POOR care received by a Fermanagh toddler before her death nearly 18 years ago was “initially and deliberately concealed” by clinicians at two hospitals, a public inquiry has found.

Lucy Crawford, from Letterbreen, died on April 14, 2000 at the Royal Belfast Hospital for Sick Children (RBHSC), a day after being transferred from the Erne Hospital in Enniskillen.

On Wednesday, the failure to learn lessons from her death was highlighted by Sir John O’Hara QC, the Chairman of the Inquiry Into Hyponatraemia-related Deaths.

First announced in 2004, the Inquiry initially examined the deaths of three children, including Lucy Crawford, but was expanded four years later to include two more.

Hyponatraemia is a condition in which the concentration of sodium in the blood falls below safe levels.

In May 2008, Lucy’s parents requested that their daughter’s case be withdrawn from the scope of the Inquiry.

However, following consultation, the Inquiry Chairman decided that the terms of reference still required investigation into the aftermath of Lucy’s death, such as the failure to identify the correct cause of death.

In the Inquiry's damning report, which is now available online, Sir John stated: “Having reflected upon the evidence, I am of the view that the poor care which Lucy received was initially and deliberately concealed by clinicians at both the RBHSC and the Erne Hospital from the family, the Coroner and the pathologist who all should have been told of the suspected mismanagement of fluids.”

The Chairman further found that the failure by senior clinicians to address the issue with appropriate candour “suppressed the truth” and inhibited proper examination of what had gone wrong.

“The motivations for this concealment may be multiple, but I count amongst them a determination to protect professional colleagues from having to confront their clinical errors,” he stated.

Sir John found that, as a result of this, the opportunity to learn lessons was disregarded and critical learning was lost to clinicians delivering fluid therapy to other children in Northern Ireland.

He stated: “When Raychel [Ferguson] came to be treated in the Altnagelvin Hospital fourteen months later, Solution No. 18 was still being used without appropriate guidance as to the risks.”

The report, which also examined the deaths of Adam Strain, Raychel Ferguson, Claire Roberts and Conor Mitchell, has made a total of 96 recommendations.

This includes the implementation of a “statutory duty of candour” so that every healthcare organisation and everyone working for them must be open and honest in all their dealings with patients and the public.

Speaking in Belfast on Wednesday, the Inquiry Chairman said apologies from Northern Ireland’s health authorities had to be dragged out of them through expert evidence to his inquiry.

He was especially critical of an anaesthetist whose patient died during an operation but who failed to acknowledge his errors for many years.

Sir John said: “It is time that the medical profession and health service managers stop treating their own reputations and interests first and put the public interest first.”

After the publication of the report, the Western, Southern and Belfast Health Trusts released a joint statement unreservedly apologising to the families of Adam Strain, Claire Roberts, Lucy Crawford, Raychel Ferguson and Conor Mitchell for their “many failings”.

The Trusts stated: “We made mistakes, we were not as open and transparent as we could and should have been and opportunities to learn from each other to make our care safer were missed – for this we are truly sorry.

“There can be no greater pain for a parent than to lose their child and then to learn that errors occurred which were avoidable.
“Since these tragic deaths significant lessons have been learned in how we safely manage fluids in children and many improvements have been put in place.

“Although much has been achieved to promote an open and transparent culture, we know that much more still needs to be done. We are wholly committed to achieving this and welcome the recommendation of a duty of candour.”

During the course of its investigations, the Inquiry received 538 witness statements and more than 12,634 documents.

It heard evidence from 179 witnesses over 148 days of public hearings, which were held at the Courthouse in Banbridge.

The inquiry is estimated to have cost over £13.8 million so far.