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Reviews / 2018

Statutory inquiryPublishedChildrenNorthern Ireland

The Inquiry into Hyponatraemia-related Deaths

Mr Justice O'Hara · work from 2004 · published 2018

What this was

Statutory inquiry into the deaths of children in Northern Ireland hospitals, including deaths associated with hyponatraemia and fluid management. It found failures of care, candour and how the system treated families afterwards.

Why it sits in the hub

A duty of candour for Northern Ireland was a central recommendation and remained unfinished for years. It is the clearest UK example of a candour recommendation that inquiries in England assumed had already been solved.

Findings

  1. Finding 1

    Children died after failures in fluid management, and families were not told the truth.

    CandourChildren and safeguardingTraining and competence

  2. Finding 2

    The institutions investigated themselves in ways that did not withstand scrutiny.

    Culture and conductLearning from harm

Recommendations in this hub

Paraphrase of the public recommendations, not the official text.

  1. 1Partly doneNorthern Ireland Executive

    Introduce a statutory duty of candour in Northern Ireland.

    Candour
  2. 2Partly doneHealth and Social Care trusts

    Train clinicians in the management of fluids in children and audit that practice.

    Children and safeguardingTraining and competence