Every Northern Ireland hospital death must be scrutinised, urges grieving dad
Just days before the findings from Northern Ireland's Hyponatraemia Inquiry are to be published, one of the bereaved families has called for all hospital deaths to be independently scrutinised in the future.
Nine-year-old Claire Roberts died in 1996 at the Royal Belfast Hospital for Sick Children. Hers is one of the five child deaths between 1995 and 2003 investigated by the inquiry.
Its report will be released on Wednesday.
Claire's father Alan told The Detail website: "We attended every day of the oral hearings of the inquiry. We didn't miss a day. Hopefully there will never be another public inquiry like this.
"But we need a more rigorous, robust system in place to ensure that what happened to Claire doesn't happen again."
The children all died from hyponatraemia-related conditions.
These can occur when the level of sodium in the blood becomes abnormally low as a result of the accidential intravenous adminstration of too much fluid.
This issue of fluid management is central to all the cases, but the inquiry was also tasked with investigating why some of the deaths were not referred to the coroner.
Claire was prescribed intravenous fluids after being admitted to hospital following vomiting and drowsiness. Two days later she suffered a respiratory arrest and never recovered.
However, her case was not referred to the coroner immediately, and an official investigation was only carried out 10 years later.
Mr Roberts believes the inclusion of his daughter's case in the inquiry is vital to correcting past mistakes.
He said: "When Claire's case did go to inquest we believe it failed to identify an accurate and correct cause of death.
"We currently have two medical certificates of cause of death that are, in our view, totally inaccurate."
A death in a hospital should be reported to the coroner if it is the result of negligence or if the cause is unknown.
Under the current system in Northern Ireland, doctors involved in the treatment of a patients will make the decision about whether or not a case should be referred to the coroner. There have been a number of previous reviews and inquiries which have highlighted the need for this system to be reformed.
In January 2000 Dr Harold Shipman was handed 15 life sentences for murders committed by administering fatal doses of diamorphine to his patients. The GP is thought to have killed as many as 250 patients in England over 23 years.
He was able to sign certificates giving a false cause of death without referring any to the coroner and without any questions being asked.
In the aftermath of Shipman, a public inquiry led by Dame Janet Smith and a review chaired by Mr Tom Luce both advocated major change in the death certification system.
One of the main recommendations was that there should be scrutiny by a medical examiner of all deaths that are not referred to a coroner.
Mr Roberts added: "Obviously Shipman is the pinnacle of medical concealment and medical cover-up.
"One of the recommendations that came out of that case is that, at the very least, all hospital deaths should be scrutinised by an independent body and I truly believe something along those lines has to be put in place."
The UK Government has committed to introducing a medical examiners system in England by April 2019.
This means that all deaths not referred to the coroner will be subject to further independent scrutiny.
Here, health trusts have an internal scheme known as the Regional Mortality & Morbidity Review system which monitors all deaths that occur in local hospitals.
The Department of Health said: "It will be for any incoming ministers and the Executive to determine if a medical examiner role is necessary for Northern Ireland and the extent of such powers and duties."
It is understood the Hyponatraemia Inquiry report will address a number of issues around the need for death certification reform, as well as whether or not there should be a statutory duty of candour in Northern Ireland.
This would put a legal duty on doctors to be open and honest with patients about incidents that have caused or have the potential to result in significant harm.