Consultant’s report after child death “hopelessly incomplete” says inquiry chairman

Dr Hanrahan leaving Banbridge courthouse

Dr Hanrahan leaving Banbridge courthouse

By Niall McCracken

THE chairman of the inquiry investigating child fluid deaths has labelled a consultant paediatrician’s reporting on the cause of death of a 17-month-old child as “hopelessly incomplete”.

Dr Donncha Hanrahan, one of the consultant paediatricians involved in the care of Lucy Crawford, admitted that he made “very important omissions” in conversations with the coroner and state pathologist’s office about the cause of her death.

Lucy died at the Royal Belfast Hospital for Sick children (RBHSC) in April 2000. The aftermath of her death is being investigated by the Hyponatraemia Inquiry.

Dr Donncha Hanrahan was consultant paediatric neurologist at RBHSC when Lucy was transferred from the Erne hospital. Giving evidence today he said he did not remember mentioning hyponatraemia as potential cause of death when discussing it with the pathologist or the coroner’s office following Lucy’s death.

He said: “It was an omission, it wasn’t a deliberate omission, but it was a very important omission.”

Inquiry chairman, Mr Justice O’Hara said it was a “hopelessly incomplete report on Lucy’s death.”

For more information on why the Hyponatraemia Inquiry was established please click here.

Dr Hanrahan provided treatment and neurological assessment to Lucy when she was transferred to the children’s hospital. Along with another doctor he made a diagnosis of brain stem death on April 14 2000.

Dr Hanrahan also reported the death to the coroner’s office and spoke to Dr Michael Curtis, assistant state pathologist, about whether or not there should be a coroner’s post mortem examination. The outcome of that conversation was that a hospital post mortem was directed instead.

Senior counsel to the inquiry Monye Anyadike-Danes QC questioned Dr Hanrahan about the fact that his notes for Lucy’s treatment at the children’s hospital stated: “if she succumbs, a post mortem would be desirable, coroner will have to be informed.”

Monye Anyadike-Danes QC :Did you discuss this with the family?

Dr Hanrahan: I can’t remember.

Monye Anyadike-Danes QC: Lucy’s parents were concerned that in the Erne her IV fluids had taken some time to be stopped.

Dr Hanrahan: I do remember that they were unhappy with her treatment in the Erne.

Monye Anyadike-Danes QC: Did you understand the basis of their concern?

Dr Hanrahan: I don’t remember that specifically.

Monye Anyadike-Danes QC: In your first witness statement to the inquiry you say they were distressed about the IV line replacement. So they were concerned about it and that all feeds into the appropriateness of her fluid regime at the Erne.

Dr Hanrahan: I think I’ve already said that I do remember fluid difficulty being discussed, but translating that into sodium was the big issue in so far as the information that was available to me at the time.

Senior counsel to the inquiry Monye Anyadike-Danes QC

Senior counsel to the inquiry Monye Anyadike-Danes QC

Dr Hanrahan was also asked to explain why he had left a section about the coroner blank on one of Lucy’s hospital forms he filled out after she died.

The chairman: So you’re completely in the dark as to why Lucy has died.

Dr Hanrahan: It is unexpected and highly unusual.

Monye Anyadike-Danes QC: There’s a place on the form asking if this is a coroner’s case that you’ve left blank. Why?

Dr Hanrahan: I’m not sure, I shouldn’t have. I may not have seen that. That’s an omission because I’ve gone on the record before saying that the coroner should have been informed.

On further evidence Dr Hanrahan said that when it came to discussions with the coroner’s office about Lucy’s death it was his first time reporting to the coroner’s office.

Monye Anyadike-Danes QC: Did you take any advice if this was your first time?

Dr Hanrahan: Maybe it should have been more of a team effort. I could perhaps be accused of going off a little bit on my own without involving other people but that’s hindsight.

Dr Hanrahan outlined that since the publicity surrounding Lucy and Raychel’s death there is now a policy that junior doctors have training on how and when to report to the coroner.

Senior counsel asked Dr Hanrahan if he thought when contacting the coroner’s office that there would be someone there in a position to make a decision.

Dr Hanrahan: Yes or to guide me. I think in hindsight the information that I gave to the coroner’s office was incomplete. I detailed gastro-enteritis, dehydration and cerebral oedema. I didn’t mention hyponatraemia, It was an omission, it wasn’t a deliberate omission, but it was a very important omission.

Dr Hanrahan said that “in retrospect” he accepted that given the three reasons that he had stated as potential cause of death it would have been difficult for either the coroner’s office or the pathologist to understand the death as dilutional hyponatraemia. The chairman questioned Dr Hanarahan on this point:

The chairman: Sorry doctor there’s no retrospect about it, to put it bluntly, it was a hopelessly incomplete report on Lucy’s death.

Dr Hanrahan: It was.

Dr Hanrahan said that he could not recall the exact conversation he had with assistant pathologist Dr Curtis.

Senior counsel stressed the importance of not relaying the full information to Dr Curtis.

Monye Anyadike-Danes QC: Dr Curtis said in his inquiry witness statement if he had have heard the term hyponatraemia, the death would have warranted further enquiry and therefore an inquest or coroner’s directed post mortem would have occurred.

Dr Hanrahan: Yes my impression at this stage was still that hyponatraemia was not low enough to cause…

Monye Anyadike-Danes QC: I understand that…

Dr Hanrahan: Therefore I clearly didn’t give it enough weight or as much weight as I should have.

Monye Anyadike-Danes QC: I know hindsight is a wonderful thing, but this is a significant event. If an inquest had have been directed, lessons could have been learned and this may have had an effect on Lucy’s treatment. There was an opportunity in a public way to find out what happened.

Dr Hanrahan: It’s a possibility, we don’t know for sure, but I think with hindsight I’d have to accept that yes.

The chairman also stated that he could not be entirely sure if Lucy’s death was ever discussed at a hospital mortality meeting as none of the witnesses so far, including Dr Hanrahan, could specifically recall it.

As previously reported by The Detail last week, Dr Caroline Stewart, specialist registrar in Paediatric Neurology at the RBHSC, recalled in her evidence that Dr Hanrahan had told Lucy’s parents that they should go back to the Erne Hospital to find out what had happened.

Senior counsel asked Dr Hanrahan for his account of this.

Monye Anyadike-Danes QC: What were you suggesting the parents should do?

Dr Hanrahan: I can’t remember, I think it was a response to the fact that the parents weren’t happy with Lucy’s treatment at the Erne. I may have mentioned the fact that fluids were a bit off, but I didn’t follow it up by implicating that in her death.

The Chairman: Would there have been anything wrong with saying there may have been something wrong with the fluids she received in the Erne?

Dr Hanrahan: I may well have said that, but what I clearly did not do was say ‘these fluids killed your little girl.‘ But if I had knowledge at all at the time I think I would have done something about it or went back to the coroner.

Inquiry officials confirmed to The Detail that Northern Ireland’s senior coroner, John Leckey would be giving evidence to the inquiry on June 25 2013.

The hearing continues tomorrow.