Inquiry into child hyponatraemia deaths recommends service improvements

Inquiry chair says services had been ‘largely self-regulating and unmonitored’.

Improvements to children’s nurses’ practice have been recommended by an inquiry into the deaths of five children at hospitals in Northern Ireland.

Picture: Alamy

The 14-year inquiry into hyponatraemia-related deaths concluded that four of them could have been avoidable.

Inquiry chair Mr Justice O’Hara made 96 recommendations in his final report published last week, and warned that the inquiry had found a health service that was ‘largely self-regulating and unmonitored’.

Hyponatraemia is a condition in which the concentration of sodium in the blood falls below safe levels.

Instigation of the inquiry

The Inquiry into Hyponatraemia-related Deaths was established in 2004 following concerns about the hospital treatment of three children – Adam Strain, Lucy Crawford and Raychel Ferguson – who had died in cases where hyponatraemia had caused or was a major factor in their deaths.

In 2008 the inquiry was expanded to include the cases of two other children, Claire Roberts and Conor Mitchell.

All five children, who were aged between 17 months and 15 years old, died at the Royal Belfast Hospital for Sick Children after becoming seriously ill in other hospitals run by different trusts.

In the 700-page report of the inquiry, Mr Justice O’Hara recommends that:

  • Health and social care trusts in Northern Ireland ensure all nurses caring for children should have access to e-learning on paediatric fluid management and hyponatraemia
  • All children’s wards should have an identifiable lead nurse – in addition to current staffing levels – to whom all the other nurses report
  • The lead nurse should understand the care plan for each patient and be visible to patients and staff to discuss any concerns. The report of the inquiry states: ‘Such leadership is necessary to reinforce nursing standards and to audit and enforce compliance'
  • The accountable nurse ‘insofar as is possible’ should attend every interaction between a doctor and child patient
  • A statutory duty of candour across healthcare organisations in Northern Ireland be introduced to promote openness and honesty
  • Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident

Trusts apologise to families of children who died

The Belfast, Southern and Western health trusts, which run the hospitals where the children were treated, said they ‘unreservedly apologise’ to the families of the five children and would urgently review the recommendations.

Department of Health Northern Ireland permanent secretary Richard Pengelly said discussions were already taking place with a number of organisations, including the Nursing and Midwifery Council, regarding an action plan following the recommendations.

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