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The public inquiry into Hyponatraemia-related Deaths was announced in 2004
A HOSPITAL consultant who played a key role in compiling new guidelines on fluid management after the death of a young patient, today insisted he’d had no knowledge of another child’s death until it had become public knowledge years later.
Dr Geoffrey Nesbitt denied all knowledge of the death of 17 month-old Lucy Crawford at the Erne Hospital in Enniskillen a year before nine year-old Raychel Ferguson died in Altlnagelvin in Derry, the hospital where he was medical director, even though he sat on a working group into fluid dangers, with other doctors who were aware of what had happened to Lucy.
Lucy died in 2000 but the cause of her death was not reported to the coroner and was not reflected in her death certificate at the time. It was only brought to the attention of the coroner in 2003 shortly after he investigated Raychel’s death.
Dr Nesbitt also rejected accusations that he had held out false hope to Raychel’s family in the aftermath of her collapse by transferring her to the Royal Victoria Hospital, where she was pronounced brain dead without further treatment.
He rebuffed the parents’ claims that he had suggested to them that Raychel would have surgery there but he maintained that he had fixed in his mind that Raychel might have suffered a haemorrhage and that the transfer to the specialist unit in the Royal was justified.
Giving evidence into the inquiry into the deaths of Raychel and other children from fluid deaths in Northern Ireland, Dr Nesbitt said he had seen other children in a similar position to Raychel – having suffered severe brain swelling and whose pupils were fixed and dilated – survive.
He also countered previous evidence from a junior doctor who recalled that after a second scan at Altnagelvin there had been a discussion with the doctors in Belfast in which it was confirmed that there was no haematoma [a clot of blood] on the scan and where it was agreed that Raychel had a very bad prognosis – she would not survive.
Dr Nesbitt said the doctor concerned had been “wise after the event” and had been claiming that the team at Altnagelvin knew the full picture; “We didn’t. I was there, I was the senior consultant and was heavily involved in the treatment.”
Questioned by Inquiry Chairman, Mr Justice O’Hara, he agreed that sometimes, perfectly innocently, people’s memories of different events merged or were just wrong.
Dr Nesbitt: It’s a danger. A real danger. I can see it myself when you listen to other people’s evidence. It almost affects what you remember yourself, and I have examples of that where I almost changed what I was thinking, but realised that, no, I was right all along.
Dr Nesbitt said he was stunned by the death of Raychel and immediately set about researching the cause and soon encountered two journal articles which pointed to the danger of fluid – especially the hypotonic fluid used in children’s wards in Altnagelvin at that stage, Solution 18.
Immediately after Raychel’s death he was critical of the volume of fluid given to her, believing it to had been too high, but he said he then looked at it again in the following days and concluded that it was a safe amount of fluid – had it contained sodium – and that it was the composition of the fluid which was to blame, combined with an “idiosyncratic reaction” on Raychel’s part and the fact that her post-operative state made her more likely to retain water.
Shown documents by Counsel to the Inquiry, Mr John Stewart, in which Dr Nesbitt subsequently appeared to acknowledge that Raychel’s fluid infusion was excessive, he said that this was “a technicality”.
The week after Raychel’s death Altnagelivin hosted a critical incident review which brought members of the team together to discuss what had happened to Raychel. There had been a rumour that the Royal was critical of Altnagelvin, he said.
Dr Nesbitt: The feeling in the room was that we were going to be criticised for having done something, used the wrong fluid, and of course I had done the research over the weekend from the Sunday and had read about No. 18 Solution … had obviously put two and two together and realised that the risk associated with No. 18 Solution was key to the whole thing. So putting that together with the rumour that we’d used the wrong fluid, was attracting the idea certainly was that we would be criticised by the Royal. I mean, that was the feeling in the room. We felt “gosh, what have we done wrong?”
Dr Nesbitt confirmed that he had a conversation with a doctor at the Royal in which the doctor told him that the Royal no longer used Solution 18 and referred to other fluid deaths but Dr Nesbitt said he assumed these were outside Northern Ireland.
He said he also phoned other hospitals to warn them about Solution and, in the course of this discovered that the Tyrone County in Omagh – part of the then Sperrin Lakeland Trust to which the Erne also belonged – had also stopped using Solution 18.
Asked if he phoned the Erne, he said:
Dr Nesbitt: I don’t recall ringing the Erne. That’s not to say I didn’t. There are hospitals I have listed that I remember distinctly it wasn’t a record in that way. I never thought it would come to this.
Mr Justice O’Hara: The Erne was in the same — at that time was in the same Western Board area, wasn’t it?
Dr Nesbitt: I rang Omagh hospital. So for me Sperrin Lakeland is two hospitals, the Erne Hospital and Omagh hospital. And from the Sperrin Lakeland perspective I rang Omagh because I actually knew the anaesthetists in Omagh better than I would have done the anaesthetists in the Erne.
Mr Justice O’Hara: You’re now describing this as if you took a conscious decision not to ring the Erne.
Dr Nesbitt: No, I’m not describing that. I may have rung the Erne, I don’t recall it.
Mr Justice O’Hara: If you’d rung the Erne, you must have received the information about Lucy unless there’s some extraordinary development. Because they had a death in which Solution No. 18 was implicated.
Dr Nesbitt: You would assume that that’s the case, but if I had phoned the Erne and I wasn’t told that, that would be a criticism of the Erne.
The inquiry also explored the working group which involved a doctor from the Erne and doctors from the Royal. The inquiry has established that those doctors all knew about Lucy, but Dr Nesbitt, who sat on the group with them, maintained that Lucy’s case never surfaced in the discussions.
Mr Justice O’Hara: I am very concerned about how much information was shared at the time. Dr Carson it was who came to this inquiry and said that doctors are very good at announcing their victories but not proclaiming their mistakes, and what we’re exploring here is whether there was more which was known behind closed doors than has been disclosed to the inquiry or faced up to. I think you know the point of this questioning.
Dr Nesbitt: I do know the point.
Mr Justice O’Hara: And it seems very curious to us that if there is a working party and this is a build-up to the working party, which is reviewing hyponatraemia, which can be fatal in children’s cases, that there was not at least some discussion about the fact that apart from Adam Strain [who died in 1995 during surgery at the Royal], other children had died in Northern Ireland from deaths associated with hyponatraemia. At the very least that must — even if we say that there was some misdiagnosis of the reasons for Claire’s death [Claire Roberts who died in 1996 at the Royal but whose true cause of death only emerged in 2004], which might be a generous assumption, I don’t know and can’t understand how this exercise, this exchange of the people who knew most about this area of medicine and the people who discussed it most, the people who were most worried about it and the people who drew up the guidelines could possibly have done this work without revealing Lucy. And what Mr Stewart is probing is the question of whether in fact Lucy was known about, but that nobody — to put it bluntly, nobody’s letting on about it.
Dr Nesbitt: Well, can I, for avoidance of doubt, say that I did not know of Lucy Crawford. I did not know the details of Adam Strain … If other people in the room knew that they too had a case like that, it was for them to say it. I had no way of second-guessing them.
Mr Justice O’Hara: Do you appreciate how — I mean, I’ll obviously weigh up all your evidence with all the other oral evidence and the documentary evidence, but do you understand how to an outsider it seems at the very least curious that not even Lucy’s death cropped up in the context of the working party?
Dr Nesbitt later said that the remit of the meeting had been to get consensus on intravenous fluids in children, not to investigate the deaths of any particular children but the inquiry chairman said:
Mr Justice O’Hara: What strikes me at the moment as being a little strange about that is if you’re going draw up guidelines as a result of deaths, the people who are drawing up the guide lines need to know something about the circumstances in which each child dies to ensure that the guidelines will cover the circumstances of those deaths. And if there’s no discussion about Adam, if there’s no discussion about Claire and there’s no discussion about Lucy, and the only child who’s discussed is Raychel, then how does the working party know that the guidelines which it has drawn up will actually cover the deaths which have occurred in Northern Ireland?
After further exchanges, Dr Nesbitt said: “If you’re asking me should they have discussed those deaths, then I think, yes, they should.”
Later Dr Nesbitt was shown a press statement written by the trust and released by the WHSSC in February 2003, which stated that the clinical practices used during Raychel’s care were at that time accepted practice in all other area hospitals in Northern Ireland – when Dr Nesbitt knew that the use of Solution 18 had been abandoned in the Royal and Omagh prior to Raychel’s death.
Dr Nesbitt said that this was “semantics” but Mr Justice O’Hara interjected to disagree, stating that the release had been sending out “a would-be reassuring message” to the public. And he said it was “unacceptable” to suggest that in February 2003 it was not recognised in Altnagelvin that mistakes had been made in Raychel’s care.
Mr Justice O’Hara: My point to the doctor is that he says he wants to — the purpose of this press release is to encourage public confidence or reassure the problem in the greater Derry area to bring their children to Altnagelvin. And my question is: does it ever occur that public confidence might be increased if Altnagelvin or any other hospital sometimes says, "We made mistakes but we are sorry we made mistakes, we are learning from them and the fact that we are learning from them is a reassurance for the public”. … That’s my concerns. I have been told about doctors’ defensiveness, I’ve been told about nurses’ defensiveness. This is institutional defensiveness … It doesn’t work. If there’s one thing that this inquiry shows it’s that that doesn’t work. If you want to reassure the public, doctor, just be open with the public.
Dr Nesbitt also maintained at today’s hearing that Raychel’s level of sickness after her operation and before her collapse had not been severe – a position which had been central to the trust resisting" admitting liability for Raychel’s death for twelve years until last Friday.
Dr Nesbitt denied having seen an expert report by Dublin doctor, Declan Warde – commissioned by the trust itself but then withheld by it – which referred to Raychel’s nausea as “severe and protracted” nor a report, also commissioned by the trust, by Dr John Jenkins which sought more information on how sick Raychel had been.
However he said he did see the expert report provided to the Coroner by Dr Edward Sumner from Great Ormond Street Hospital in London, which also remarked on very severe sickness suffered by Raychel.
The inquiry has already seen a letter within the Trust shortly before Raychel’s inquest which sets out that its barrister believes the trust should try to “counter” Dr Sumner’s claim and call the nurses to the inquest to challenge it. Dr Warde’s report was never shared with the coroner and Dr Warde was not called to give evidence.
Mr Justice O’Hara said that Dr Sumner’s report appeared to agree with the family’s analysis of the family about the severity of Raychel’s vomiting.
Mr Justice O’Hara: Then Dr Warde’s report comes in and he too seems to agree with the analysis. Now, at that point how come it doesn’t occur to somebody: “look, actually the family’s right. The family’s right about the severe and prolonged vomiting”. So insofar as the recollections of the critical incident review end with Dr Fulton being unable to reconcile or you being unable to reconcile the views of the family on the one hand and the nurses on the other, there are then two experts’ reports which come in, which are pretty much in the family’s camp. So why wasn’t that recognised and faced up to?
The inquiry continues tomorrow.
© The Detail 2013