By
The public inquiry into hyponatraemia-related deaths was announced in 2004
By Niall McCracken
A SENIOR clinician who worked at the Royal Belfast Hospital for Sick Children (RBHSC) at the time of a toddler’s death from fluid mismanagement has admitted to the Hyponatraemia Inquiry that the fact that her parents were not given an explanation in the aftermath was “not good enough”.
Consultant paediatric anaesthetist Dr Anthony Chisakuta told the inquiry in Banbridge yesterday (Wednesday, May 29) that he had concerns about the fluid management and standard of treatment 17-month-old Lucy Crawford had received at the Erne Hospital before being transferred to the RBHSC in April 2000.
The inquiry which is examining the deaths of three children is not investigating the circumstances of Lucy’s death at the request of her family. However, it is looking into what extent there was a failure to learn lessons from her death and what impact this may have had on the death of another child 14 months later.
The inquiry is focusing on criticism made in relation to the fluid management of Adam Strain (4), Claire Roberts (9) and Raychel Feguson (9), whose deaths are being investigated.
Among the issues being examined is how the cause of Lucy’s death was established and agreed by clinicians.
Hyponatraemia is a condition which results in a low level of sodium in the blood stream causing the brain cells to swell with too much water and in some cases resulting in death.
Dr Chiskauta was consultant paediatric anaesthetist at the Royal’s Paediatric Intensive Care Unit (PICU) when Lucy died in 2000.
Giving evidence at the inquiry yesterday Dr Chisakuta said at the time of Lucy’s death he had believed it could have been caused as a result of cerebral oedema brought on by fluid mismanagement at the Erne hospital.
Cerebral oedema is a swelling of the brain. It can happen for a variety of reasons. In some of the cases under investigation by the inquiry, water moved rapidly into the brain from the bloodstream.
When questioned by inquiry chairman John O’Hara QC about his concerns around Lucy’s standard of treatment at the Erne, Dr Chisakuta said Lucy’s medical notes outlined that she had been given a solution at the Erne that in his view looked as if “the volume was a little bit on the high side.”
Mr O’Hara asked Dr Chisakuta if he shared these concerns with Lucy’s parent’s following her death:
The Chairman: “Did you share these concerns with Lucy’s parents?”
Dr Chisakuta: “I cannot recall that no. Maybe if they had asked me a direct question.”
The Chairman: “So only if the parents, who don’t have medical knowledge, ask the direct question…”
Dr Chisakuta: “That’s not exactly true.”
The Chairman: “Then how do the parents get that answer if they don’t ask the direct question?”
Dr Chisakuta : “When I speak to parents after an event I’ll try and explain what the problem has been usually, but I can’t remember what the case might have been with Lucy’s parents.”
The chairman suggested that as this information was not included in a complaint that Lucy’s parents would eventually make about the Erne Hospital, it was unlikely that they were aware of it:
The Chairman: “That strongly suggests that Lucy’s parents weren’t given this information.”
Dr Chisakuta: “That might be the inference, yes.”
The Chairman: “And if that’s the case do you agree that it’s just not good enough?”
Dr Chisakuta: “Yes, it’s just not good enough.”
Counsel to the inquiry Moyne Anyadike-Danes QC asked Dr Chisakuta that, given that he suspected that something was awry at the Erne Hospital, why did he not pursue the issue further after Lucy’s death.
Dr Chisakuta said: “Of course I wanted to know but sometimes work and other things take over and you get overwhelmed.”
In response, Mr O’Hara said: “Doctor, what would you say if I was to say that the circumstances around Lucy’s death were allowed to fade away because of the issues around fluid management and how doctors, colleagues, managed these issues.”
Dr Chisakuta said: “It’s difficult for me to answer all these years later why things happened the way they happened. I would have hoped it would have been better.”
When the inquiry was first announced Lucy’s parents asked for personal reasons that her death not be included in the inquiry.
The chairman ruled that the inquiry would only investigate “relevant events” following the death of Lucy which are the clinical, hospital management and trust governance issues arising from the 17-month-old’s death.
The inquiry heard that at approximately 02.55am on 13th April Lucy suffered a seizure and was subsequently found to be hyponatraemic. Her pupils became fixed and dilated. She was transferred to the intensive care unit at the Erne Hospital where steps were taken to stabilise her for transfer to the RBHSC.
Lucy was declared dead at 1:15pm on April 14 2000 at the the RBHSC in Belfast. Her death was brought to the attention of the coroner’s office the same day by Dr Donncha Hanrahan, a consultant paediatric neurologist.
It was decided that it was unnecessary to conduct a coroner’s post-mortem examination but it was agreed that there would be a hospital post-mortem exam. The post mortem report did not reveal whether hyponatraemia or Lucy’s fluid management may have contributed to her death.
Also giving evidence at the inquiry on Wednesday (29 May) was Dr Caroline Stewart, specialist registrar in Paediatric Neurology at the RBHSC. She recorded notes relating to the outcome of Dr Hanrahan’s discussions with the coroner’s office.
The chairman questioned Dr Stewart about the fact that Lucy’s pupils were fixed and dilated before being transferred to RBHSC:
The Chairman: “Was Lucy being sent to the Children’s Hospital for treatment or to confirm that she’s dead and find out why?”
Dr Stewart: “I think it’s the latter.”
During her evidence she also said that after Lucy died, she remembered Dr Hanrahan telling Lucy’s parents that they needed to go back to the Erne and ask what happened.
Questioning Dr Stewart on this fact the chairman said:
“So there’s a concern in the Royal that Lucy received too much of the wrong fluid at the Erne Hospital, did Dr Hanrahan say this to them?”
Dr Stewart: “I don’t remember that specific concern being mentioned.”
The Chairman: “What could possibly be wrong with steering the Crawfords towards finding out exactly went wrong?”
Dr Stewart: “He may have outlined that more specifically at some point, I wasn’t there for all of the conversation. Perhaps later; I don’t know.”
The Chairman: “I suspect if he had have outlined that clearly and specifically that would have stuck out in your mind, doctor.”
Dr Stewart: “Yes probably.”
The hearing continues today.