The coroner is urging that the forced availability of defibrillators be considered in all childcare facilities after the infant died from a choking incident in Cresch, Wicklow two years ago.
A verdict of death of Lauren Boland (2) was returned after choking at Pea while attending Little Explorers Center in Greystones, Co Wicklow.
Coroner Claire Keene was also sought to review dietary guidelines related to the risk of choking in children.
A court investigation of the Dublin District Coroner's Court showed that a single peas measuring 11x5mm found in her body after death was sufficient to obstruct the infant's airways at the narrowest point.
Lauren, a native of Delgany, Wicklow, passed away on January 19, 2023 in Ireland, the day after the choking incident.
Dr. Keene recorded the verdict of death from bad luck, saying that the girl's death was definitely due to peas being a risk factor.
The coroner said he would also notify relevant authorities in connection with the defibrillator and recommendations regarding the risk of choking.
The survey heard that CCTV footage of Creech showed that the toddler was visibly suffering at 12:06pm shortly after being served lunch on January 18, 2023.
A series of witnesses also outlined the efforts by Kresh staff to support the young girls.
Lauren's father, Matt Boland, shed tears upon hearing it being read out by the court registrar, but her daughter was always happy and smiling, with no health issues, explaining how she smiled.
He recalls the way Lauren was referring to the moon and says “the sun” when he dropped her off in Kreche on the morning of January 18th, 2023.
“That's the last thing she told me,” he observed.
Mr. Boland said when he arrived in Kresh after his wife warned him, everyone was crying and there was a “sense of panic.”
He explained how he held her daughter's hand and told her he loved her.
Someone told him that her heart stopped for 40 minutes before she was placed in the ambulance.
The investigation heard that Lauren's family had decided to donate her organs, but before they arranged, she suffered from cardiac arrest and died in her parents' arms.
The late mother, Lisa Boland, said she was contacted by Kresh at 12:17pm and informed her that her daughter appears to have swallowed the stabbed peas.
Witnesses received another call two minutes later to say Lauren had responded.
Mr. Borland said when he saw her daughter lying on the pale green creche floor and her skin was cold to the touch, she “cried out of pure shock.”
She says she tried to give Lauren a mouth-to-mouth resuscitation before being advised by the staff at Kresh that they hadn't done so due to concerns blocking the airways.
Mr. Borland said Kresh staff were frozen in shock and didn't seem to know what to do.
She was either told to calm down or reminded her that she had to leave.
Borland said he never knew why no one had thought of pediatric pads for use with defibrillators.
She investigated that unlike her brother Jack, who had several such incidents, Lauren was never difficult to swallow.
Karen Kinsella, Kresh's interim manager, gave evidence that she saw Lauren point her throat and breathe the air just after coughing while eating lunch.
Kinsella said she gave the toddler many slaps on the back and asked other staff for help when the girl felt choking.
In response to a question from the coroner, she said she looked into Lauren's mouth and found nothing.
Creach's assistant manager, Debbie Cassidy Canavan, has taken over her attempts to revive the toddler, but has given evidence that she felt incredible when she realized “this is not the way we wanted it to.”
Two other Kresh staffers, Grace Kennedy and Amy Roberts, also told the hearing how they provided CPR to Lauren before community responders and paramedics arrived.
The director of the company that operates Gina McGurry at Little Excollors Center said a full review of Kresh's policies and procedures was conducted after the incident and no issues were identified.
McGarry said defibrillators were offered at all centres, despite their lack of obligation, as a result of fundraising efforts.
She told the coroner she insisted that all managers were trained in a highly trained emergency response.
McGarry confirmed that four Kresh staff members had received such training on the day of the incident, despite the at least one regulation required.
The investigation has heard that the DPP has directed that no criminal prosecution should arise as a result of Garda's investigation into Lauren's death.
Pathologist John O'Neill said that after death, he revealed that a single “compressed but intact” peas had been found in Lauren's larynx, large enough to block the airways at the narrowest point.
Dr. O'Neill confirmed that she died as a result of lack of oxygen in the brain due to the prolonged cardiopulmonary arrest caused by episodes of choking.
William Martin Smith BL, a lawyer for Lauren's family, argued that the girl was in a controlled environment and that the verdict of misfortune or storyline was most appropriate.
Martin Smith said many issues were identified, including attempted operation of Heimrich, which included the call of an ambulance after Lauren was assisted by a third emergency responder on the scene.
However, Veronica McKinnerney BL, Kresh's attorney, argued that the accidental death verdict was the correct finding as multiple Kresh staff acted quickly and followed first aid training guidelines.
After the verdict of misfortune was returned, Mr. Borland said:
She added: “Every day we are tortured about how things can be different from What ifs. The injustice of not being with Lauren is so heavy.
Ms. Borland described her daughter as “the brightest star” and “the light of our lives.”
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She sobbed repeatedly, “She brought a sense of magic to every day. Her warmth and love for life were simply contagious like her big smile and heartfelt laughter. She was a baby in the house, but she was the boss.”
She observes that Lauren never failed to meet her younger brother, Harry.
After the investigation, seeking comment, the couple responded: “Lauren believed it was safe, and every child in this country deserves to feel safe and secure.
They added: “We need to place protocols and call emergency services immediately. We need to learn lessons for the safety of all children in this country.”
