock. The inquest at an Dublin court concluded that medical misadventure was a major contributing factor in her death at Sligo University Hospital (SUH) in March 2023.
Kate, who had Down syndrome and additional needs, was admitted by ambulance, discharged a few days later, and then readmitted. The jury found unanimously that she should not have been discharged on the morning of Thursday, 30 March 2023, and that the discharge contributed to the deterioration that followed.
The inquest verdict and the family’s response
The four-person jury delivered a verdict of death due to medical misadventure. Kate’s parents, Claire and Matthew Colum, spoke of a life well lived and welcomed the outcome as a step toward accountability and future safety. They emphasised that while the verdict cannot bring Kate back, it helps close a painful chapter and paves the way for improved training to prevent similar cases.
“Kate’s smile was infectious, her laugh, her love farming with the boys, her love of bottle feeding the sheep, the trampoline, chocolate buttons, colouring and watching Peppa Pig,” the family shared, highlighting the bright life Kate led beyond her health challenges. They said Kate led a full life with playschool, Fridays for dancing, and farming in the family’s daily routine.
A commitment to better training: the KATE framework
In the wake of the inquest, the Colum family agreed to collaborate with the HSE on training for medical professionals in caring for children with Down syndrome and additional needs who may be neurodivergent. A key outcome is the KATE mnemonic, designed to guide clinical practice:
- K for Kind – recognising the emotional and practical demands on families
- A for Alert – acknowledging that some children may appear well while acutely ill
- T for Time – ensuring careful, thorough assessment as deterioration can be rapid
- E for Experts – valuing input from parents or guardians who know their child best
Health authorities indicated that training incorporating KATE will be promoted to support earlier recognition of sepsis signs and to avoid premature discharge in vulnerable pediatric patients.
Kate’s family remembers a life cut short
Ms Colum described her daughter as healthy and resilient, with Down syndrome not diminishing her vitality. She recalled Kate’s illness beginning the week of 29 March 2023, with a high fever and vomiting, and expressed that blood tests and urine samples were not pursued at the time under medical advice that Kate would be fine at home. In the hours after discharge, Kate’s condition worsened, and she was readmitted before she passed away at 8:50am on the following Friday.
Concerns were raised about the timeliness of sepsis diagnosis and record-keeping in Kate’s final days. Her father recalled that Kate “paid the ultimate price” and stressed that her experience should drive change to prevent similar tragedies. The coroner highlighted that Kate’s life, love for family, farming, and play, must be remembered and honoured.
Looking forward
The HSE’s apology on behalf of Sligo University Hospital’s management and staff emphasises a commitment to learning from Kate’s death. The Colum family’s goal is not only remembrance but systemic improvement that could spare other children unnecessary harm. As the coroner noted, Kate’s name will live on through the KATE framework, guiding medical teams toward greater compassion, vigilance, and parental partnership in pediatric care.
Impact on policy and practice
While the immediate verdict addresses Kate Colum’s case, the ongoing work involves training reforms and the adoption of standardized procedures for evaluating seriously ill children in hospital settings. Advocates say that such measures, rooted in Kate’s memory, can help clinicians recognize sepsis earlier and avoid the avoidable harm that can follow a discharge when a child remains unwell.
