By
The public inquiry into hyponatraemia-related deaths was announced in 2004
By Niall McCracken
THE chairman of the inquiry into child fluid deaths has said that a hospital could have withheld crucial information from the parents of Lucy Crawford because it was “embarrassing" that it “hadn’t bothered fulfilling” recommendations in a report about their daughter’s death.
The inquiry previously heard that the findings of the review into Lucy’s death were published in July 2000, but her parents did not become aware of its existence until they began their own complaints procedures in September 2000.
Today the inquiry heard that Lucy’s parents did not receive a version of the review report until January 2001. The inquiry heard that the report was a short version of the original review report and did not contain the recommendations or appendices.
For more background information on the issues being examined by the Hyponatraemia Inquiry please click here.
Mr Eugene Fee, former director of acute hospital services at Sperrin Lakeland Trust, gave evidence at today’s hearing. He was appointed by the chief executive of the trust, Mr Hugh Mills, to co-ordinate the review into Lucy’s care and treatment at the Erne Hospital along with Dr Trevor Anderson.
Junior counsel to the inquiry, Mr Martin Wolfe, asked Mr Fee why a shorter version of the review report was sent to Lucy’s parents in January 2001. The version the Crawfords received did not contain the recommendations or appendices. Mr Fee said he could not explain why this was the case.
The chairman Mr Justice O’Hara questioned Mr Fee on this point:
The chairman: Can I suggest at least one reason. If the family had been sent the full report in January 2001, they would have seen that in July 2000 there was a recommendation that it would be appropriate for another meeting to be held with them and that would have been terribly embarrassing for the hospital to tell the family, almost six months later that the hospital had been sitting on a recommendation which it hadn’t bothered fulfilling. That would be very embarrassing wouldn’t it?
Mr Fee: Perhaps, I don’t recall that being part of any rationale.
Mr Eugene Fee (left) and Dr Murray Quinn (right)
The chairman also asked Mr Fee why there were differences in the questions that were put to the nurses compared to the doctors as part of the review into Lucy’s death:
The chairman: There seems to have been a deliberate decision to ask the nurses about fluid management but not the doctors, I think you’ve already agreed that is curious.
Mr Fee: Yes.
The chairman: How could it come about that doctors were not asked about the fluids? I think your answer previously has been that there was no deliberate decision not to ask them.
Mr Fee: That’s correct.
The chairman: And I have to say I have a bit of trouble accepting those two propositions together.
Also giving evidence at today’s inquiry was Dr Murray Quinn, consultant paediatrician at Altnagelvin Hospital. He examined Lucy’s care and treatment by reference to her clinical notes and records as part of the review process.
During his evidence the chairman questioned Dr Quinn on evidence that had been given by Dr Anderson, who co-ordinated the review, earlier in the week. The chairman outlined that Dr Anderson had thought Dr Quinn’s report was wrong but because Dr Quinn was a paediatrician and he was an obstetrician he thought he should go with it.
Mr Wolfe questioned Dr Quinn on this point:
Mr Wolfe: Are you hiding behind today an explanation of your analysis of the notes in that you say you were looking at what you thought the doctors intended to do rather than properly conceding that you provided an analysis of the fluids that was completely wrong?
Dr Quinn: I’m not hiding behind anything.
Earlier in the day junior counsel asked Mr Fee about a telephone conversation he had with Dr Quinn after the broadcast of a UTV documentary. Dr Quinn told the documentary that he was “sweet talked” into doing the report for the review:
Mr Wolfe: In his statement to the inquiry Dr Quinn has said when he used the phrase ‘sweet talked’ he was referring to the fact that he thought he was supposed to be doing an oral report for you and Dr Anderson, but was persuaded to provide a written report.
Mr Fee: I must say I was surprised when I heard that comment on the documentary, but I took it in the context that the man was door stepped.
Mr Wolfe: Did you have a conversation with Dr Quinn after the documentary?
Mr Fee: I don’t recall having one.
Mr Wolfe: In your statement to the police after its broadcast you said that he phoned you in a panic after he was door stepped.
Mr Fee: I told the police that?
Mr Wolfe: Yes.
Mr Fee: I can’t recall that.
Mr Wolfe: You’re telling the police six or seven years ago this conversation happened. It must have seemed quite unusual to you at the time?
Mr Fee: To be honest I can’t recall that conversation at all.
The Chairman: Was there any pressure on Dr Quinn to produce a written report?
Mr Fee: I don’t recall pressure being put on him. We would have been clear that we wanted a report.
When Dr Quinn was asked about this issue he said the phrase ‘sweet talked’ was an inappropriate word to use, but he had done so under pressure after being door stepped by a journalist:
Dr Quinn: I would have been better saying that I was persuaded to write a summary report following my case note review.
Mr Wolfe: The impression from the use of such language was that you were the subject of inappropriate pressure to produce the report.
Dr Quinn said that there was no pressure put on him by anyone to influence his opinion.
In concluding today’s hearing Mr Wolfe referred Dr Quinn to a letter sent by the then chief executive of the Sperrin Lakeland Trust, Mr Hugh 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 gave his reaction to this:
Dr Quinn: Well I’m surprised at that because I was one small cog in the wheels of the inquiry. Why should I be singled out as the person to reassure the parents of a child that nothing went wrong?
In finishing his evidence Dr Quinn said 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.
Mr Mills is due to give evidence to the inquiry on Monday morning (June 17).