Attorney General concerned at Northern Trust's reporting of deaths

By Niall McCracken

NORTHERN Ireland’s Attorney General has expressed “very great concern” that a number of deaths being investigated at the Northern Health Trust were only referred to the coroner after intervention from his office.

On March 28 2014 the then Health Minister, Edwin Poots, told the Assembly that 11 deaths were under investigation at the Northern Trust because the trust’s response was said to be “below standard”.

Now the Attorney General, John Larkin QC, has stated in a letter to Stormont’s Justice Committee that six of the cases had not been reported to the coroner immediately after death. He said four of these were “only referred” after his request for information, which occurred immediately after he read media reports of the deaths on March 30.

In Northern Ireland doctors have a statutory duty to report any sudden or unexplained deaths to the coroner.

The Northern Trust said: "In six incidences there had been a delay in notifying the coroner. The trust can confirm that all incidences were notified to the coroner by 24 April 2014.

“Following the identification of these incidences a training programme is underway in the trust to ensure that the coroner is notified immediately and that appropriate action is taken as necessary.”

We asked the trust to comment on the specific timing of when the four cases highlighted by the Attorney General were reported to the coroner, but it declined.

In his letter, Mr Larkin said: "Of these deaths, six had not been reported to a coroner at the time of death and four were only referred after my request for information.

“That medical practitioners had not reported these deaths before my intervention, and a considerable time after these deaths, is of very great concern.”

The latest development comes as Mr Larkin is seeking new powers to investigate hospital deaths here. However this is currently being opposed by the Chief Executive of the Health and Social Care Board who has told the Justice Committee that the powers are “neither necessary nor desirable”.

While the circumstances in the majority of these cases are unknown, in the past some hospital deaths have been been referred late to the coroner as a result of internal reviews uncovering new information.

A GAP IN INFORMATION

Mr Larkin is the chief legal advisor to the Northern Ireland Executive.

In Northern Ireland the Attorney General can direct the coroner to hold an inquest into deaths where he considers it “advisable to do so”. This includes deaths that occur in a hospital setting.

As reported by The Detail earlier this year, Mr Larkin previously told Northern Ireland’s Justice Committee that he lacked the necessary powers to “obtain papers or information that may be relevant to the exercise of that power”.

As a result he asked the committee to arm him with new powers to compel health trusts to disclose documents on controversial hospital deaths.

The Attorney General is currently seeking this power through an amendment to the Justice Bill which would give his office access to confidential health documents, such as Serious Adverse Incident reports.

In March this year the former Health Minister, Edwin Poots, told the Northern Ireland Assembly that he had been made aware of 11 deaths in the Northern Health Trust in which the trust’s response was said to be below standard.

Despite questions by MLAs at the time, Mr Poots did not reveal in how many of the cases there had been late reporting to the coroner.

However in a letter sent to the Justice Committee on September 16 2014 , the Attorney General outlined that his office had sought information about the 11 deaths being investigated by the Northern Trust.

Mr Larkin said the information further underlined the need for his office to be granted new disclosure powers.

In the letter he stated: “I immediately sought information from the Northern HSC Trust concerning each death and on 6 June 2014 I was supplied with material relating to eleven deaths.

“Of these deaths, six had not been reported to a coroner at the time of death and four (of these) were only referred after my request for information.

“That medical practitioners had not reported these deaths before my intervention, and a considerable time after these deaths, is of very great concern and highlights the importance of my proposed amendment in closing the current information gap.”

In a statement to The Detail the Northern Trust said: "In six incidences there had been a delay in notifying the coroner. The trust can confirm that all incidences were notified to the coroner by 24 April 2014.

“Following the identification of these incidences a training programme is underway in the trust to ensure that the coroner is notified immediately and that appropriate action is taken as necessary.”

“A VERY SERIOUS MATTER”

John Larkin’s intervention comes just months after a string of hospital tragedies have come under scrutiny – including a failure to report serious incidents to the coroner.

In a previous story, The Detail interviewed the family of a man whose death is one of the 11 under investigation by the Northern Trust.

Eighty-one year old Neil Cormican died in April 2010 after he was mistakenly prescribed potassium while being treated at Antrim Area Hospital.

Following his death health staff failed to immediately refer the case to the coroner’s office and gave the family the option of not referring the case.

During Mr Cormican’s inquest last year, Northern Ireland’s senior coroner, John Leckey, expressed his frustration at delayed referrals and said a failure to report hospital deaths that require further investigation to his office was a “very serious matter” that could warrant police investigation.

In August this year The Detail also reported on the case of 61-year-old Alfie Hannaway who had been on the blood thinning drug warfarin after a major heart operation at the Royal Victoria Hospital. He died of a brain haemorrhage after being re-admitted to the hospital three weeks after his surgery in September 2013.

His death was not initially investigated by the Coroners’ Service for Northern Ireland but was re-opened following a campaign by the Hannaway family.

While the case was still being investigated by the coroner the Attorney General intervened and directed an inquest into Mr Hannaway’s death warning that “any further delay could have an adverse effect on public safety”.

A DEGREE OF URGENCY

The Attorney General’s proposed amendment for new powers was initially considered during the committee stage of the Legal Aid and Coroners’ Courts Bill.

During an evidence session in May this year Mr Larkin stressed that the amendment would be confined to deaths that occurred within a health and social care setting and would not affect historic inquests which involved the police or military.

When the committee asked for written submissions on the proposed amendment, several organisations responded in favour of the Attorney General’s proposal including the Human Rights Commission, the Law Society and the Information Commissioner’s Office.

A number of Health and Social Care Trusts responded with varying degrees of support for the amendment, stressing the need for further clarification.

The then Health Minister Edwin Poots stated that the power would have to meet data protection requirements and that there would have to be a clear indication of how it could be used in practice.

At the time members of the committee decided that further clarification was needed and the amendment was not included as part of the Legal Aid and Coroners’ Courts Bill.

As a result the amendment is now being considered as part of the the Justice Bill which is being scrutinised by the Justice Committee.

In a written submission to the committee, the Health and Social Care Board said it was unable to support the Attorney General’s proposal as the power was “neither necessary nor desirable”.

In relation to the specific issue of the Attorney General obtaining access to Serious Adverse Incident Reports (SAls), the board stressed that the purpose of SAl investigations was to learn from mistakes.

In a letter to the committee from September 15 2014 , the board’s Chief Executive Valerie Watts said: “As such, openness in reporting is positively encouraged in return for an assurance about the confidential nature of any such report. The SAl reporting system is expressly intended not to be an investigation to determine fault or blame but rather to try to facilitate learning in order to prevent recurrence.

“The granting of this statutory investigatory power to the Attorney General where he has expressly stated that he would intend to exercise this power to gain access to SAl documentation in order to assist him in exercising his discretion under Section 14 could well have the detrimental effect of discouraging openness and transparency during the SAl investigative process.”

In concluding his letter to the Justice Committee Mr Larkin stated that he did not believe that his amendment would create a burden on the health service and said that given the circumstances surrounding the Northern Trust deaths, the issue should be dealt with "a degree of urgency”.

To read The Detail’s previous coverage around health care and accountability issues please click here.