Are lessons being learned over hospital deaths?

The Hyponatraemia Inquiry investigated fluid management issues after the deaths of five children in hospital.  It is due to report before the summer

The Hyponatraemia Inquiry investigated fluid management issues after the deaths of five children in hospital. It is due to report before the summer

Following a major report by The Detail on gaps in the investigations of hospital deaths, journalist Denzil McDaniel reflects on the dangers of a system that critics claim largely polices itself.

Faced with criticism over deaths in hospital, or other serious incidents, the health authorities often respond with a well-worn phrase.

Lessons will be learned, the public is told. A press statement often goes as far as to say that lessons have already been learned, probably as the result of new guidelines.

More often than not, the response is to the case coming to light in one of a limited number of ways; either a frustrated family has failed to get answers from a hospital trust and taken their circumstances to investigative journalists. Or a whistleblower within the system has brought a case to public attention.

Either way, it would seem that lessons being learned is often, though not always, a reactive process. And, the fact that we continue to read of many such cases does not bode well for the perception that the system is a health service investigating itself when things go wrong.

The Detail has reported on a number of such cases across Northern Ireland, and this week reveals that the Attorney General John Larkin, QC, is seeking greater powers to scrutinise hospital deaths.

I recall hearing the reference to lessons being learned well over 10 years ago. In April 2000, a 17-month-old Fermanagh girl, Lucy Crawford died in the Erne Hospital in Enniskillen. A previously healthy child, she’d been admitted with a tummy bug, but died after being put on a drip. Attempts by her shocked parents to find out what had happened hit a brick wall.

Initially, there was no inquest. But when another child, this time nine-year-old Raychel Ferguson died at the Altnagelvin Hospital, a patient advocate saw similarities in the two cases.

Almost four years after her death, an inquest was held and the Coroner John Lecky found that Lucy died as a result of serious errors at the Enniskillen Hospital in the administration of her fluids, and that the wrong cause of death had been given on her death certificate.

The Sperrin Lakeland Health Trust, who managed the hospital, issued a statement saying they would “carefully reflect” on the Coroner’s conclusions, and “ensure that our Trust and others learn the lessons.”

Significantly, when I asked the Trust Chief Executive, Hugh Mills in April 2004, if his organisation had reported the death to the Chief Medical Officer, he replied: “At the time there was no formal reporting mechanism for unexpected deaths to be conveyed to the CMO.”

The cases of Lucy and Raychel were two of those which form the Inquiry Into Hyponatraemia-Related Deaths. The inquiry, set up in 2004, under the chairmanship of John O’Hara, QC has now completed its hearings and the report is due to be published by this summer.

The fact that many of the details of how children died emerged for the first time during the Inquiry is testament to the fact that deaths in Northern Ireland hospitals are not a new phenomenon; and it remains to be seen as to what the O’Hara report says about reporting mechanisms for deaths and serious adverse incidents.

Mistakes happen in hospitals, but if the system is to be truly open and accountable when things go wrong, it cannot be left to grieving families to fight for truth, or for the community to hope that whistleblowers and investigative journalists will pick up the slack.

The Department of Health believes that its current procedures are sufficiently robust; but although some progress has been made, the Attorney General here clearly disagrees and is being supported by Dame Janet Smith, who chaired the Shipman inquiry, and says that the current system still allows for “bad practice” to be concealed.

  • Denzil McDaniel is the former editor of the Impartial Reporter newspaper in County Fermanagh. He has a career in journalism that spans 40 years from stories of death and destruction to issues surrounding health and education.