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The Hyponatraemia Inquiry is being heard at Banbridge court house
By Ruth O’Reilly
A FORMER high-profile health chief was today challenged over her leadership of one of Northern Ireland’s biggest hospitals as a public inquiry heard her deny knowledge of a series of events surrounding the death of a child there.
Stella Burnside, who was chief executive of what was Altnagelvin Trust in 2001, the time nine year-old Raychel Ferguson was infused with a lethal dose of fluid, was also scrutinized over the trust’s willingness to fully own up to its responsibility for the death to her parents, the Coroner and the public.
At the inquiry into fluid deaths in Banbridge, Mrs Burnside denied there had been any attempt to mislead the coroner about Raychel’s death, saying she had no knowledge of a letter to him that rebutted the family’s account of events – which had been backed up by an expert – Dr Ted Sumner – acting for the Coroner.
She said she has no knowledge either of another report produced by a different medical expert – Dr Declan Warde, who had been commissioned by lawyers acting for the trust – which clearly pointed to the hospital’s culpability in Raychel’s death but which was withheld from the coroner.
Mrs Burnside was also questioned by Counsel to the Inquiry, John Stewart, about why a letter had been sent to the coroner, stating that nurses had been interviewed in depth about how the severity of sickness Raychel had experienced – when no such interviews had taken place.
Mr Stewart: Do you think it’s right for a trust to write to a coroner before the inquest to put before him such inaccurate misinformation?
Mrs Burnside: I appreciate you’re saying it’s inaccurate and misinformation. I didn’t compose the letter. I don’t believe I was shown the letter. I certainly didn’t expect anyone would have intended to mislead and if they had, I would have had the dimmest view of it.
Mrs Burnside said she only became aware of the existence of the Warde report earlier this year and had no part in any decision over whether it would be handed to the coroner, when he held his inquest in 2003.
And she was asked about a press statement issued by the trust in 2003 which said that the hospital had been following what was accepted practice in all hospitals in Northern Ireland at the time – when it was known that two hospitals had stopped using fluids of the type associated with Raychel’s death, before she died.
Mrs Burnside: I would not have deliberately misled the public. That was saying, ‘It was a terrible thing that happened but we were behaving, largely, in accordance with what we knew was established practice at the time’.
And she indicated that she had been keen for the trust to reach a quick settlment with Raychel’s family, when they sued back in 2003 – in the event, it took until last month for liability to be accepted by the trust.
Mrs Burnside was manager of Altnagelvin Hospital from 1993 and led it into trust status in 1996. She stepped away from the post in November 2004 to become the inaugural chief executive of the Regulation and Quality Improvement Authority.
Questioned about the structures for ensuring best practice in the hospital, she said that since the trust started to move towards trust status, she had set out to change the culture and accountability systems of the hospital but she emphasized that clinical professionals such as doctors, nurses and physiotherapists were personally accountable for their professional actions.
And at one stage she spoke about problems in the health service broadly of managing people who belonged to professional bodies.
Mrs Burnside: It was regarded as very difficult to deal with poor performance in doctors because everything was seen as being clinical and professional. And it was very hard within those sorts of rules to deal with them as employment matters, which would have done as a matter of employment contract with every other member of staff. So this was trying to cross that barrier to make sure that poor performance could be deal with by employers and get a grip with by employers and not have to wait from the long time reports back from the GMC.
Mr Stewart, questioned her about recommendations from a National Confidential Enquiry into Patient Outcome and Deaths (NCEPOD), particularly one that junior doctors should not carry out surgery without speaking to a consultant first – the inquiry has established that Raychel’s named consultant, Robert Gilliland was unaware of her existence until – at the earliest – the morning after a junior doctor removed her appendix.
Mr Stewart: Mr Gilliland was unaware of the 1989 NCEPOD recommendations that trainees were not to undertake surgery without consultant consultation. How was it that the recommendation of NCEPOD were not widely known, implemented, understood and adhered to within the hospital?
Mrs Burnside: I believe they would have been widely known … clinical experts would have brought them to the attention of the most senior level in the organization … that then informed how we were reshaping and redesigning services and we did a lot of service redesign in the organization to try and make sure that we met the parameters of NCEPOD.
The inquiry chairman, Mr Justice O’Hara, then set out the significance of how the recommendations had been overlooked.
Mr Justice O’Hara: Mrs Burnside, the reason why this is directly relevant to Raychel is this: if the NCEPOD recommendation had been followed, Mr Gillliland would have been contacted before Raychel was operated on ….If Mr Gilliland had at least been aware that she was in … at least it would have raised in his mind Raychel’s presence. Because Mr Gilliland is left with a best guess that she must have been mentioned to him at some point on the Friday morning on the ward round.
He also spoke of how the non-implementation of the recommendations continued, even after Raychel’s death and a critical incident review which was supposed to establish shortcomings in Raychel’s care.
Mr Justice O’Hara: In the aftermath of Raychel’s death there is no reference to NCEPOD recommendations – there’s still nobody picking up the fact that the NCEPOD recommendations weren’t on the radar.
Ms Burnside: I accept that.
Asked later what was Altnagelvin doing about the “wealth” of external advice, recommendation and requirement, she said:
Ms Burnside: Altnagelvin had a clinical director in charge of the speciality who was familiar with NCEPOD recommendations … who was responsible in his directorate for ensuring that consultants were assured about standards of performance of their juniors.
She was later asked about recommendations – reflected in the trust’s own annual report before Raychel’s death – for such deaths to be the subject of a multi-disciplinary clinical audit and to what extent such an approach had been used.
Ms Burnside: At the stage of 2001 I’m not sure how sophisticated a system of multidisciplinary clinical audit was … Audits of a multidisciplinary nature were undertaken by the clinical effectiveness co-ordinator … getting people from different disciplines around a table was almost unprecedented.
Mr Justice O’Hara interjected:
Mr Justice O’Hara: It’s short of a multi-disciplinary audit .. And if you don’t do a multi-disciplinary clinical audit in Raychel’s case, when do you do it?
Mrs Burnside: I’m humbled by what you say, chair, and clearly the very early and tardy development of clinical governance and recognition of internal systems within an external framework, we were slow and slower than I would have liked to have seen.
Mrs Burnside confirmed that a protocol had been set up at the trust the year before Raychel’s death for very serious incidents, but admitted that it had not been followed.
Mrs Burnside: I had not thought about this. I mean, this did not occur to me. I regret to say, until you brought this up at this inquiry, that I would not have followed protocol.
Mr Stewart: Why hadn’t it occurred to you? What’s the point of having a protocol when you don’t follow it?
Mrs Burnside: On reflection, in the cold light of day, that’s what a protocol is for.
She later suggested that because Raychel was pronounced dead at the Royal Victoria Hospital, rather than Altnagelvin, the protocol was not prepared for such an event.
She was then asked why the Clinical directors of Children’s and women’s services, Dr Denis Martin, and of Surgery, Mr Paul Bateson, did not attend the critical incident review which took place the week after Raychel’s death and which was attended by some staff involved in Raychel’s care.
She said she did not know where they were – but was then shown a document demonstrating that they were attending the management team meeting, which she was also attending.
Mr Justice O’Hara: In terms of showing leadership, in the most awful event that you can have, the death of a previously healthy child, how did the two doctors areas touch on the care of this child not go to the critical incident review?
Mrs Burnside: I’m afraid I cannot answer that but I have no doubt that Mr Bateson had a conversation with Mr Gilliland before he attended. I do not know whey were not there.
The inquiry has already heard that members of staff who did attend the review objected to minutes being taken out of fear of the notes being used in later litigation. The group meeting was the only engagement with staff; there had been no individual statements taken from staff for the review and the chair of the review left the meeting with a single sheet of paper, setting out a six-point action plan.
Mrs Burnside said she had been “clearly” led by the thinking that a routine administration of intravenous fluid had a potential danger that no-one at the hospital had recognized – at which stage the inquiry chair interjected.
Mr Justice O’Hara: I don’t accept that that is the singular concern about Raychel’s death. There’s a lot more went wrong in Raychel’s case than the fact that she was on Solution 18. And that’s why so many other children on Solution 18 didn’t die. If the Critical Incident Review focused only on Solution 18 as the reason for Raychel’s death, it missed a lot.
Mrs Burnside: I would just ask you to listen to what I’m saying and if it was misguided, which clearly in the light of all of the information that has been uncovered, say and daily here 12 years later, it was with great humility that I sit here and say my vision was narrow.
© The Detail 2013