Report into Hyponatremia Fourteen Years in Making Is to be Published Today

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Wednesday 31st January 2018

A report looking into the circumstances surrounding the deaths of five children in Northern Ireland will be published later today, 14 years after the launch of the inquiry. The chairman of the public inquiry has said he wanted to deliver his findings in 10 months, but it would take 8 years for even the first witness to be called.

The individual stories, times and circumstances were different, but are connected to a single cause of death: hyponatremia. Hyponatremia is a low sodium level in the blood which can be fatal depending on its severity and was alleged to have been caused by mistreatment by staff in Northern Irish hospitals.

The calls for an inquiry first came about with the release of a documentary. Insight: When Hospitals Kill was broadcast by Ulster Television on 21st October 2004 and immediately made waves. The result of their own 8 month long investigation, Insight alleged that Lucy Crawford, Raychel Ferguson and Adam Strain may have been killed by errors made by the medical staff, specifically regarding the amount of fluids given to them. This, it was alleged, led to the hyponatremia that led to their deaths.

An inquiry was announced by Angela Smith, then Health Minister for Northern Ireland, two weeks later on 1st November 2004, with John O’Hara QC appointed to head it and a remit to focus on the medical care and treatment provided to Strain, Crawford and Ferguson.

The aim was to produce a report and recommendations by July 2005, but problems arose immediately that halted its progress.

Northern Ireland Police requested the inquiry be postponed as they were investigating the deaths to determine if anyone would face criminal charges, stopping the inquiry entirely in July 2005. It would only be picked up three years later when the Public Prosecution Service dropped its own investigations, and so the inquiry continued with the deaths of Claire Roberts and Conor Mitchell added to the inquiry.

The parents of Lucy Crawford also ask for her death to not be considered in any way by the inquiry. This request is granted with the caveat that the investigation into the aftermath of her death is still required. This delays the inquiry further, along with the revelation in November 2011 that documents that the inquiry team had been told were destroyed had in fact been found. New evidence coming to light continued to be an issue, to the point that for the first 8 years of the inquiry, there had only been one full public session. Soon after the inquiry was adjourned four times in less than a year, and evidence was heard.

The evidence and testimony demonstrated overdoses, incorrectly and illogically filled in death certificates, prior knowledge that donor organs were not functioning properly and a number of other revelations that revealed a failure in the duty to protect the children.

The final report will make for sobering and difficult reading, particularly after 14 years, but hopefully changes have already started to be made and plans are put in place to ensure needless deaths such as these do not happen again.