Hyponatraemia inquiry: Children’s hospital deaths were avoidable

Image caption Adam Strain, Raychel Ferguson, Claire Roberts and Conor Mitchell. Lucy Crawford’s family chose not to release a photograph

An inquiry into the deaths of five children in Northern Ireland’s hospitals has found that four of them were avoidable.

The findings followed a 14-year inquiry into hyponatraemia-related deaths

Hyponatraemia is a medical condition that occurs when there is a shortage of sodium in the bloodstream.

The damning report was heavily critical of the “self-regulating and unmonitored” health service.

Mr Justice O’Hara was scathing of how the families were treated in the aftermath of the deaths and also of the evidence given to the inquiry by medical professionals.

He said that “doctors and managers cannot be relied on to do the right thing at the right time” and that they had to put the public interest before their own reputation.

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Media captionMarie Ferguson said her daughter Raychel’s death “destroyed me”

He also said that some witnesses to the inquiry “had to have the truth dragged out of them”.

The inquiry was set up in 2004 to investigate the deaths of Adam Strain, Claire Roberts, Raychel Ferguson, Lucy Crawford and Conor Mitchell.

The chairman said that the deaths of Adam Strain, Claire Roberts and Raychel Ferguson were the result of “negligent care”.

Image caption The inquiry’s report has made 96 recommendations

In his report, Mr Justice O’Hara found that:

  • in investigating the death of Adam Strain, the inquiry had been met with “defensiveness and deceit” and that “information was withheld” about what happened to Adam in the operating theatre
  • there “was a cover up” in the death of Claire Roberts, whose death was not referred to the coroner immediately to “avoid scrutiny”
  • poor care was “deliberately concealed” in the death of Lucy Crawford
  • there was a “reluctance among clinicians to openly acknowledge failings” in the death of Raychel Ferguson
  • in the death of Conor Mitchell, there was a “potentially dangerous variation in care and treatment afforded to young people at Craigavon Hospital”

In total, the inquiry made 96 recommendations including the establishment of a duty of candour on medical professionals “that would impose a duty to tell patients and their families about major failures in care and to give a full and honest explanation”.

Mr Justice O’Hara added that the “reticence of some clinicians and healthcare professionals to concede error or identify underperformance or colleagues was frustrating and depressing”.

Long-running inquiry

The inquiry was set up in 2004, but has been dogged by repeated delays and adjournments.

The first witness was not called until April 2012 and it stopped taking evidence in November 2013.

Mr Justice O’Hara was a senior barrister when the inquiry began and is now a High Court judge.

A total of 106 doctors and other medical professionals gave evidence and 179 witnesses were called.

Fifty lawyers were involved, representing the inquiry, the families and the health trusts.

Initial reports suggest the inquiry cost £13.5m, but that figure is expected to rise.


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