Implementation of recommendations from the Inquiry into Hyponatraemia-Related Deaths

Date published: 28 June 2018

The Department of Health today provided an update on work to implement the recommendations of the public inquiry report on Hyponatraemia-related deaths.


The Department has established workstreams to take forward important action points. Key workstream groups in areas such as establishing a duty of candour and an independent medical examiner will be chaired by individuals from outside the health and social care system (HSC).

There are 120 actions relating to the 96 recommendations from the public inquiry report which are being taken forward under the auspices of a programme management group.

It includes representation from service users, carers, the voluntary and community sector, the Department and the wider HSC system. The individual recommendations will be taken forward by a number of workstreams and sub-groups whose memberships are made up of individuals from equally diverse backgrounds.

Quintin Oliver will chair a group which will co-produce proposals to implement recommendations on a duty of candour.

Paul Finnegan, the NI Director of CRUSE Bereavement Care, will lead the work on introducing an independent medical examiner.

Several other groups will be led by individuals from outside the Department and the HSC system. These individuals will also be members of the programme implementation group which will oversee the work of implementing all 96 recommendations.

Over the next few weeks, the Department will be running information sessions for everyone who is participating on a group under the programme.

The Department is also offering briefing sessions to CoPNI, NICCY, the Ombudsman, the Human Rights Commission, and the Equality Commission as well as to organisations which represent HSC staff or who regulate HSC staff.

The Department will also be organising a number of briefing sessions for community and voluntary sector groups to take place in September, by which time all of the workstreams and sub-groups will be up and running.

Permanent Secretary, Richard Pengelly commented: “The appointment of a number of workstreams and group Chairs from outside the health & social care sector is a strong signal of our commitment to co-produce proposals to implement recommendations of the Inquiry and to ensure public confidence in what we are doing. 

“A substantial amount of work has already been going on in the background over the last number of months. Our aim has been to ensure that we have the involvement of people from many diverse backgrounds in taking forward the implementation of these recommendations. We have also sought to put in place arrangements to support service users, carers and others from outside the HSC who will now be part of this programme.”

Membership of individual groups will also include individual service users, carers, Non-Executive representation from the Boards of several HSC bodies including Trusts, the PHA, HSCB and RQIA.

Mr Pengelly continued: “Individual service users and carers have a critical role to play as members of the groups taking forward the implementation of recommendations. It is also very important that members of the public in general take every opportunity to make their views known by engaging with the implementation programme.

“It is essential that there is strong buy-in, support and leadership from our HSC Trusts, the HSCB, PHA and other health & social care sector bodies. For this reason Non-Executive Directors will be represented on workstreams and sub-groups. In addition, the Department will be organising a health & social care sector-wide event for Non-Executive Directors from across the HSC to share learning from the implementation of the IHRD recommendations and as part of the assurance process.”

Mr Pengelly concluded: “The Department will be providing regular updates from individual workstreams on our website. Individual members of the public can also register their interest to be kept informed about developments across the implementation programme by sending their email address to They will then be able to receive updates from the programme including details of any published proposals and consultation and engagement events.”

Notes to editors: 

1. Terms of Reference

The scope of the work is the implementation of the recommendations.  Each workstream has been allocated recommendations to implement and a project brief.

2. Timescale

The aim is to ensure that each of the workstreams and Sub Groups has met for the first time the end of before September 2018.  Each workstream will then plan its implementation timescales from that point.  It is expected that many workstreams will complete their work within a year.  However, where legislative changes are required, the timescale may take three to four years.

3. Workstream and Sub Group Chairs

Health and Social Care sector and the Third Sector as follows:

  • Workstream 1 – Duty of Candour – Quintin Oliver (Stratagem)
    • Being Open Sub Group – Peter McBride (INSPIRE)
  • Workstream 2 – Death Certification and Implementation Working Group – David Best (DoH)
    • Preparation for Inquests Sub Group – Vivien McConvey (VOYPIC)
    • Independent Medical Examiner Sub Group – Paul Finnegan (CRUSE)
    • HSC Bereavement and Pathology Network – Sharon Wright (DoH)
  • Workstream 3 – Duty of Quality – Dr Eddie Rooney
    • Arms’ Length Body Effectiveness Sub Group – Jim Moore (Translink)
    • RQIA Remit Sub Group – Linda Greenless (DoH)
  • Workstream 4 – Paediatric Clinical Collaborative – Dr John Simpson
  • Workstream 5 – Serious Adverse Incidents – Conrad Kirkwood (DoH)
  • Workstream 6 – Training – Angela McLernon (NIPEC)
  • Workstream 7 – User Advocacy & Experience – Rodney Morton (DoH)
  • Workstream 8 – Workforce & Professional Regulation – Andrew Dawson (DoH)
  • Workstream 9 – Assurance – Olive MacLeod (RQIA)

4.   For media queries please contact the Department of Health Press Office team on 028 9052 0074 or email  For out of hours you can contact the Duty Press Officer via pager number on 07623 974383 and your call will be returned. Follow us on twitter @healthdpt

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