NEWS of another hold-up marked the opening of the long-awaited Inquiry into Hyponatraemia-Related Deaths today (Monday) but the first public hearing also cast light on another phenomenon: extraordinary delays in the processing of investigations against individual doctors in the cases.
The inquiry formally opened in Banbridge, only to adjourn for what is expected to be a matter of weeks. But in the course of the opening statement presented by Counsel to the Inquiry, Moyne Anyadike-Danes QC, it emerged that complaints against eight doctors lodged in 2004 with the General Medical Council took at least four-and-a-half years to process, with three still unresolved more than seven years on, including a complaint against a doctor who has tried to erase himself from the medical register.
Chairman of the Inquiry, John O’Hara QC, and his team are investigating the deaths of five children who died in hospitals in Northern Ireland between 1995 and 2003. Each of the children’s intravenous fluid regime is implicated in the deaths; it is said to have caused low sodium – hyponatraemia – in four of the children, which in turn caused lethal severe brain swelling.
The children are:
Adam Strain who died in November 1995, aged four years, in the course of a kidney transplant at the Royal Belfast Hospital for Sick Children;
Claire Roberts who died in October 1996, aged nine years, at the Royal Belfast Hospital for Sick Children. At the time her death was wrongly linked to epilepsy;
Lucy Crawford who died in April 2000, aged 17 months, following treatment at the Erne Hospital, Enniskillen, for a stomach bug. Like Claire, Lucy’s death was not reported to the Coroner at the time of her death. Instead it was attributed to dehydration, rather than the fluid overload caused by the hospital;
Raychel Ferguson who died in June 2001, aged nine years following an appendectomy at Altnagelvin Hospital, Derry;
Conor Mitchell who died in April 2003, aged 15 years, who died following treatment at Craigavon Area Hospital. Like the other children, Conor suffered brain swelling, although his fluid regime appears to have caused hypernatraemia – excess sodium – rather than the low sodium noted in the four other cases.
Most of the day’s proceedings revolved around Mr O’Hara’s announcement that he would be adjourning proceedings following fresh evidence by a new senior expert witness, who has cast doubt on whether hyponatraemia was the cause of Adam’s death.
However Ms Anyadike-Danes also raised the many questions to be answered by the inquiry about how the clinical practices of the doctors and nurses involved, as well as the culture within Northern Ireland’s healthcare system which allowed deadly mistakes in our hospital go undetected – and then be repeated over the course of years.
She revealed the status of investigations by the General Medical Council (GMC) which licences doctors in the UK and the Nursing and Midwifery Council (NMC) which performs the same function in the nursing profession.REFERRALS BY THE CORONER
The first of those investigations was instigated by Northern Ireland’s Chief Coroner, John Leckey, in February 2004 following the conclusions of the belated Inquest into Lucy Crawford’s death. The coroner described what he saw as his “very serious concerns about the quality of the medical care Lucy received whilst a patient in the Erne Hospital”.
The referral concerned the conduct of Dr. Jarlath O’Donohoe, Consultant paediatrician and Dr. Amer Malik, Senior House Officer at the Erne Hospital. Ms anyadike-Danes revealed that in September 2008 the case against Dr. Malik was cancelled. Meanwhile on 30th October 2009, a Fitness to Practise Panel found Dr. O’Donohoe guilty of serious professional misconduct after a public hearing.COMPLAINTS BY RAYCHEL’S PARENTS
In November 2004, the parents of Raychel Ferguson made a formal complaint to the GMC about six doctors. The Ferguson’s complaints against five of them focused on their behaviour in the aftermath of Lucy’s death. They argued that the death of Raychel could have been avoided if Lucy Crawford’s death had been “properly and independently investigated in 2000”.
The doctors concerned were variously implicated in the failure to report Lucy’s death to the Coroner – which would have prompted an inquest much sooner; the failure to clearly and publicly flag up hyponatraemia as the cause; and the failure to make hospitals sufficiently aware of the dangers of intravenous fluids so as to prevent subsequent deaths.
It took the GMC five years to decide that no further action should be taken in the case of the then Chief Medical Officer Dr Henrietta Campbell, but it noted that she should “reflect on this decision and the concerns expressed by the complainants”, Ms Anyadike-Danes, disclosed.
Further action was also ruled out in the cases of the Clinical Director of Critical Care at Altnagelvin Hospital, Dr Geoffrey Nesbitt; and Dr John Jenkins, a consultant paediatrician at Antrim Area Hospital and the Department of Child Health at Queen’s University, Belfast.
However the cases against Dr Donncha Hanrahan, Consultant Paediatric Neurologist RBHSC and Dr. James Kelly, former Medical Director at Sperrin and Lakeland Trust (now subsumbed into the Western Trust) are still on going –seven years later.
In November last year the GMC also informed the Inquiry that Dr Murray Quinn, Consultant Paediatrician at Altnagelvin Hospital, who privately provided Sperrin Lakeland Trust with a report into Lucy’s death which failed to identify hyponatraemia as a factor, had applied for “voluntary erasure”. This application was refused in December 2011 on the basis that it was “not in the public interest to dispose of his case in this way”, the inquiry heard. As a result the case against Dr. Quinn is also continuing.THE NMC
The NMC have also dealt with two sets of complaints. The first concerned complaints made in October 2004 about four members of the nursing staff at the Erne Hospital by Lucy Crawford’s parents and their involvement in Lucy Crawford’s case. They were Bridget Swift, Sally McManus, Bridget Jones and Teresa McCaffrey. Those complaints were all investigated in 2007 and closed in January 2007 on the basis of there being no case to answer, Ms Anyadike-Danes told the hearing.
The other complaint was made in December 2009 by Conor Mitchell’s grandmother, Judith, about a nurse at Craigavon Area Hospital and her involvement in Conor’s case. On 13th July 2011, the Conduct and Competence Committee panel of the NMC found nurse Ruth Bullas guilty of professional misconduct and her fitness to practise impaired.
The inquiry heard that the first of the three charges against Nurse Bullas concerned the failure to: “document in the nursing notes, the reports you received from patient A [Conor]’s mother and grandmother that they had witnessed patient A suffering from seizures”. The second concerned a failure to escalate to a senior member of staff for a second opinion, the reports of such activity. The panel accepted the evidence of Sister Irene Brennan that no one had reported any seizures, spasms or twitchings to her concerning Conor and that if she had been informed of that type of activity she would have attended Conor herself. It found as part of its reasons for the finding of impairment:
A ‘striking off Order’ had been made in the case of Nurse Bullas, the inquiry was told. The panel stated as part of its reasons for the sanction imposed: “Responsibility for the deficiencies in the care provided to Conor at Craigavon Area Hospital should [not] be borne by her [Ruth Bullas] alone. The evidence before the panel revealed further wide-ranging and systemic deficiencies in Conor’s treatment and care. These included the fact that the Registrant was delegated responsibility for Conor’s nursing care with little or no ongoing support despite her lack of experience and the fact that she had not yet completed her preceptorship, inadequate handovers, briefings and reporting processes, a failure to provide Conor with nursing staff who were sufficiently and suitably qualified, and a lack of timely access to paediatric facilities and expertise.”
The Inquiry will consider the findings and observations made by the panel in relation to the knowledge of the nurses at Craigavon Area Hospital of appropriate record keeping and the Hyponatraemia Guidelines.
The public hearings were delayed in November last year when the inquiry was made aware of new documents discovered by the Belfast Trust.
The schedule for the inquiry is suppose to see it run from February 20th until November 19th this year.
The Inquiry Chairman said that despite the “unavoidable delays” he was determined to make this deadline.