Belfast Telegraph

Heartbroken mum of transplant boy blames doctors for son’s death

By Lisa Smyth

The mother of a boy who died following a failed kidney transplant has blamed doctors caring for her son for the tragedy, an inquiry into his death has been told.

The Hyponatraemia Inquiry is examining the treatment of four-year-old Adam Strain, who never recovered from a kidney transplant carried out at the Royal Belfast Hospital for Sick Children in November 1995.

His death is one of five which are being probed by an independent public inquiry into hyponatraemia-related deaths of children in Northern Ireland hospitals between 1995 and 2003.

Adam’s mother, Debra Slevin, has been gagged by health bosses from speaking publicly about her loss, but in a statement given to the inquiry she said: “I feel the doctors at the Royal were responsible for his death.”

However, she went on to praise the doctor in charge of Adam’s care, Professor Maurice Savage, and the nursing staff who looked after him throughout his life.

Extracts of her statement were read out during the second day of oral evidence and later the solicitor acting on behalf of Mrs Slevin, David Hunter, formally thanked Prof Savage.

During questioning by the inquiry’s lead counsel, Prof Savage told the inquiry he believed Adam died as a result of swelling of the brain as a result of too much fluid.

He also admitted mistakes were made in relation to Adam’s case.

Mr Hunter said: “But of course, when mistakes are made, and it is your child, that's very difficult.

“And I'm sure you can understand where Debra is on that. It's obviously very, very difficult for her to live with all of this.”

Prof Savage replied: “I completely understand where Debra stands and comes from.

“After Adam died, I did spend a considerable length of time with her, trying to help her to get through those terrible days.”

Prof Savage also told the inquiry he felt it necessary to attend the post-mortem carried out on the body of the four-year-old after his death.

He said: “I probably also felt that there should be someone there that knew Adam, not just a cold autopsy room.”

He also defended the decision to carry out the transplant on Adam.

He said: “I think it's important for everyone to understand that if you're a paediatrician and a paediatric nephrologist in the situation that there is an opportunity to transplant a child, that at some level you think to yourself, if this was my child, would I go ahead?

“I would have gone ahead if it was my child because we were close enough to Adam that he was almost part of us.

“I felt that it was the best course for Adam and his best chance, and as you've asked me before, did I anticipate that there would be a problem with his fluids? No.

“Did I anticipate there would be a problem with the transplant? No.

“Was there a risk to Adam's life? I thought that risk was pretty small. Only the risk of any major surgery.”

He described the moment he was told problems had arisen during the surgery as “like a cold hand on your heart”.

Prof Savage, who established the paediatric renal transplant service in Northern Ireland, added: “We have made considerable changes and advancement and we do everything to make sure that their treatment is safe and that our care for them continues to be of the highest standard as they are children that are close to every one of our hearts.”

Background

Adam Strain was placed on the waiting list for a kidney transplant on November 24, 1994. An offer of a kidney for Adam was made on November 26 the following year. He received a kidney from a 16-year-old donor. An inquest into Adam's death identified hyponatraemia contributed to his death. Hyponatraemia is a condition where there is too much fluid in the body and the inquiry is looking at the fluid management of Adam prior to and during his transplant surgery.



‘I would not have consented had I known the full details’

Extracts from a statement made by Debra Slevin to the Hyponatraemia Inquiry:

“My memory of this is poor, but knowing the kind of doctor Dr Savage is, I am sure that he talked me through the surgery.

“I was aware of risks associated with surgery, but I know I was completely unaware of the dangers of fluid mismanagement until after Adam's death.

“Nothing would ever have prepared me for the catastrophic events which unfolded during Adam's operation.

“I did not have any concerns at the time about information given to me before, during and after Adam's operation.

“When confronted with Adam's grave condition, my mind was not occupied with assessing the quality of information I was getting.

“My focus was simply on what could be done to save Adam and my expectation was that the doctors and nurses were thinking in exactly the same way.

“Adam had undergone surgery at the Royal many times since he was three months old.

“It would never have occurred to me that there could be anything sinister going on.

“It was only when the initial shock had worn off in the months after Adam's death that I started to realise just how little I had been told.

“In retrospect, no-one was giving me a proper explanation as to what had happened.

“Dr Taylor's comment that it was a one-in-a-million thing indicated that he had at least some knowledge of what had happened to Adam — but he did not explain it to me.

“I feel that doctors at the Royal Victoria Hospital were responsible for Adam's death. But I am still grateful to other doctors — namely Dr Savage and the staff at Musgrave Ward.

“If I had been told the full details about the kidney and the team, I would certainly not have consented at that time.

“If I had known about Mr Keane's relative lack of experience in child transplants I would have been concerned, and may not have given consent.”

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