Inquiry criticises "culture of keeping quiet about mistakes"

The Hyponatraemia Inquiry is being heard at Banbridge court house

The Hyponatraemia Inquiry is being heard at Banbridge court house

By Niall McCracken

Northern Ireland’s top health officials are to be called before an inquiry into child deaths in hospitals here to address concerns about a “dominant culture of keeping quiet about mistakes which were made”.

Speaking at the final day of the Hyponatraemia Inquiry before summer recess the chairman, Mr Justice John O’Hara, said he would ask senior representatives of the Belfast Trust and the Department of Health, including the Permanent Secretary, to give evidence to the inquiry in the autumn in a bid to restore “public confidence”.

The chairman said he wanted to be reassured that the systems now in place are significantly better than those that had left the inquiry team “concerned and unhappy over the past year”.

Earlier this week the inquiry heard that unseen documents concerning nine-year old Raychel Ferguson’s treatment had now been uncovered.

Raychel Ferguson’s case is one of five deaths being examined by the Hyponatraemia Inquiry. In each case the intravenous fluid regime is implicated in the cause of death.

Yesterday (Monday) the inquiry was told by representatives from the Directorate of Legal Services (DLS), which manages all health and social services’ legal cases, that the Service Head of Acute and Community Paediatrics at the Western Trust, Mrs Mary McKenna, had now found previously unseen clinical notes directly linked to Raychel Ferugson’s care:

Mr Stitt (DLS): So having discovered [these documents] in fact — and she will say she felt quite shocked. ‘Shocked’ is probably too, strong a term, but she was very surprised to have found these documents which she didn’t know existed and she thought, ‘I had better have another search’. She literally got down on her hands and knees and, in the bottom of her office, obscured from view, she found a brown cardboard folder, which she pulled out, and it had the name Raychel Ferguson on it, and that did shock her.

Mr Stitt acknowledged that the folders could have been lying “undiscovered by anyone” for 10 years. The chairman described the late discovery of the new documents as “disappointing” and meant the inquiry might have to revisit the clinical aspect of Raychel’s case.

The Chairman: So we understand how these notes came about, and then, if necessary, we’ll raise further requests for witness statements from anybody who it touches on. Obviously, the fact that these documents have been provided to us means that this isn’t a cover-up, but it’s frustrating beyond words that they have emerged after we had understood that we’d finished the hearing into the clinical aspects of Raychel’s care.

The final hearings in Raychel’s case are due to start in late August 2013. Concluding yesterday’s evidence the chairman pointed out that if the new documents raised fresh questions it could mean recalling a number of witnesses, something he said the inquiry team would be reluctant to, but “would if it had to”.

Commenting on the issue earlier today Mr Justice O’Hara said the inquiry benefited from complete information and that he would be requesting further witness statements as a result of the new documentation.

Concluding this part of the inquiry the chairman said he had heard evidence about a dominant culture of “keeping quiet about mistakes which were made, even those mistakes that led to the death of children”.

Mr Justice O’Hara said that it had become clear that the trusts and the department were anxious to reassure people that lessons have been learned. He said as a way of testing those assurances he would be inviting representatives from the Belfast Trust and the Department to present a paper to the inquiry and give evidence in the autumn. He said:

The chairman:I will be asking them to set out what the current systems are and why they’re significantly better than the systems that have left us particularly concerned and unhappy over the past year.

Hearings resume in late August 2013.

© The Detail 2013