Findings of inquiry are deeply disconcerting
It is not hyperbole to describe the findings of a lengthy investigation into the deaths of five children in Northern Ireland hospitals as damning, shocking and frightening.
Sir John O'Hara QC, who led the 14-year-long Hyponatraemia Inquiry, delivered a damning series of verdicts. His revelation that some witnesses had to have the truth dragged out of them and others deliberately withheld vital information is a shocking condemnation of those involved.
But that was not all. Sir John said it was time that the medical profession and health service managers stopped putting their reputations and interests first.
The deaths of three of the children, he said, were avoidable, with all three given medical care which fell well below acceptable standards.
Perhaps the most damning comment came in relation to one of those, four-year-old Adam Strain, who died folowing a kidney transplant in 1995. Sir John said that after all the written and oral evidence he had received he still doesn't know the full story of what went on in the operating theatre and he believes that evidence was withheld.
Seldom has anyone heading an inquiry like this been so emotional when delivering the findings. Sir John was obviously deeply affected by what he uncovered and by the consequences for the families.
Those families deserve the highest praise for their determination to uncover the truth of what happened to their children and for their resolution in staying with the inquiry for such a long period of time.
One of the families was misled time after time over why their child died, and the death was not referred to a coroner for a substantial period of years to avoid, in the words of Sir John, the scrutiny of negligent care she had received.
Quite rightly the expertise, dedication and care displayed by those who work in the health service is frequently praised. But in the cases under investigation not only was care negligent in some instances, but determined efforts to conceal what went on were made. That was inexcusable and is not only an indelible blot on the health service, but the actions of a few have cast a cloud over the work of the many. All of us have had our faith in the health service shaken.
Sir John's recommendation that a duty of candour should be placed on all who work in the health service - they must tell the truth or face possible criminal charges - is a positive one, but also a sad commentary.