Mother’s tears at inquiry into five children’s deaths

The mother of one of five children whose deaths are the subject of a public inquiry broke down as details of her son’s final hours were discussed.

The inquiry into hyponatraemia-related deaths re-opened on Monday, eight years after it was first set up. It has now adjourned.

Conor Mitchell, 15, died in 2003, at the Royal Belfast Hospital for Sick Children.

His mother, Joanna, left the courtroom in tears.

On Monday afternoon, the inquiry chairman, John O’Hara QC, said the adjournment was “regrettable”, but following fresh evidence he had no other option but to delay proceedings.

A progress hearing is to be held on 1 March.

As well as Conor, four other children are involved in the investigation.

They are are four-year-old Adam Strain, who died in 1995 at the Royal Belfast Hospital for Sick Children.

Claire Roberts who was nine, died in 1996 and Lucy Crawford, who was 17 months old, died in 2000, both at the Royal Belfast Hospital for Sick Children.

Lucy had been initially treated in the Erne Hospital in Enniskillen.

Raychel Ferguson was nine when she was brought to the Royal Belfast Hospital for Sick Children in 2001 having been treated at Altnagelvin hospital.

The common link is whether these children were administered the wrong amounts of fluid which eventually led to their deaths.

The inquiry’s remit is also examining the lack of records and potential cover-up by a health care trust and some medical staff.

In her opening address on Monday, the counsel to the inquiry confirmed that the actions and response of the then chief medical officer, Dr Henrietta Campbell, are under investigation.
Nine-year-old Raychel Ferguson died in hospital in 2001 Nine-year-old Raychel Ferguson died in hospital in 2001

Among the questions being asked are why the implementation of hyponatraemia guidelines was found to be incomplete among senior medical staff.

Hyponatraemia is a condition which results in a low level of sodium in the blood stream causing the brain cells to swell with too much water.

In some cases this action can result in death.

The inquiry has been postponed several times including last November when the Belfast Health Trust revealed it had recovered documents which the inquiry team had originally been told had been destroyed.

In a separate development, one of the expert witnesses, Professor Fenella Kirkham, is questioning the verdict of the inquest into the death of Adam Strain.

The inquiry into hyponatraemia-related deaths was established in 2004 and was primarily set up to investigate the deaths of Adam Strain, Claire Roberts and Raychel Ferguson.

The remit of the inquiry was later broadened to investigate events following the death of Lucy Crawford and also issues arising from the treatment of Conor Mitchell.

The latter will include an investigation into record-keeping with reference to the Department of Health and Social Service’s guidelines on hyponatraemia that had been issued by the time of Conor’s treatment, and their focus on proper fluid management.

The inquiry will also examine whether the fact that Conor was admitted to an adult ward rather than a children’s ward was relevant to the issue of whether the guidelines were adhered to.

The inquiry, which is expected to end by November 2012, is to investigate the events which followed Lucy’s death including the failure to identify the correct cause of death.


It is also to examine the alleged Sperrin Lakeland cover-up of Lucy’s death because it is argued that if her death had been recorded and reported properly in the Erne, Raychel Ferguson may not have died.

Solicitors representing Raychel’s family argue that had lessons been learned from the way in which fluids were administered to Lucy, defective fluid management would not have occurred so soon afterwards, 14 months later in Altnagelvin, a hospital within the same Western Health and Social Services Board area.

In this latest development, Professor Finella Kirkham, a paediatric neurologist, has raised doubts about whether Adam Strain actually died from hyponatraemia.

Until now there had been consensus from all the expert witnesses but this latest report from Professor Kirkham changes that and will undoubtedly determine how the hearings will proceed.

The chairman of the inquiry, John O’Hara QC, said on Friday that the development would have some knock-on effect on the inquiry timetable.

However, he is hopeful that there is some built-in flexibility which will still allow completion by the end of November.

The inquiry was also suspended in 2005 to allow the PSNI to undertake investigations related to the three cases which it was initially examining.

In 2008, the police indicated that their investigations were complete and the Public Prosecution Service directed that there would be no prosecutions.

As a result, the inquiry announced the resumption of its work at a progress hearing on 30 May 2008.