A different jurisdiction, another investigation

As I am from Northern Ireland (NI) the recent report of the Inquiry into Hyponatraemia-related Deaths caught my eye.

This inquiry was chaired by John O’Hara QC and cost nearly £14 million.

It relates to the deaths of five children who received intravenous fluid therapy at various hospitals in NI between 1995 and 2003. The central issue of the inquiry was that of the hospital fluids management. Hyponatraemia is a medical condition that occurs when there is a shortage of sodium in the bloodstream and when fluids are not administrated properly.

The report is hugely detailed and extends to almost 700 pages.

BBC NI coverage will provide some background for those not familiar with the issues:

Hyponatraemia inquiry: Timeline of hospital deaths investigation
Hyponatraemia report: A long and difficult road for families
Hyponatraemia inquiry: Children's hospital deaths were avoidable

While the deaths took place some time ago and the clinical governance system at that time is now different to that operating in England (for example, there is not currently a statutory duty of candour) there are some points which come out of the inquiry which are worth taking note of.

We highlighted a number of the criticisms made of the healthcare professionals, hospital managers and lawyers. Concerns were also raised about the standard of record keeping and poor communication between the medical staff.

The inquiry sought and received an undertaking from the Director of Public Prosecutions that the evidence of witnesses would not be used in criminal proceedings against them. This was done to encourage co-operation.

However John O’Hara stated that he “was surprised at how difficult it was to persuade some witnesses to be open and frank with the work of the Inquiry. All too often, concessions and admissions were extracted only with disproportionate time and effort. The reticence of some clinicians and healthcare professionals to concede error or identify the underperformance of colleagues was frustrating and depressing, most especially for the families of the dead children”.

Recommendations and comments

A total of 96 recommendations are made – we have flagged six key proposals but there are many more. O’Hara notes that while much has been achieved, much remains to be done. 

• Review meetings should be digitally recorded. 
• Further and advanced training in incident investigation to intensify the search for underlying and interconnected causes of adverse incidents rather than fuelling fears of individual blame. 
• The Healthcare Safety Investigation Branch are undertaking investigations in NI relating to serious adverse incidents. 
• The best leadership is critical and there should be investment in the best. 
• The appointment of an independent Medical Examiner. 
• Consideration of abolition / reform of clinical negligence litigation.

You can find the recommendations at pages 84 – 97 of Volume 3 of the report.

Ian Paterson inquiry

Turning back to England, the next inquiry coming down the tracks is the inquiry into Ian Paterson, to be chaired by the Right Reverend Graham James, Bishop of Norwich. He has already indicated that he will also investigate medical colleagues who may have “stood by” while Paterson carried out hundreds of dangerous and unnecessary operations.

So watch this space!