Review into child fluid death gave “false comfort”

Hugh Mills

Hugh Mills

By Niall McCracken

THE chairman of the inquiry into child fluid deaths here has said the initial review into toddler Lucy Crawford’s death “significantly underplayed what was wrong” and as a result gave “false comfort”.

Mr Justice O’Hara made the comments today as the former Chief Executive of the Sperrin Lakeland Trust – now part of the Western Trust – was giving evidence to the Hyponatraemia Inquiry.

The chairman also told Mr Hugh Mills that he believed that it was “no accident” that Lucy’s parents received a shortened version of the report and that a “deliberate decision” was taken not to send certain information to them.

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

Mr Mills directed that a review of Lucy’s care and treatment be carried out when her case was reported to him. He arranged for Dr Murray Quinn, consultant paediatrician at Altnagelvin Hospital, to assist the review when the need for a paediatrician was identified.

Junior counsel to the inquiry, Mr Martin Wolfe asked Mr Mills about questions around the independence of Dr Quinn at the time:

Mr Mills: I was aware of the fact that Dr Quinn had worked in the hospital before and would have known the nursing staff, but I believe I actually saw that as an advantage. I would have weighed that up in my decision versus potential questions about Dr Quinn’s independence.

Mr Wolfe: So it was something that you were internally turning over in your mind as opposed to seeking views about it.

Mr Mills: Yes I wasn’t ignoring that fact.

Mr Mills said that he had confidence in Dr Quinn’s abilities and this had a big influence on his decision to involve him in the review. Mr Wolfe asked him if he knew Dr Quinn on both a professional and personal level.

Mr Mills: Yes I would have met him occasionally in the context that I was involved in the local sailing club and I think Dr Quinn mentions that in his statement.

Mr Wolfe: Had you socialised with him?

Mr Mills: Well when you say socialise if you mean an occasion such as meals or a social engagement then no, but I would have seen him as he was involved in sailing events and sailing occasions.

The inquiry previously heard that the parents of Lucy Crawford did not become aware of the review until they initiated their own complaints procedure about their daughter’s case, two months after the review findings were published.

Mr Mills said that he had agreed with a member of the review team in April 2000 that a health visitor should contact the family about the review. Mr Mills was asked by the inquiry team why he did not follow this up:

Mr Wolfe: Was that not something so pivotal you would expect to receive assurances of clarification on that point?

Mr Mills: I would say that would certainly happen nowadays. In the year 2000 it wouldn’t have automatically happened. In my opinion and from my experience it wouldn’t have automatically happened that the review team would have approached the family.

The chairman: You have spoken about the value of Dr Quinn was that he had the confidences of the nurses. Now, who in the review had the confidence of the family? And with all due respect to health visitors, on the medical hierarchy health visitors are fairly low down the scale. They do important work but they are not comparable to directors; isn’t that right?

Mr Mills: No they’re not comparable to [a] director’s chair.

The chairman: So the fact that the family weren’t automatically spoken to doesn’t really take us anywhere, does it Mr Mills?

Mr Mills: No chair, I’m advising you of our thinking at the time and that’s the conclusions we would have realised at the time.

Mr Mills agreed that he’d taken reassurance from Dr Quinn’s report. Mr Wolfe asked how this could be the case, given that, while Dr Quinn said that fluid management had been appropriate, there were still questions raised about the fluids administered after Lucy had a seizure.

The chairman also questioned Mr Mills on this:

The chairman: The concern I have is that Dr Quinn’s report significantly underplays what was wrong and the review significantly underplays what was wrong and it gives a false comfort. The question is how this wasn’t effectively picked up by you when you read it.

Last week the inquiry heard that when Lucy’s parents eventually received the review report it was not the full version and did not contain the recommendations or appendices. Speaking at the inquiry today Mr Mills said could not give an explanation for this.

The chairman expressed his view on this point:

The chairman: This isn’t an accident. I’m telling you now Mr Mills. I do not believe that it was an accident. I believe a deliberate decision was taken not to sent certain information to the parents. Nobody from the old Sperrin Lakeland Trust can explain to me how this happened. So unless something else emerges, I believe a deliberate decision was taken not to give that information to the Crawfords. If you have anything else to say on this point I will listen to it.

Mr Mills: I certainly chair, cannot recall any deliberate decision being taken not to share that information with the Crawfords.

During Dr Murray Quinn’s evidence last week, Mr Wolfe referred him to a letter sent by Mr Mills, to Lucy’s parents sometime after the review into Lucy’s death.

Mr Wolfe outlined that in the letter Mr Mills told Lucy’s parents that Dr Quinn, as an independent consultant from another hospital, found that the treatment of Lucy was not inadequate or of poor quality.

Dr Quinn told the inquiry he raised a lot of questions in his report around record-keeping and the management of fluids and that it was not his intention for this view to be expressed to the parents on his behalf.

Questioning Mr Mills on this today, Mr Wolfe said:

Mr Wolfe: You conveyed to the parents there was no mismanagement in her case.

Mr Mills: And I said subsequently that was incorrect and we subsequently have apologised to the family for conveying that.

Mr Mills was also asked why another doctor from the Erne Hospital, Dr Muhammad Asghar, who had raised concerns about the treatment of Lucy by the paediatrician Dr Jarlath O’Donohoe, was not interviewed as part of the review process.

Dr Ashgar had sent a letter to Mr Mills a month before the review was completed outlining these concerns. Mr Mills said Dr Asghar wasn’t included in the review because he wasn’t involved in the treatment of Lucy.

Mr Wolfe questioned Mr Mills on this point:

Mr Wolfe: That would be a satisfactory answer if it wasn’t for the fact that sister Traynor, who wasn’t involved in the treatment of the child, was spoken to.

The inquiry previously heard from Dr James Kelly, medical director of the Sperrin Lakeland Trust, who said that there was a broad view held by some at the time that Dr Asghar was a trouble-maker who was attempting to find “as much dirt as possible” on Dr O’Donohoe. Mr Mills said he was not aware of such a view.

The inquiry continues.

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