Belfast Telegraph

Hyponatraemia Inquiry: Northern Ireland children's deaths 'avoidable' - doctors covered up failures

The deaths of four Northern Ireland children could have been avoided and doctors covered up failures in patient care, a major inquiry has found.

Hyponatraemia Inquiry chair Sir John O'Hara QC said medical professionals should stop treating their own reputations and interests first and put the public interest first.

Sir John O'Hara QC investigated the deaths of children in Belfast, examining whether fatal errors were made in the administration of intravenous fluids, and said some medics had behaved "evasively, dishonestly and ineptly".

He was scathing of some witnesses saying they "had to have the truth dragged of them".

The Hyponatraemia Inquiry delivered its findings on Wednesday. It examined the deaths of five children, finding that four of them were avoidable.

The inquiry was set up almost 14 years ago to examine whether fatal errors were made in the administration of intravenous fluids.

Sir John said: "The failure by senior clinicians to address the issue with appropriate candour suppressed the truth and inhibited proper examination of what had gone wrong.

"The motivations for this concealment maybe multiple but I (saw) amongst them a determination to protect their professional colleagues from having to confront their clinical errors.

"As a result the opportunity to learn lessons was disregarded and critical learning was lost to clinicians delivering fluid therapy to other children in Northern Ireland."

Hyponatraemia is a dangerous, sometimes fatal, condition caused by low sodium levels in the blood.

The probe investigated the deaths of four-year-old Adam Strain, who died in November 1995; Claire Roberts, who died aged nine in October 1996; and nine-year-old Raychel Ferguson, who died in June 2001.

It also examined events following the death of 17-month-old Lucy Crawford in April 2000 as well as specific issues arising from the treatment of 15-year-old Conor Mitchell in May 2003.

All five children were being treated at the Royal Belfast Hospital for Sick Children when they died, although some had been transferred from hospitals in other parts of Northern Ireland.

The mother of one of the children, Marie Ferguson whose daughter Raychel died in 2001, echoed the inquiry's call for a law forcing doctors to be candid.

She said: "No family should have to go through the mental and physical stress, hurt and undermining that we are still going through.

"I would like in memory of Raychel the introduction of a statutory duty of candour - Raychel's Law."

The inquiry chairman said apologies from Northern Ireland's health authorities had to be dragged out of them through expert evidence to his inquiry.

He was especially critical of an anaesthetist whose patient died during an operation but who failed to acknowledge his errors for many years.

"It is time that the medical profession and health service managers stop treating their own reputations and interests first and put the public interest first."

The inquiry, estimated to have cost in excess of £15 million, has been hit by multiple delays.

It was first ordered in 2004 by the then-direct rule minister for health in Northern Ireland Angela Smith after allegations that mistakes had been made by hospital staff administering intravenous fluids.

The inquiry initially examined the deaths of Lucy, Raychel and Adam. Claire and Conor's deaths were added to the terms of reference in 2008.

Belfast Telegraph Digital


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