Hyponatraemia inquiry: Information given to coroner was 'inadequate'
The chairman of the inquiry into events following the death of a child in 2000 has decided that information given to the coroner was hopelessly inadequate.
Mr Justice O'Hara was referring to the death of Lucy Crawford.
The two-year-old died after being treated in the Erne hospital in Enniskillen, County Fermanagh.
The inquiry is not investigating the circumstances of her death but to what extent there was a failure to learn lessons from her death.
It is also examining whether this had an impact on the death of another child 14 months later.
The hyponatraemia inquiry, which is sitting at Banbridge courthouse, is examining the deaths of five children.
The inquiry heard from consultant paediatrician, Dr Donncha Hanrahan on Wednesday. He was one of several doctors who treated Lucy at the Royal Belfast Hospital for Sick Children (RBHSC).
Lucy was admitted to the Erne hospital on 12 April feeling lethargic.
She died two days later from hyponatraemia at the RBHSC.
Dr Hanrahan accepted when it was put to him by Mr O'Hara that if more information had been provided to the coroner on the day of Lucy's death, including about hyponatraemia, that it would have triggered an inquest.
This could have had implications for other cases, including that of Raychel Ferguson, who died under similar circumstances one year later.
Dr Hanrahan said in retrospect he should have sent a copy of Lucy's notes to the coroner's office, including his own thoughts about what had happened in the case.
Senior counsel to the inquiry Monye Anyadike-Danes QC added that the significant of a coroner's inquiry was to find out exactly what caused the death and to share that information in a public way.
Dr Hanrahan accepted that he handled the issuing of the death certificate very badly.
While he did not sign it, he did provide the information placed on it
"I just think I was trying to give some degree of closure to this family, I did jump the gun. It was thoughtless and that is something I completely and sincerely regret," he told the inquiry.
Monye Anyadike-Danes QC put it to him that "an illogical set of causes of death were put on the death certificate" to which Dr Hanrahan said "yes".
The court heard that three causes of death were given including gastroenteritis, dehydration and cerebral oedema.
The court heard that despite hyponatraemia being mentioned on the autopsy form, which was completed by a different doctor, this information was not provided to the coroner nor was it put on the death certificate.
Dr Hanrahan accepted that hyponatraemia should have been included.
Earlier he told the inquiry that there was some vagueness and confusion about who was in charge of Lucy's care.
Dr Hanrahan said that, due to the confusion in Lucy's case, each child that is admitted to intensive care is now allocated a dedicated team.
The inquiry is attempting to establish if the fluids administered to Lucy were at the appropriate level and if that information was communicated appropriately between doctors in the Erne hospital and the RBHSC.
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.
Among the issues being examined is how the cause of Lucy's death was established and agreed by clinicians.
This inquiry is examining the clinical, hospital management and trust governance issues arising from the two-year-old's death.
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 inquiry is also examining the deaths of Adam Strain, aged four, Raychel Ferguson and Claire Roberts, nine, and it is also investigating the events following the deaths of Lucy Crawford, aged 17 months, 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.
It was also revealed 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.