Belfast Telegraph

Act on Hyponatremia inquiry findings, says Shipman probe judge

By Mark Edwards

The recommendations of Northern Ireland's Hyponatremia inquiry "cannot be allowed to sit on the shelf", a senior judge who led the probe into notorious killer Dr Harold Shipman has warned.

The inquiry, headed by Sir John O'Hara QC, investigated the deaths of five children between 1995 and 2003 and examined whether fatal errors were made in the administration of intravenous fluids.

Last week its report found that four of the deaths were avoidable and said some medics had behaved "evasively, dishonestly and ineptly".

Hyponatremia is a sometimes fatal condition that occurs when there is a shortage of sodium in the bloodstream.

Dame Janet Smith, who chaired an inquiry into serial killer Shipman in 2001, told news website The Detail that the lack of a functioning NI Executive should not prevent the Hyponatremia Inquiry's recommendations being implemented.

"In the absence of ministers, it would be helpful if senior civil servants were to prepare for implementation of Mr Justice O'Hara's recommendations," she said.

"Otherwise there is a danger that public concern will wane, the moment will pass and these important findings will sit on the shelf, as many of my recommendations have done for 14 years."

Dame Janet found that Shipman had probably killed as many as 250 of his patients in England over a 23-year period.

One of her central recommendations was that the position of medical examiner should be created to scrutinise all deaths that weren't already being referred to the coroner.

The measure has yet to be implemented, although the current UK government has said it will do so in England in 2019.

This recommendation had also been made by Mr Justice O'Hara in the Hyponatraemia Inquiry.

The probe investigated the deaths of four-year-old Adam Strain, who died in November 1995; Claire Roberts, who died aged nine in October 1996, and nine-year-old Raychel Ferguson, who died in June 2001.

It also examined events following the death of 17-month-old Lucy Crawford in April 2000 as well as specific issues arising from the treatment of 15-year-old Conor Mitchell in May 2003.

All five children were being treated at the Royal Belfast Hospital for Sick Children when they died, although some of them had been transferred from hospitals in other parts of Northern Ireland.

The inquiry is estimated to have cost £15m.

Belfast Telegraph

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