AN English judge over oversaw the inquiry into serial killer Dr Harold Shipman has urged civil servants in Northern Ireland to implement the recommendations of a scathing report into the hospital deaths of five children.
Dame Janet Smith, who also led the review into the paedophile Jimmy Savile, said the report into hyponatraemia-related deaths cannot be allowed “to sit on the shelf” in the absence of a power sharing executive.
The extensive review, which was published last week 14 years after it first ordered, investigated the deaths of Adam Strain (four), Claire Roberts (nine), Raychel Ferguson (nine) 17-month-old Lucy Crawford and Conor Mitchell, who was 15.
Hyponatraemia is a medical condition that occurs when there is a shortage of sodium in the bloodstream.The investigation examined whether fatal errors were made in the administration of intravenous fluids to five children. It concluded four of the deaths were “avoidable”.
The deaths took place at the Royal Belfast hospital for Sick Children in Belfast between 1995 and 2003.
Sir John O’Hara QC, who headed up the inquiry, said there was an “indefensible” culture in which parents were “deliberately misled” by doctors and health trust chiefs intent on “avoiding scrutiny” and protecting their own reputation.
Speaking to The Detail website, Dame Janet Smith said: “In the absence of ministers, it would be helpful if senior civil servants were to prepare for implementation of Mr Justice O’Hara’s recommendations.
“Otherwise there is a danger that public concern will wane, the moment will pass and these important findings will sit on the shelf…”
“Although it is rare for a healthcare practitioner to harm a patient deliberately, it is not rare for patients to be harmed through incompetence or mistake. Such incidents can too easily be covered up at present…”
According to the public inquiry she chaired, the former GP killed at least 250 of his patients over 23 years and covered up his crimes by faking death certificates.
The high-profile judge’s comments come after the most senior civil servant at the Department of Health, Richard Pengelly, that a “dedicated team” has been established to come up with an “action plan” to address Mr Justice O’Hara’s 96 recommendations.
Mr Pengelly, who is the Permanent Secretary at the Department, confirmed that professional bodies who regulate doctors and nurses had already been contacted following the release of the report, which details the names of health professionals involved in the children’s care.
In the case of Claire Roberts, the Mr Justice O’Hara found that a “cover up” was “attempted” by two consultants involved in the little girl’s care.
“I am compelled to the view that clinicians did not not admit to error for the obvious reasons of self-protection and that this defensiveness amounted to concealment and deceit. Such can have no place in the Health Service but appear nonetheless to have become established in the regional paediatric training hospital.”
The report is also heavily critical of health trust officials and warns of failings in “Trust leadership” in Belfast that allowed the work of doctors and nurses to go “unscrutinized” – which he said led to “institutional complacency”.
“Most disturbingly, the Chief Executive (William McKee) stated that he operated at that time (November 1995 to December 1996) on the basis that neither he nor the Trust Board had any responsibility for the quality of healthcare given to patients in the hospital,” the report states.