Hyponatraemia inquiry: Children's hospital deaths were avoidable

An inquiry into the deaths of five children in Northern Ireland's hospitals has found that four of them were avoidable. The findings followed a 14-year inquiry into hyponatraemia-related deaths.

Who were the children? Timeline of hyponatraemia inquiry Hyponatraemia is a medical condition that occurs when there is a shortage of sodium in the bloodstream. The damning report was heavily critical of the "self-regulating and unmonitored" health service.

The Belfast, Southern and Western health trusts said they "unreservedly apologise" to the five families. Media captionMr Justice O'Hara calls on medical professionals to put the public interest first.
Mr Justice O'Hara was scathing of how the families were treated in the aftermath of the deaths and also of the evidence given to the inquiry by medical professionals.

He said that "doctors and managers cannot be relied on to do the right thing at the right time" and that they had to put the public interest before their own reputation. He also said that some witnesses to the inquiry "had to have the truth dragged out of them".
Media captionJennifer Roberts speaks about the death of her daughter, Claire
The inquiry was set up in 2004 to investigate the deaths of Adam Strain, Claire Roberts, Raychel Ferguson, Lucy Crawford and Conor Mitchell. The chairman said that the deaths of Adam Strain, Claire Roberts and Raychel Ferguson were the result of "negligent care". Image caption The inquiry's report has made 96 recommendations In his report, Mr Justice O'Hara found that:

while investigating the death of Adam Strain, the inquiry had been met with "defensiveness and deceit" and that "information was withheld" about what happened to Adam in the operating theatre
there "was a cover up" in the death of Claire Roberts, whose death was not referred to the coroner immediately to "avoid scrutiny"
poor care was "deliberately concealed" in the death of Lucy Crawford
there was a "reluctance among clinicians to openly acknowledge failings" in the death of Raychel Ferguson in the death of Conor Mitchell, there was a "potentially dangerous variation in care and treatment afforded to young people at Craigavon Hospital"
In total, the inquiry made 96 recommendations including the establishment of a duty of candour on medical professionals "to tell patients and their families about major failures in care and to give a full and honest explanation".


Media captionThe chair of the hyponatraemia inquiry believes evidence was withheld about Adam Strain's death Mr Justice O'Hara added that the "reticence of some clinicians and healthcare professionals to concede error or identify underperformance or colleagues was frustrating and depressing".

Marie Ferguson, the mother of Raychel, said that the inquiry was "confirmation of what we knew happened".

Image caption Marie Ferguson, the mother of Raychel, during the delivery of Mr Justice O'Hara's findings "She went into hospital as a young, healthy girl and was neglected by the nurses, neglected by the doctors and, ultimately, died because of the negligence of those we consider health professionals."

Mrs Ferguson added that she had been devoted to finding the truth and "what I experienced during this journey is inexcusable".

"The trust and their lawyers abused their position by trying to cover up the truth. They robbed me of the most precious wee girl," she said.

"For hospital medical staff to make a mistake is forgivable, however, to orchestrate a cover-up and to deliberately mislead is totally unforgivable." The family of Conor Mitchell said medical staff had "failed Conor so badly".

"The reticence with which the investigation has been handled by the trust and their advisers and the grudging way in which the limited acceptance of failings and minimal apology given were extracted, indicates a reluctance on their part to undertake the learning and the change in attitude needed to reduce the trauma caused in cases such as these," they said.

source: www.bbc.com