Girl’s ‘totally avoidable’ death was due to hospital treatment, rules coroner
A schoolgirl's death was due to treatment she received at a Belfast hospital, a coroner has ruled.
Claire Roberts passed away at the Royal Hospital for Sick Children in 1996 after being admitted with symptoms which included vomiting and drowsiness.
The nine-year-old was found to have died from a condition known as hyponatraemia, which is linked to a shortage of sodium in the blood.
She was one of five children whose deaths were investigated in the Hyponatraemia Inquiry.
Delivering his findings in Belfast yesterday after a four-day inquest, coroner Joe McCrisken said her death was "totally avoidable".
He said it had been "a distressing and sensitive" inquest during which he had heard what he called "complex" medical and pathological evidence from 10 different experts.
He said the tragedy of Claire's death when she was "at her most vulnerable" will "weigh heavily" on her parents Alan and Jennifer "for the rest of their lives".
"Their grief is compounded by knowing that her death was totally avoidable," he added.
Mr McCrisken found the cause of Claire's death to be cerebral oedema due to hyponatraemia, which was due to inappropriate infusion of fluids in combination with the effects of a viral illness and toxicity from treatments she had been given.
He said a re-evaluation of the fluids being administered to Claire, from Rochester Road in east Belfast, should have taken place and that medical staff had not realised that she was "deteriorating in front of their eyes".
"If medics had taken proper care to carry out the correct tests, in all likelihood, and with appropriate treatment, Claire would have recovered.
"Her death was caused by the treatment that she received in hospital," he said.
The Hyponatraemia Inquiry, headed by Sir John O'Hara QC, ruled in 2012 that Claire's death had been preventable and ordered the new inquest, which started on Monday.
Sir John ruled that medical professionals were involved in a cover-up following the tragedy.
Mr McCrisken said the inquiry had found that lessons had not been learned from her death and that of four-year-old Adam Strain, who died from hyponatraemia in November 1995 at the same hospital as Claire.
"Mr and Mrs Roberts have made it clear that they remain to be convinced that lessons have indeed been learned from their daughter's death," Mr McCrisken added.
"They have lost trust in the health service and have presented it with an immense challenge to show us that things have changed and prove to us that lessons have been learned.
"The challenge, it seems to me, is one that the health service must strive to meet."
After the findings at Belfast Coroner's Court, Mr Roberts thanked Mr McCrisken, adding: "We have struggled for 22 years to establish the truth but from what we have heard from you this morning sir, you have delivered the truth."
Sinn Fein's health spokesperson Pat Sheehan, who attended yesterday's hearing, said afterwards: "The coroner has found that the Belfast Trust needs to re-establish trust and demonstrate change.
"The Belfast Trust, and the Department of Health, can only re-establish trust by addressing the findings - as well as the recommendations - from last year's Inquiry into Hyponatraemia related deaths which also investigated Claire's death. This is the least which is owed to the Roberts family, and other families affected by the inquiry into Hyponatraemia related deaths."
The Belfast Trust extended its sympathies to the Roberts family.
"We will carefully consider the Coroner's conclusions and recommendations to ensure that the Trust learns from Claire's death," a spokesman said. "Over the past decade the guidance and training around the management of fluids in children in Northern Ireland has been radically transformed to ensure as far as possible their safety. Additionally, Belfast Trust, as part of the wider Health and Social Care system, is fully participating in a process to consider and implement the recommendations from Sir John O'Hara's Inquiry Report which was published in January 2018."