Six years after inquiry set up, another death to be examined

THE public inquiry into Hyponatraemia-related Deaths in Northern Ireland has been provided with information about a new case involving the death of a young girl at Antrim Area Hospital, six years after the inquiry was first announced.

The Northern Health Trust has confirmed to The Detail that they are assisting the Coroner’s Office in an investigation into the death of 15 year old Shauna Shivers from Castledawson. The Trust also confirmed that it has passed on details to the public inquiry chaired by John O’Hara QC. Shauna passed away on the 3rd of December 2009. Her death certificate, seen by The Detail, identifies Cerebral Oedema and Diabetic Keto-acidosis (DKA) listed as the cause of death.

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.

DKA is a common complication of diabetes when the blood sugar levels are no longer under safe control and the blood becomes too acidic. If left unchecked DKA can lead to a coma or death. 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 across into the brain from the bloodstream.

Fluid overload happens when excessive amounts of intravenous (i.v.) drip fluid is delivered into a patient’s veins. This, in turn, exceeds the body’s ability to cope with this large volume. This appears to be the common factor between Shauna’s case and all of the cases being looked at by the inquiry.

At the latest preliminary hearing of the inquiry in Banbridge Courthouse on March 9th, legal representatives for one of the families briefly raised the issue of “other recent cases” in open hearing. Subsequently The Detail approached all five trusts and the coroner’s service asking about the existence of other Hyponatraemia-related Deaths. After a reply from each of the trusts claiming that there were no such cases, a second request was sent asking if there were any deaths in recent years which were the result of cerebral oedema or fluid overload.

The Coroner’s Service eventually confirmed that the investigation into the case of 15-year-old Shauna Shivers was on-going but that a decision had not yet been reached on whether or not an inquest was to be held.

The inquiry was announced in 2004 by the then Health Minister Angela Smith following an investigation by UTV into the death of baby Lucy Crawford and two other children who had died as a result of suspected fluid overload. The “Impartial Reporter” newspaper had also raised serious questions about the death of 17-month-old Lucy, from Letterbreen, died in April 2000 following fatal errors in administering fluid in a drip. She had initially been admitted to the Erne hospital for treatment of a stomach bug. The inquiry was delayed after the PSNI decided to conduct investigations into the deaths. The Public Prosecution Service later ruled that no one at the Sperrin Lakeland Trust should be prosecuted.

Now,11 years after Lucy’s death, the inquiry has been handed new information about Shauna’s death which occurred only a year and a half ago.

Speaking exclusively to The Detail, Shauna’s mother, Margaret Shivers confirmed that within the past two weeks, the police had been to her home to take a statement from her on behalf of the coroner. Unofficially it has been indicated to the family that an inquest into their daughter’s death is unlikely to happen before next year.

Speaking publicly for the first time, the family told how Shauna walked into Antrim A&E on the morning of her death with a letter from her GP stating the correct diagnosis (DKA).

Margaret Shivers told The Detail:

• How the family expected her to receive the correct amount of intravenous. fluid and to be home with 48 hours.

• Contrary to protocol she was admitted to an adult ward, even though she was under 16 years old.

• That she was treated by an adult physician and not a Paediatric consultant.

• That Shauna was given excessive intravenous fluid which “would have been more appropriate for an adult.”

Margaret believes that despite signs and symptoms of the pressure increasing within her brain, there was no intervention until her heart arrested. She was then transferred to ICU with severe brain swelling (cerebral oedema) which eventually led to brain death a week later.

Although the family repeatedly expressed their concerns to the medical staff, Shauna’s death was treated by Antrim Area Hospital doctors as being due to ‘natural causes’. Given this information, the Coroner and his Medical Adviser decided against a post-mortem. Looking back now Margaret regrets the way things were handled in the aftermath of her daughter’s death.

“We actually contacted the Coroner ourselves. They had no coroner’s post mortem and we were told there was no post-mortem, because of the portrayal that Antrim Area Hospital’s treating doctor gave across to the Coroner’s medical adviser, that everything was fine and that it was an open and shut case, as far as he was concerned. Yes, we were offered a hjospital post-mortem, but that was after a very harrowing week and everything was portrayed at such gruesome details to us, it was nearly like, it was presented in a way that we would refuse it.

“It was only on reflection after, that we thought, ‘actually, she should of had a post-mortem’, and then we contacted the Coroner and the Coroner had said that with the information he had got that there was no evidence to show that there was any family concerns, or anything untoward had happened,” she said.

Her parents believe that Shauna’s death was brought on by an overload of intravenous ervenus (i.v.) fluid and that this was a direct result of fluid mis-management, a common factor amongst all those included in the Iinquiry is failure to correctly administer fluids to these children.

The death of Conor Mitchell, which is one of the four cases being examined by the inquiry, is included despite the fact that it was not a classic Hyponatraemia-related Death. On the inquiry’s website it states that the reason for including Conor Mitchell was failure in fluid management – in the face of existing guidelines. (The guidance on the prevention of hyponatraemia in children can be accessed on the DHSSPS website, www.dhsspsni.gov.uk and the CREST guidance, Management of Hyponatraemia in Adults (2003).)

For now though, the Shivers family are hesitant to go down the inquiry route.

Margaret said: “You know, as far as we’re concerned, we don’t fit into (the inquiry’s) category. The only feelings that we have is that it’s important for anybody bringing a child in through the hospital doors to be aware, and just to watch everything and question everything. That would be my main message.”

Similarly, during early proceedings of the inquiry, the family of Lucy Crawford had made clear that they did not want their daughter’s case involved in the Inquiry. However after the terms of reference of the inquiry were amended by the Minister in November 2008 to exclude any inquiry into the events surrounding and following the death of Lucy Crawford in 2000, the Chairman had to consider how they would be interpreted in their new form. He issued a consultation paper in June 2009 and said that the terms would still permit and require an investigation into the events which followed Lucy’s death.

Despite having information about their daughter’s death, the Shiver’s family have confirmed that they have had no contact from the inquiry to date and for the time being Margaret and her family are purely concerned with dealing with their grief and keeping their daughter’s memory alive.

“She was the centre of attention, she hated seeing anybody unhappy. Anywhere that she went she made sure that everybody was having a good time. Her friends absolutely adored her.

“When something like this happens and a child dies for no good reason, it’s heart breaking. Of course we don’t want Shauna’s death to be in vain. Shauna’s daddy is diabetic, had been since 12 years of age. He had the same symptoms at her age. He had multiple hospital admissions and nothing like this ever happened. It’s so real in our house now, Shauna’s younger sister is eight and she’s diabetic, so if she gets sick, where do we take her?”

The family confirmed that they have not been contacted by the Hyponatraemia-related Deaths Iinquiry. In a statement to The Detail, a spokesperson for the Inquiry said that unless the Chairman formally includes the investigation of any other childs death to their work, details of cases which have or are being given consideration by the Inquiry, will not be released. The next hearing will take place on Thursday 19th May at 11am at Banbridge Courthouse.