Damning verdict of medical failings and cover-ups in deaths of children in Northern Ireland
The tragic deaths of three children at Northern Ireland hospitals were preventable and the result of medical negligence, a public inquiry has found.
The chair of the Hyponatraemia Inquiry also said there was a cover-up by doctors following the death of one of the children.
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Sir John O'Hara QC yesterday delivered the damning findings of a 14-year probe into the deaths of Adam Strain, Raychel Ferguson, Claire Roberts, Lucy Crawford and Conor Mitchell between 1995 and 2003.
The report is likely to have far-reaching consequences for the health service, with the families urging the PSNI to launch a fresh investigation, while Mr O'Hara has called for a law to be introduced in Northern Ireland forcing medical professionals to be candid.
Mr O'Hara revealed he is to write to the head of the Coroner's Service, Mrs Justice Keegan, to warn coroners to "probe more carefully and more deeply when they receive information from hospitals about the care of patients".
He said he had uncovered examples of doctors and health service managers "working against the principles behind inquests rather than with them".
And he expressed frustration at the fact that some inquiry witnesses "had to have the truth dragged out of them", while others deliberately withheld vital information.
He said: "It's time that the medical profession and health service managers stop putting their own reputation and interests first. The evidence from this inquiry shows that doctors and managers can't simply be relied upon to do the right thing at the right time."
In a highly emotive speech to a packed hotel conference suite, he added: "The death of Adam Strain was avoidable. The death of Claire Roberts was avoidable. The death of Raychel Ferguson was avoidable. The evidence given in Banbridge Court showed all three children received medical care which fell far below acceptable standards. The death of each child was as a result of that negligent care."
Referring to his investigation into four-year-old Adam, who died in 1995 after a kidney transplant, Mr O'Hara said: "Even after all the written and oral evidence, I don't know the full story of what happened in the operating theatre. My belief is that evidence was withheld about what happened there. That's truly shocking."
In relation to the death of nine-year-old Claire, he said her heartbroken parents Alan and Jennifer were "misled when told she had received good care".
He added: "The fact that her death wasn't referred immediately to the coroner is indefensible. It's not just indefensible with hindsight, it was indefensible at the time. The reason for not referring the death to the coroner was to avoid the scrutiny of negligent care she had received.
"In fact, there was a cover-up by the consultants they spoke to when she died."
Mr O'Hara said even after the couple contacted the Belfast Health Trust following a UTV programme highlighting the deaths of children from hyponatraemia and raised concerns about Claire's treatment, "efforts to avoid telling the truth continued".
He said: "At the inquest nearly 10 years after her death, efforts to minimise or deny failings in the care given to Claire continued."
And commenting on the case of 17-month-old Lucy, he said there was a "lack of professionalism and candour".
"There was a failure to report her death to the coroner in the way it should have been reported. Such efforts were hopelessly incompetent," he said.
"The death certificate issued in 2000 was wrong, illogical and simply made no sense - it was medical gibberish. There were no lessons learned from Lucy's death and those lessons could have affected Raychel's care."
He also hit out at the lack of details provided to the family of nine-year-old Raychel after her death. He said officials knew "much more than they were prepared to share" with Raychel's parents during a meeting to discuss her care. "How much anguish, anger and frustration would have been spared if they had told the truth from the start," he said.
Mr O'Hara also criticised former Chief Medical Officer Dr Henrietta Campbell in her response to media enquiries about the deaths of the children. He branded her response "inaccurate, defensive, evasive and complacent".
The inquiry was set up in 2004 to investigate the fluid management of the children.
Hyponatraemia played a role in the deaths of all the children, except Conor. The condition occurs when there is a shortage of sodium in the bloodstream, which can arise as a result of a patient receiving too much fluid.