On 31 January 2018 the report of the Inquiry into Hyponatraemia-Related Deaths (IHRD) (Link) was published following an extensive investigation into the deaths of five children in hospitals in Northern Ireland. After hearing evidence from a wide range of individuals and organisations, it concluded that the five deaths had been avoidable and that the culture of the health service at the time, arrangements in place to ensure the quality of services and behaviour of individuals had contributed to those unnecessary deaths.
In the report Justice O’Hara acknowledged that progress had been made in hyponatraemia practice and guidance but that a more comprehensive approach for learning from error was needed for further unnecessary harm to be avoided. He set out 96 recommendations across 10 themes where he had identified failings in “competency in fluid management, honesty in reporting, professionalism in investigation, focus in leadership and respect for parental involvement”.
The Department of Health is currently taking forward a programme of work to implement the recommendations arising from the Inquiry. Click here to read further information about the Inquiry and recommendations.