Belfast Telegraph

Trust withheld information from inquest, children’s death probe told


Many more child deaths may have been caused by hyponatraemia but never disclosed by the authorities, the chairman of a public inquiry has warned.

John O’Hara QC was speaking as it emerged that a health trust in Northern Ireland withheld evidence from an inquest probing the death of a nine-year-old girl.

Mr O’Hara said hospital managers had also rewritten statements which were later submitted to inquests.

He was addressing an inquiry which is focusing on the deaths of three children in hospitals in Northern Ireland.

It is also looking at the events following the death of another infant and issues arising from the death of a fifth child.

The issues of hyponatraemia and fluid management are central to the probe.

Mr O’Hara told yesterday’s hearing that a “specific concern” was “the underplaying of information or the withholding of information” — which he described as a “recurring theme in this inquiry”.

Referring to the revision of one individual’s statement by managers, he told Senior Coroner John Leckey: “This isn’t the only example in this inquiry of a statement being changed at the instigation of managers within the hospitals in order to control the information which reached you. I presume you find that disappointing?”

“I do,” Mr Leckey replied.

The inquiry heard that Altnagelvin Health and Social Services Trust — which is now part of the Western Trust — obtained a report from a consultant paediatric anaesthetist following the death of Londonderry schoolgirl, Raychel Ferguson.

The nine-year-old died in June 2001, 36 hours after she wasadmitted to Altnagelvin Hospital with stomach pains and nausea.

In the report by a Dr Warde, he cited severe and prolonged vomiting following surgery carried out on Raychel.

The report was not provided to Mr Leckey, who was the coroner presiding over Raychel’s inquest at the time, the inquiry heard.

“This is one public body, one judicial officer (the Coroner’s Office) investigating the causes of a child’s death, and a public body (the trust) obtaining an expert’s report and then deciding that, because it’s inconvenient to them, they will withhold it from the Coroner,” Mr O’Hara said.

He added that while the inquiry is focusing on five children, “the truth is that nobody knows if there are more hyponatraemia deaths which haven't been disclosed”.

Earlier yesterday, Mr Leckey said he was “extremely disappointed... and upset” to learn that best practice guidelines were not circulated to all hospitals in Northern Ireland.

The inquiry heard that senior staff at the Royal Belfast Hospital for Sick Children were not aware of the proposed guidelines.

Mr Leckey revealed that he had “real concerns” around the circumstances of the children’s deaths.

However, he added that there is more “openness” of late in cases which are referred to the Coroner’s Service.

He said that could be explained by “medical professionals being encouraged to admit mistakes if they believe mistakes may have occurred”.


The inquiry is examining the deaths of three children — Adam Strain, Claire Roberts and Raychel Ferguson.

It is also looking at the events following the death of Lucy Crawford (17 months) and specific issues arising from the treatment of Conor Mitchell (15).

The children died in hospitals across Northern Ireland between 1995 and 2003.

In the case of four of the children, the inquest verdict on their death stated that hyponatraemia was a factor.

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