The fitness to practise of a doctor who admitted allowing an “inaccurate” and “illogical” cause of death to appear on a child’s death certificate is not impaired, a tribunal has found.
Dr John Donncha Hanrahan, a paediatric neurologist at the Royal Belfast Hospital for Sick Children, faced a number of allegations of failings in relation to his actions following the death of a patient.
Lucy Crawford, referred to as Patient A during the hearing, was 17-months-old in May 2000 when she died at the Royal Belfast Hospital for Sick Children following errors in the amount of fluids she received.
A death certificate, issued on May 4, 2000, stated she died as a result of cerebral oedema, due to dehydration, due to gastroenteritis. However, an inquest held in 2004 found she died from cerebral oedema, due to dilutional hyponatraemia, due to excess dilute fluid and gastroenteritis.
At the time, the coroner said errors in the amount of fluids Lucy was given led to hyponatraemia, which ultimately resulted in her death.
Lucy was one of five children whose deaths were examined by the Hyponatraemia Inquiry into mismanagement of fluids in local hospitals. In his findings, the inquiry chairman said he was satisfied Dr Hanrahan knowingly permitted an inaccurate description of the cause of death to appear on Lucy’s death certificate which he described as a "matter for gravest concern”.
However, a Medical Practitioners Tribunal Service panel said Dr Hanrahan “made an error which he has admitted” over the death certificate.
Tribunal chair Alice Moller said: “His error did not constitute serious professional misconduct, nor can it properly be regarded as deplorable, it would not attract opprobrium or bring the medical profession into disrepute. His actions were taken in good faith, despite being ill-judged. His error was not repeated in the subsequent 21 years of practice, nor anything similar alleged.”
It came after the panel accepted Dr Hanrahan’s evidence that his responsibility did not include fluid management.
Ms Moller also said Dr Hanrahan was not under a duty “to notify the coroner’s office of any concerns regarding” Lucy’s fluid management.
“This was because he and his colleagues were oblivious, at this time, of the risks associated with Solution 18, no longer in use, or the fact that Erne Hospital (where Lucy had been treated previously) had administered two and a half times the correct volume of fluid to Patient A.”
She added: “He had not been involved at any stage in the clinical care preceding Patient A’s death.”