A senior doctor accused of deliberately failing to properly investigate the death of a four-year-old patient will face no action by his regulatory body, it can be revealed.
Dr George Murnaghan was director of medical administration of what is now the Belfast Trust when Adam Strain died following a kidney transplant at the Royal Belfast Hospital for Sick Children in November 1995.
Adam is one of five children whose deaths in hospital were examined by the Hyponatraemia Inquiry - which resulted in a scathing report into the care they received.
In his damning assessment of Dr Murnaghan's role - alongside consultant anaesthetist Dr Joseph Gaston - in the investigation after Adam's death, inquiry chair Sir John O'Hara QC said the "failure to investigate was blatant".
He added: "I believe their failure to conduct a thorough investigation was deliberate.
"Their response to Adam's death was to commit as little to writing as possible and to reveal as little by investigation as was consistent with appearing to assist the coroner.
"Realising, as they must have done, the vulnerabilities of the trust to criticism, I interpret their actions on behalf of the trust as essentially defensive. That was inappropriate."
Sir John was also critical of Dr Murnaghan accepting reassurance from colleagues about the fitness to practise of Dr Bob Taylor, the anaesthetist during Adam's operation.
"That approach meant the safety of Dr Taylor's patients may have become dependent upon the supervision his colleagues provided," he said.
"That was unacceptable."
He also referred to the fact that Dr Taylor did not accept that Adam had died from hyponatraemia, meaning Dr Murnaghan "could not therefore have been satisfied that lessons had been learned".
He added: "Drs Gaston and Murnaghan failed to place patient safety before other interests. I conclude that overall Dr Murnaghan engaged in a 'damage limitation' exercise to protect the reputation of the hospital.
"That was not the role of one who should have been motivated to assist the coroner."
In respect of learning lessons as a result of Adam's death, Sir John said: "There is no evidence that Dr Murnaghan did anything."
He referred to the fact that Dr Murnaghan was involved in drafting recommendations to help prevent future cases of hyponatraemia.
These were to be presented at Adam's inquest, with Sir John stating "the suspicion arose that the draft recommendations had been cynically provided to the coroner" to stop him from taking further official action.
Sir John also said he heard evidence that the recommendations were not distributed beyond the small group of anaesthetists who drafted them in the first place.
He added that Dr Murnaghan and Dr Ian Carson, who was the trust's medical director at the time, "should never have allowed so important a learning opportunity to go unexplored" and that "lessons were not learned and that was to compound tragedy".
Dr Murnaghan is one of a number of clinicians criticised in the Hyponatraemia Inquiry who have been investigated by the General Medical Council (GMC) and will not face a fitness-to-practise hearing.
A decision to close an investigation does not mean that the concerns raised about a doctor were not serious - by law, the GMC must apply a threshold to all complaints and can take action only where there is a risk to future patients or public confidence.
A GMC spokeswoman said: "Our thoughts and sympathies are still with Adam Strain's family, and all those affected by hyponatraemia-related deaths in Northern Ireland.
However, after carefully considering this case, we did not find evidence that action would be necessary to protect future patients."
Dr Murnaghan has described the GMC decision as a "welcome conclusion" into his "involvement in this unfortunate and tragic patient outcome".