Hyponatraemia inquiry adjourned over 'new evidence'

Adam Strain Adam Strain is one of five children whose deaths are being investigated

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The inquiry into the deaths of five children in Northern Ireland hospitals has been adjourned until September after new evidence emerged.

A new document - written more than 17 years ago - was found during a search of hundreds of boxes held in storage.

It casts doubt on testimony given by senior clinicians about the death of Adam Strain.

Adam, four, died following a transplant operation at the Royal Victoria Hospital for Sick Children in 1995.

The hyponatraemia public inquiry in Banbridge is investigating the deaths of Adam, Claire Roberts, Raychel Ferguson, Lucy Crawford and issues arising from the treatment of Conor Mitchell.

Analysis

The newly discovered information is significant, as it casts doubt on the evidence already provided to the inquiry.

Some four, perhaps six key witnesses, are going to have to be recalled to be questioned about this latest document.

That is going to have a knock-on effect on the inquiry's timetable.

At this stage it should have completed its questioning over the death of Adam Strain.

The inquiry team had hoped to resume in September and begin the new session with exploring the circumstances surrounding the death of Claire Roberts.

That deadline is already slipping.

Lessons

They all received treatment in hospitals in Northern Ireland between 1995 and 2003.

Hyponatraemia is an abnormally low level of sodium in blood and can occur when fluids are given incorrectly.

In Adam's case, the inquiry is looking into what happened during his kidney transplant operation and what lessons, if any, were learned which may have impacted on the care of other children.

Among the issues being examined in Adam's case are the condition of the kidney that was used, and if the surgery should have gone ahead.

So far, senior clinicians who were involved have told the inquiry that the new kidney was partially functioning during his operation.

But a new document produced at the inquiry on Wednesday has now suggested that some of those same doctors told the hospital's solicitor they knew the donor kidney had, in fact, stopped working.

The document had been written before the 1995 inquest into the child's death.

Failing

It was written by the solicitor Mr G Brangam, from the solicitors Brangam and Bagnall, a firm which represented the former Royal Hospitals Trust in the 1990s.

The document said that Dr G Murnaghan, Dr J Gaston, Dr R Taylor and Dr M Savage told the solicitor that the kidney was failing to operate and clearly was not working by the time the operation was over.

The inquiry had previously heard that the kidney had belonged to an adult and that perhaps there was too long of a delay between the kidney being taken from the donor and transplanted to Adam.

The chairman of the inquiry, John O'Hara QC, said the new document had raised several issues including, why had some of those clinicians told the inquiry something completely different?

It also raises the question, what other documents exist?

Mr Stephen Quinn, QC who represents the family of Claire Roberts, asked why they were being "drip fed information".

Mr Quinn said "the truth nearly escaped the inquiry until this document escaped from storage".

Recall

The inquiry heard how the document was found after lawyers, who were representing some of the doctors, were asked to search for any other outstanding documents.

Those documents were contained in some 338 boxes which had been placed in storage after the hospital's solicitors Brangam & Bagnall closed.

The Royal Hospitals Trust has now been replaced by the Belfast Health and Social Care Trust.

The chairman of the inquiry said he had no other option but to recall some of those doctors who were involved with the document so they could be re-questioned.

He said he would adjourn early for the summer to address some of the issues raised.

Mr O'Hara is also sending in his own team to sift through more than 300 boxes to see if there is other information, which may relate to Adam's case or that of Claire Roberts.

The inquiry, which was established in 2004, has been postponed on several occasions.

It will resume again in early September.

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