By MONIQUE DEVEREUX
It has been almost three years since Brenda and Paul McKay booked their twin toddlers in for a routine operation to remove their tonsils and adenoids.
Blonde, blue-eyed Megan Clare and Caitlin Marie were 2 years old when they arrived at St George's Hospital in Christchurch for the surgery, which the surgeon's notes describe as uneventful.
Megan recovered well but Caitlin's progress was not as good. She went back to her doctor, who insisted the McKays be more forceful with the paracetamol that he believed would help her heal.
But seven days after surgery Caitlin suffered a dramatic haemorrhage from her throat and nose.
Her family could only attempt to stem the flow of blood as they waited for an ambulance to negotiate rush-hour traffic to their home near Christchurch Airport.
By the time the toddler arrived at hospital, 46 minutes after the 111 call was made, she had suffered cardiac arrest and was unconscious.
When she went back into surgery, a ruptured artery, the cause of the bleeding, was found and stopped.
But it was too late. The next morning Caitlin's life support was stopped.
Her death was an exceptionally rare event internationally.
Statistics based on Starship children's hospital figures of 600 such tonsil operations a year, show that a fatal haemorrhage of this type is only likely to happen every 120 years.
In a coroner's court hearing in Christchurch yesterday, the McKays finally took the opportunity to face Jeremy Hornibrook, the surgeon who operated on both girls.
It had taken so long to get an inquest, mainly because of the other agencies which had to complete investigations into Caitlin's death.
ACC has ruled it a medical mishap, a rare and severe complication of treatment properly given, but found no fault with Mr Hornibrook.
Health and Disability Commissioner Ron Paterson also investigated, and found Mr Hornibrook had breached the Code of Consumers Rights by failing to warn the McKays of the risk of haemorrhage.
Yesterday, an emotional Mr Hornibrook took the stand and apologised to the McKay family. He said he had attended Caitlin's funeral and had hoped to have been able to talk to the family before now.
He did not because they refused.
"Caitlin's memory will live on with me for always. I cannot bring her back," he said.
The court heard from two expert witnesses, Starship paediatric ENT director Colin Barber, and Peter Blake of Wellington Hospital.
Both emphasised the rarity of such a death and agreed that an infection had "quarried" deep beneath where Caitlin's left tonsil was removed.
Mr Barber believed that infection had caused the artery to "blow out".
A tonsillectomy is a routine operation. Mr Blake said most surgeons who perform them would do three or four a week, or 5000 in their career.
Complications such as Caitlin suffered would probably happen only once in every three or four generations. Mr Blake called the tragedy a "cruel trick of Mother Nature".
In a Christchurch Press feature last year, the McKays described their grief. Despite two investigations they did not understand why Caitlin died and needed to know if anything could have been done to save her.
Yesterday they got an answer.
Coroner Richard McElrea asked pathologist Martin Sage if there would have been a "window of opportunity" to save Caitlin.
Dr Sage said such a sudden and massive arterial rupture was "fairly grave under any circumstances".
"Sadly this tragic outcome has to be regarded, for my purposes, effectively tragic but inevitable."
The coroner reserved his decision.
* Two-year-old twins Caitlin and Megan McKay both had their tonsils and adenoids removed in September 2001.
* One week after the surgery Caitlin suffered a dramatic haemorrhage in her throat, and a cardiac arrest. Life support was turned off the next day.
* In the past 33 years at least 15 million tonsillectomies have been performed worldwide. Only 22 people have suffered any kind of arterial haemorrhage afterwards and not all of those have died.
* Statistics from Starship children's hospital estimate this rare death is likely to happen once every 120 years.