Hyponatraemia inquiry: Consultant had no training on reporting deaths
A senior consultant has told the public inquiry into the death of a toddler in 2000 that he had not received any training about his obligation to report a death to the coroner while working in the Erne Hospital.
As he did not report it, there was no inquest into Lucy Crawford's death.
The inquiry is exploring what impact that may have had on the death of other children.
Her death is one of five being investigated.
Lucy, who was 17-months-old was admitted to the Erne hospital on 12 April feeling lethargic.
She died two days later from hyponatraemia at the Royal Belfast Hospital for Sick Children (RBHSC).
Central to the investigation is the type and amount of IV fluid that she had been given and an alleged cover-up of the full facts at the Sperrin Lakeland Trust, now known at the Western Health Trust.
Addressing the Belfast Health Trust's legal team, Mr Justice O'Hara said he wanted to know why that trust's order of IV solution Sol 18 had fallen away to a minimum level after 2000.
The inquiry chairman said he did not believe that no-one in the trust could provide the answer.
"I would simply like the answer to one basic question. What happened in the Belfast trust around 2000, particularly 2001, which led to the purchases of sol 18 dropping?
"Something happened Mr Lavery, I don't believe that nobody knows.
"I would really like an answer to that question. It might have nothing to do with the inquiry, it might have something to do with the inquiry... I simply don't believe that nobody knows."
Mr Lavery assured the chairman that everything was being done to find the answer.
"I assure you all efforts are being made," he said.
Mr Justice O'Hara said: "Since the purchase of Sol 18 fell away to a minimal level and stayed at that for a decade, somebody with the trust must know what happened."
On Thursday, the inquiry also heard from Dr Jarlath O'Donohoe, a consultant paediatrician at the Erne Hospital, who described Lucy's care as "inadequate" and admitted that he should have written out her prescription for the IV fluid.
The inquiry is also trying to establish why Lucy's hospital notes, made during her time in Erne Hospital, were not sent in the ambulance with the toddler when she was transferred to the RBHSC.
These notes would have contained information including test results, and the levels of IV fluids that were administered to Lucy.
Instead the inquiry heard that a transfer letter was sent in the ambulance instead.
When asked by counsel to the inquiry, Mr Martin Wolfe, about its contents, Dr O'Donohoe answered: "It's not a letter I am proud of."
Mr Wolfe added: "Would it be wrong to conclude from the poverty of information contained in the transfer letter that you we're seeking to hide relevant information?"
To this Dr O'Donohoe firmly replied "no".
Among the many questions the inquiry is trying to answer is why some of Lucy Crawford's doctors failed to identify how she died and why they did not bring her case to the coroner.
Providing evidence, Dr O'Donohoe said he did not tell the coroner because he did not have enough information at the time.
In response to that, Mr O'Hara argued that he could have said the 17-month-old had arrived at the Erne Hospital with a minor illness, had died within hours, that she had received excess fluid and at that stage there was no medical explanation for her death. That, according to Mr O'Hara, would have been enough to trigger an inquest.
The inquiry is exploring if an inquest in 2000 into Lucy's death may have helped save Raychel Ferguson's life - she died under similar circumstances one year later.
The inquiry is not investigating the circumstances of Lucy Crawford's death but to what extent there was a failure to learn lessons from her death.
In 2008, her parents asked, for personal reasons, that her death be removed from the inquiry.
While that wish was respected, the inquiry's chairman said the issues raised by her death remained vital to the wider community.
The inquiry is particularly concerned to examine why the contribution played by hyponatraemia in causing her death was not recognised and acted upon at the time.
Hyponatraemia is the term for a low level of sodium in the bloodstream causing the brain cells to swell with too much water.
The issue of fluid management is central to the cases of all five children who died in hospitals in Northern Ireland.
The inquiry is also examining the deaths of Adam Strain, aged four, Raychel Ferguson and Claire Roberts, nine, and specific issues around the treatment of 15-year-old Conor Mitchell.
It is examining the fluid levels administered before their deaths.
In the case of four of the children, an inquest stated that hyponatraemia was a factor that contributed to their deaths.
The inquiry heard on Wednesday that Northern Ireland's most senior coroner John Leckey, who conducted the inquests for all the children, will give oral evidence at the inquiry before the end of June.