Health body failed at leadership level in Hyponatraemia Inquiry, says judge
The findings of an official investigation into allegations made about information supplied to the Hyponatraemia Inquiry were incorrect, a senior judge has said.
A whistleblower, who works for the Western Trust, raised a series of concerns about the supply of information to the inquiry, which examined the deaths of five children following treatment at hospitals in Northern Ireland.
The Health & Social Care Board (HSCB) carried out a probe into the allegations and found no wrong-doing.
However, chair of the inquiry, Sir John O'Hara, carried out his own separate inquiry and has identified failings in the way the HSCB looked into the allegations.
He said the failings happened "at leadership level of the health service".
Issuing the findings of his own probe, Sir John yesterday said there were gaps in the search by the former Western Health and Social Services Board (WHSSB) in relation to the treatment of Lucy Crawford and Raychel Ferguson.
Lucy was two years old when she died after being treated in the Erne Hospital, Enniskillen, in 2000. Raychel died in 2001, the day after an appendix operation at Altnagelvin Hospital, Londonderry.
Both girls died as a result of hyponatraemia, a condition that causes the brain to swell as a result of low sodium in the blood.
Sir John said former Department of Health permanent secretary Clive Gowdy, as well as the Hyponatraemia Inquiry, "were accordingly misled in 2004 as to the completeness of the searches undertaken with the WHSSB for documentation relating to the deaths" of Lucy and Raychel.
Sir John said: "That the WHSSB should have failed to conduct appropriate searches, and misled to the extent of those searches, is profoundly unsatisfactory and is to be criticised."
Referring to the subsequent HSCB investigation, he said: "However, there was a serious failure to address these concerns, whether to investigate them properly or judge them fairly.
"The wrong conclusions were reached. This was a failure at leadership level within the healthcare service. Not only was the whistleblower failed but so too was the Service.
"Confidence in the critically important systems of whistleblowing depends upon fairness and professionalism. These were absent."
He also said he disagreed with the conclusion of the Board investigation panel that there could have been no new information to give to the Hyponatraemia Inquiry and that the Board and Directorate of Legal Services were blameless.
Sir John continued: "In reaching this conclusion the panel not only failed to take some evidence into account but misread and misconstrued other evidence."
Sir John also criticised the fact that the investigation panel was appointed by the chief executive of the Board.
"I am concerned that there was insufficient distance between the three panel members and the matters under review, and that the appointments were compromised by the potential for a perception of conflict of interest," he explained.
"In addition, the panel lacked appropriate experience, training or support.
"It was a complex task and no advice was available on how to investigate."
He also said the HSCB failed to bring relevant information to the inquiry in 2013, leaving the inquiry misinformed.
He continued: "It is unsettling to be compelled to this conclusion given the many reassurances urged upon me by senior HSCB officials in open Hyponatraemia Inquiry session.
"Whilst it is for others to determine why this particular whistleblower's concerns were not accorded proper response, I reiterate my recommendation that the highest priority be accorded the development and improvement of leadership skills within the healthcare service."
Despite the criticisms levelled at health officials, Sir John said he will not change the essential findings of the Hyponatraemia Inquiry report, which was published in January last year.
A spokesman from the HSCB said the investigation panel worked to consider the issues raised in a fair and impartial manner.
He continued: "Whilst the HSCB accepts there is scope for learning, it is also important to stress that the panel members carried out a very complex investigation within a constrained timeline with honesty, integrity and dedication.
"This was done in line with the whistleblowing policy which provides for anonymity of the whistleblower in accordance with relevant legislation."
He said the HSCB is committed to working with the health service to ensure any learning is fully taken on board.
He added: "There also needs to be a wider debate in relation to what evidential and investigative thresholds and training are required for future whistleblowing investigations."