Medical director “annoyed and surprised” about unknown changes in fluid use

The Hyponatraemia Inquiry is being heard at Banbridge court house

The Hyponatraemia Inquiry is being heard at Banbridge court house

By Niall McCracken

THE former medical director of the Sperrin Lakeland Trust has said that he was “annoyed and surprised” that fundamental changes in the Royal Victoria Hospital’s use of a fluid linked to the death of three children was not communicated at an earlier stage.

Solution 18 is at the heart of criticisms made in relation to the fluid management of the children whose deaths are being investigated by the Hyponatraemia Inquiry. The inquiry previously heard that the number of bags of solution 18 ordered in the Children’s Hospital in Belfast dropped dramatically after the death of nine-year-old Raychel Ferguson in July 2001.

Giving evidence at today’s hearing, medical director Dr James Kelly said he was made aware in a conversation with another paediatrician in May 2001 that the Royal Victoria Hospital “no longer used solution 18.”

For more background information on the issues being examined by the Hyponatraemia Inquiry please click here.

The inquiry is currently examining the governance issues in the aftermath of 17-month-old Lucy Crawford’s death. The toddler was pronounced dead at the Royal Belfast Hospital for Sick Children in April 2000 after being transferred from the Erne Hospital. Nine-year-old Raychel Ferguson died at the children’s hospital nine months later.

The inquiry heard last week that documents provided by the Belfast Ttrust show that the number of bags of Solution No. 18 ordered in the Children’s Hospital in Belfast dropped dramatically after the death of nine-year-old Raychel Ferguson in July 2001.

Legal representation for the trust told the inquiry that they were making “every effort to try and find out why this came about”.

Last month the inquiry wrote to the Directorate of Legal Services (DLS), provider of legal services for the Health and Social Care Sector, to try and determine from records when the children’s hospital had stopped administering Solution No. 18.

In their initial response in early May DLS said that between January 2000 and July 2001 the pharmacy department at the hospital had placed no orders for Solution No. 18 and it was “not used in the children’s hospital” during this period.

However in a second letter to the inquiry on May 17 2013, DLS said that the information in the previous correspondence was incorrect and that during this period the pharmacy department had requested 6,493 bags of Solution No. 18 for the children’s hospital.

A further breakdown outlined that the quantity fell from 359 bags per month in January 2000 to 42 bags in June 2001 and six bags in July 2001.

During today’s hearing Dr Kelly was asked about conversations he had with other clinicians about the use of Solution No. 18 following Lucy’s death.

Dr Kelly referred to a conversation in May 2001 with consultant paediatrician at the Royal Victoria Hospital, Dr Moira Stewart, about changes in fluid management at the Royal. The conversation took place 13 months after the death of Lucy Crawford and one month before the death of Raychel Ferguson:

Dr Kelly: Dr Stewart said ‘we no longer use Solution No 18.’ I obviously expressed surprise as it wasn’t removed from the guidelines at this stage. She said they’d had some problems with it in the past, but there was no identification of any other cases or any other deaths.

Following this conversation Dr Kelly said he relayed this information in a further conversation with the medical director of the Altnagelvin Health and Social Services Trust, Dr Raymond Fulton.

The Chairman questioned Dr Kelly on this point:

The Chairman: Were you and Dr Fulton annoyed about a change in the Royal that hadn’t been communicated elsewhere?

Dr Kelly: Yes we were annoyed and surprised that something as important as fundamental as that was not shared with us.

Lucy’s death was not referred to the coroner and a hospital post mortem examination was directed.

The inquiry has already heard extensive evidence about conversations and decisions made in the aftermath of Lucy’s death and ultimately why this did not prompt a coroner’s post mortem.

Today junior counsel discussed criticisms of Dr Kelly by one of the inquiry experts, Dr McFaul, that he had not alerted the coroner to the existence of the review report into Lucy’s death.

Dr Kelly: I’m surprised Dr McFaul stated that. It certainly wasn’t convention at the time. If a death has been reported to the coroner and an inquest is expected the coroner makes contact and seeks access to the information.

The chairman: So you don’t volunteer anything which is relevant to the coroner if he doesn’t specifically know about it and asks for it?

Dr Kelly: Well as I said my understanding at the time was that you didn’t send documents to the coroner. I’m not aware of it being done by anybody else.

Northern Ireland’s senior coroner, Mr John Leckey, will give evidence to the inquiry next Tuesday (June 25).

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