Baby heart failure investigation criticised by Ombudsman

Dr. Frawley has been Northern Ireland Ombudsman since 2000

Dr. Frawley has been Northern Ireland Ombudsman since 2000

By Niall McCracken

AS the Northern Ireland Ombudsman releases his annual report today we can reveal details of one of the office’s most critical investigations into the Belfast Trust and their handling of an incident which led to heart failure of an infant during routine surgery.

What started with a campaign by one family to uncover the truth behind the near-fatal incident during their baby girl’s eye surgery, led to a damning account of the Belfast Trust’s handling of the situation, with a paper trail that leads to its most senior management.

In his report, the Northern Ireland Ombudsman Dr Tom Frawley criticises the Belfast Trust’s Medical Director Dr Tony Steven, for failing in his commitment to an “open and through” process that addressed the concerns of the family and he also highlights “serious deficiencies” in how it investigated the matter.

In a statement to the The Detail, the Belfast Trust said that it “accepted the Ombudsman’s findings and complied with its recommendations in recognition of this family’s distress.”

The mother of the infant patient involved in the original complaint has spoken exclusively to The Detail to tell us of the distress and anxiety the incident has caused her family over the past five years.

The patient is too young to remember the surgery and is unaware that the incident even occurred. For that reason her mother wishes to remain anonymous. However, she has made the decision to speak out to expose how she believes the trust failed her family.

The story comes as the publication of the Ombudsman’s annual report reveals that complaints about maladministration in Northern Ireland’s health and social care sector have increased by 12%.


In April 2007 Ms X’s 20-month-old daughter was scheduled to undergo a surgical procedure on her tear ducts at the Royal Victoria Hospital. What should have been a routine surgery appointment would result in complications when the nasal pump spray being used to administer the anaesthetic to the young patient failed to work.

As a result the nozzle was removed from the spray and it was poured into the patient’s nostrils, resulting in an overdose.

However, it would be three years before this information was fully disclosed to the family. As a result they were left in limbo about what caused the incident and if it had been an allergic reaction.

The family were never invited to attend a normal routine six week post-surgery review. In the years that followed they attended meetings and exchanged countless emails with senior trust staff, lobbied health committee members and sought their own independent advice to get answers about what happened to their daughter.

It wasn’t until February 2010 – when they received the last of three reports commissioned by the trust – that it was established that the nasal spray caused the critical incident.

However, the family wanted to pursue things further as their daughter’s medical notes had still not been amended to show clearly that she had no allergies.

On March 10 2010, the family received a final letter from Medical Director Dr Tony Stevens with no further mention of the governance issues, despite a previous commitment to investigate the matters. At this point Ms X contacted the NI Ombudsman.


In his report the Ombudsman outlined that Ms X’s daughter received an excess of a nasal preparation for surgery because the standard nasal spray ‘plunger’ used to administer the appropriate drugs was broken. As a result, the surgeon removed the top of the bottle and poured it into her nasal passage.

The dosage contained a mix of both drugs phenylephedrine and lignocaine, two drugs which are routinely used in surgeries of this nature.

The minor procedure was carried out under a general anaesthetic.

The report outlined that as it was not possible to deliver the nasal perpetration by the standard plunger method the “nasal container was opened and the clear liquid dropped into her daughter’s nasal passages without any record of the exact amount delivered to her system. Subsequently she began to show symptoms of an overdose."

The report also set out how Ms X has contended that this information had been available to senior management from the first day and that she repeatedly brought this point to their attention. However the trust’s assistant medical director Mr David Adams, in his account, claimed it was not brought to his attention until a conversation with the original anaesthetist two years later.

The trust only confirmed to the family there had been issues around a potential overdose while waiting on feedback from the first independent review. In an attempt to find answers Ms X sought her own independent advice.

In an interview with The Detail, she said: “As the trust continued to put up walls and drag their feet on their commitments for an independent review, a close friend of the family recommended that we talk to an anaesthetist who was not in any way connected to the case so that we could get a bit of perspective on the matter. So that’s what we did.

“After they examined all the medical and anaesthetic records that we had obtained from the trust, they immediately pointed to the events that had happened after the overdose. They raised concerns about the use of Propofol in the resuscitation of our daughter as it may well have introduced another risk factor.”

Three years after the surgery, Ms X received a letter from the trust’s Medical Director, Dr Tony Stevens. In the letter he advised that the trust did not accept that her daughter’s sudden deterioration was the result of an overdose of Lignocaine, followed by the “inappropriate use of Propofol”, but that that the trust’s firm belief was that it was cause by an overdose of Phenylepine.

Following her request for an external independent review, Ms X was informed that the trust had appointed an anaesthetist and ENT surgeon from outside the trust, but still within Northern Ireland.

However, as the Ombudsman highlights in his report, the two experts were not provided with the original clinical notes. Ms X says she repeatedly raised concerns about the independence of the review.

“I made no secret of the fact that I was sceptical about the independence of the reviews. I would often ask the trust to meet with me over these issues. I wanted to be part of the process but I was met with nothing. The constant pursuit for answers was just completely exhausting.”

The Ombudsman found that the initial report commissioned by the trust did not identify or fully acknowledge the failings of the trust’s initial investigation and questioned whether the review carried out by the independent experts were adequate investigations.

Dr Frawley found that early investigations were hampered by inaccurate information that assumed that the drug had been administered through a spray.

He is critical of their completeness because the trust did not provide a full range of background information, particularly the patient’s medical records.


Despite her continuing reservations about the independence of yet another consultant anaesthetist from inside Northern Ireland, Dr Stevens commissioned a review from a colleague in Belfast.

The Ombudsman’s report points out that in an email from Dr Stevens to Ms X from October 2009, Dr Stevens outlines that the objective of the review was to examine clinical issues and that he would ask someone from outside the trust to review the management of the complaint. However, this did not happen.

When Dr Stevens wrote to Ms X again in March 2010, he stated that he did not think there was any requirement to further investigate the management of the case, but acknowledged and apologised for its shortcomings.

Dr Frawley claims that this did not meet the expectation created when Dr Stevens referred to his commitment for an “open and through” process that addressed the concerns of the family and the wider issues raised in the case.

In concluding his report, the Ombudsman’s outlines his concerns around the fact that Dr Tony Stevens had stated that an independent review of governance issues would be carried out, but subsequently did not commission the review or offer any explanation of his decision not to carry out a review.


In response to the enquiries from the Ombudsman’s office from September 2010, the trust accepted that there were deficiencies in the initial investigations into the incident. The Ombudsman’s report outlines that the Trust’s assistant medical director along with the surgeon involved in the operation “deeply regretted” that neither of them explored the possibility that it could have been an overdose rather than a reaction further at an earlier stage.

The Ombudsman’s report outlines that the trust’s assistant medical director, Mr. David Adams, accepts that “he did not ask the correct questions at this point in time or access the information available to him and agrees this was an oversight on his part.”

The Ombudsman’s report outlined that while he is satisfied that the trust has acknowledged and apologised for deficiencies of the initial investigation, he is critical of the fact that the trust did not make any attempt to examine all available evidence, until the Ombudsman’s investigation.

The Ombudsman recommended that the trust provide the family with an apology of the deficiencies of its investigation and a payment of £5,000 in recognition of the “inconvenience, anxiety, distress, frustration, time and trouble in pursuit of their complaint.”

Ms X claims that lessons need to be learnt from her daughter’s case.

“I knew I had to get an answer for the simple fact that if my daughter ever had to go to hospital again, I needed to know if this incident was a result of a mistake on the day or if she did have an allergic reaction and could have been at risk in the future when taking anaesthetics.

“If the trust had have been open and honest with us when the mistake was made we could have tried to understand how it happened but they were being extremely narrow minded on the whole issue right from the get go.”

The Ombudsman ruled that the handling of Ms X’s complaint was attended by maladministration.

As a result of this case the trust say there have been new protocols developed that restricts the use of phenylephrine in children under six and the trust claim that its Adverse Incident Reporting Policy now encourages staff to report all incidents and near misses through the development and fostering of an “open and fair culture.”

Ms X remains sceptical.

She said: “I think the trust have to prove that they are going to be open and honest with people before they can make such a statement, because it certainly wasn’t my experience. I still am appalled at how long it has taken and how draining it was to try and get to the truth of what happened when we almost lost our daughter."

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