CMO "not briefed" before public comments on fluid deaths

By Ruth O’Reilly

NORTHERN Ireland’s most senior doctor at the time of the child fluid deaths today said she “deeply, deeply” regretted remarks made in interviews on the subject in which she spoke of the children concerned having an “abnormal reaction”.

Dr Henrietta Campbell said she was not fully briefed on the clinical issues before her public remarks, which prompted two of the families to refer her to the General Medical Council for misleading the public about the hospitals’ culpability in the deaths, and she acknowledged that as Chief Medical Officer it was incumbent on her to have clarity.

Earlier in her evidence to the inquiry into the deaths, she said that in spite of her key role for clinical governance in Northern Ireland, the “concealed” deaths of Claire Roberts and Lucy Crawford had not come to her attention, either at the time or through a working group she personally set up into the phenomenon.

Dr Campbell, who was CMO from 1995 – 2006, said hospital trusts and associated boards should have let her know about three deaths which occurred before 2001 and said “informal” ways of reporting such deaths at the time were “totally inadequate”.

Dr Campbell was the most high-profile figure to speak publicly about the deaths caused by hyponatraemia – low sodium caused by excess fluid leading to brain swelling – when they came to public prominence after the 2003 inquest into Raychel Ferguson’s death two years earlier. For more information on the background to the inquiry, click here.

She said that she had a central role in clinical governance in Northern Ireland but said the reporting of deaths from which learning should be shared, came to her only through “an informal mechanism”.

The inquiry chairman, Mr Justice O’Hara, told Dr Campbell that on the evidence he had heard how he could avoid concluding that “there wasn’t actually a mechanism”.

The concern was also, he said, “that it was not just an accident that these deaths didn’t reach you”.

Mr Justice O’Hara: The concern is whether decisions were taken deliberately not to report the most serious of these deaths … What happened in Claire’s case is that her death is wrongly certified and the coroner isn’t contacted, the director of public health isn’t contacted and you’re not contacted. Mrs Roberts must be sitting here today thinking, ‘That’s not an accident’. Let me put in their terms. They must think, ‘That’s a cover up’ … Why shouldn’t I believe that that was a cover-up?

Dr Campbell: I can understand how the parents might feel about that and I can understand that that impression would be left. I certainly would not want to condone a cover-up …. It’s certainly not something that we should be proud of as a service. And certainly the message that we’ve been trying to promote, and it was been promoted by leadership, across the medical fraternity and also across the NHS, is that there does need to be openness, there does need to be a candour, there needs to be a commitment to learning and that efforts do have to continue, have to be reinforced and the way it was in the past just and very bad and not good enough.

Dr Campbell set up a working group in the later half of 2001 after Raychel’s death following treatment at Altnagelvin Hospital and when it came to light that the Royal had changed its fluid protocols earlier.

Counsel to the inquiry, Monye Anyadike-Danes QC, showed her an email from that time which stated that there had been “a previous death six years ago in mid Ulster” and she asked if Dr Campbell had made further enquiries about it.

Dr Campbell: I thought it was clear from the email that there had been a previous death from hyponatraemia which the Royal had recognized and that on the knowledge of Raychel’s death I think was, was such important information that we needed to move quickly.

Ms Anyadike-Danes: I think that’s a slightly different question … Do you not want to know a little bit more about that?

Dr Campbell: Yes, of course, but the information from the email seemed to indicate that there had been a previous death and that, to me – obviously I would have expected that death to have been properly investigated and, if it were an untoward death, that it should have been a coroner’s investigation. So, I didn’t at the time think that what I wanted to do was to spend time on investigating that … I recognised that that day there were children at risk and that we needed to do something.

Ms Anyadike-Danes: Could you not have raised a query with the Children’s Hospital: what was the death six years ago and what are the circumstances of it?

Dr Campbell: I had expected that that information would come forward in the working of the working group on guidelines … I didn’t specifically try to find out names and dates but rather I felt that my energies would be on setting up the working group and in getting the guidelines underway.

Dr Campbell was then asked if she had instructed her deputy, Paul Darragh, who chaired the group, to find out about other cases.

Dr Campbell: I can’t remember whether I did or not.

The inquiry had already heard from a succession of members of the working group that they did not discuss specific cases in the course of their work – especially to suggestions that they discussed Lucy’s case had been due to hyponatraemia.

Today the inquiry chairman picked up on the subject with Dr Campbell.

Mr Justice O’Hara: Do I take it that you thought that if there were a working group looking at guidelines and looking at hyponatraemia … that the working group would necessarily discuss what the incidence of hyponatraemia and what other similar or comparable deaths or events had occurred … If I was on the working group and I had treated a child who had died of hyponatraemia after receiving Solution 18 in 1999, you’d expect me to add that to the collective knowledge of the working group?

Dr Campbell: I would.

Dr Campbell said she had delegated the guideline work to her deputies, Dr Darragh and Dr Miriam McCarthy, and did not expect to see the trail of information from them.

She has stated in her statement to the inquiry on the subject of other deaths “In the course of the deliberations of the working party I understand information was shared between members”.

She said she understood this to refer to discussion about Adam’s death in 1995 – the only other case which was immediately referred to the coroner – and which she said she only learnt about in the autumn of 2001.

Ms Anyadike-Danes: You can perhaps see it from the families’ point of view. Their concern is that there were doctors there who DID know about cases of hyponatraemia … and the reason they weren’t discussing them is that they didn’t particularly want that information to get out … and this part of the … deep suspicion that some of the families have in relation to cover-ups.

Dr Campbell: And whatever the reasons for those deaths not being discussed in the working group, I don’t know why and I am disappointed that they weren’t brought to the fore.

Asked about the nature of what remained delegated to Dr McCarthy and what she was kept informed about, she referred to the production of the guidelines themselves.

Dr Campbell: Dr McCarthy kept me fully informed about their progress and gave me an opportunity to look at a fairly final draft of the guidelines to see how I felt. So in terms of the final product, I felt I had been given an opportunity to look at them and to confirm whether I was happy or not … Dr McCarthy kept me well-informed on the research, on the published research.

Dr Campbell raised the issue of hyponatraemia and the guidelines produced by her working group with various media in 2003 and 2004, including an interview with UTV’s The Issue programme, during which she spoke about the rarity of fatal hyponatraemia and about an “abnormal reaction” by children who died.

Dr Campbell: I really want to say is that I deeply, deeply regret that anything that I said could have caused any further distress to the families. And on reflection … I realise much after the interviews, that some of the things that I said could have been misunderstood in terms of what I was trying to say, there were very poorly crafted. I wasn’t fully – I didn’t fully brief myself on he clinical issues. I’m a public health doctor. It was 30 years since I had anything to do with fluid management. So my words were not well-crafted. I did expect only to talk about the fact that we had guidelines in place and that what were doing was trying to prevent any deaths happening in future. I think I said at each interview that I knew that those deaths were all preventable, that whey were in fact clinical accidents, that they were preventable and that is the dreadful, dreadful tragedy of that. But from my own personal point of view, as a doctor, indeed as a mother, a grandmother, when you begin to understand the grief that those families are carrying, it was with deep regret that I added to that.

Ms Anyadike-Danes referred to Dr Campbell’s statement in which she said she had intended to focus on the guidelines and to ensure that people were not deterred from bringing their children to hospital for fluid therapy and asked her if she took responsibility for that being misinterpreted.

Dr Campbell: As Chief Medical Officer it was incumbent on me to have clarity ….. I have say that I was ill-prepared, particularly for one of the interviews. Normally when I have been interviewed in the past, it had been through our highly professional health correspondents who are always intent on getting the message over. I wasn’t prepared for the interview at Ulster Television. I could never be, I’m not the sort of person who can respond in that sort of stressful environment. So, therefore I take full responsibility for saying things in a way which could have been misinterpreted.

She was specifically asked about remarks she made, differentiating Adam’s case as “an entirely different clinical situation” with him having “a chronic condition” unlike Raychel, who was previously healthy.

Ms Anyadike-Danes, said her comments presented a scenario where either Adam’s condition or the surgery he was undergoing had contributed to his death, when in fact it was “an egregious error” in the development of his brain swelling and death.

The question Adam’s mother wanted to ask was, to what extent Dr Campbell had informed herself of his condition:

Dr Campbell: Can I say that I apologise because I did not make myself fully aware of Adam’s clinical condition before his operation. I was in no way trying to infer that Adam’s death was anything other than preventable. I think I was merely making the point that Adam’s underlying medical condition meant that he had to be treated in a regional centre but with Raychel, here we had an appendectomy …. And yet here too we could see that clinical incidents could happen in such a way that we get such dreadful outcomes.

The inquiry continues.

© The Detail 2013