Hyponatraemia report: Trust unreservedly sorry over mistakes that led to death of Raychel Ferguson

Raychel died from hyponatraemia, a shortage of sodium in the body, in the Royal Victoria Hospital on June 10, 2001, two days after being admitted to Altnagelvin with abdominal pains.

She had received the wrong level of sodium in a drip applied to treat her for dehydration after her appendix procedure.

The Western Trust have today apologised to Raychel's parents Marie and Ray rafter the Report of the Inquiry into Hyponatraemia-related Deaths (IHRD) was published on Wednesday.

Raychel was among five children whose deaths were subject to a public inquiry that's been ongoing since 2004.

Today that inquiry published its final report and identified several failings in the care that Raychel received before her death.

The IHRD chair John O'Hara has also recommended that the health service needs to be more candid when dealing with patients and their families.

In a joint statement, the Western, Belfast and Southern Trusts, said: “We unreservedly apologise to the families of Adam Strain, Claire Roberts, Lucy Crawford, Raychel Ferguson and Conor Mitchell for our many failings.

"We welcome today’s publication of the Report and we thank Sir John O’Hara and his Inquiry Team for their extensive work. We will urgently review the recommendations to ensure that all possible steps have been taken to prevent this ever happening again.

"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."

Meanwhile, the Health and Social Care Board (HSCB) has vowed to work to ensure the effective implementation of Mr. O'Hara's recommendations.

A spokesperson stated: "The HSCB would again like to convey its sincere sympathies to all of the families involved for the loss of their beloved children, and for the pain and distress they have gone through over the years, prior to and during the Inquiry process.

"Whilst we fully accept that it is cold comfort to the families, since the incidents leading to these tragic deaths, a number of significant changes have taken place within the wider health and social care system.

"A lot of work has gone into ensuring that when things do go wrong, incidents are reported, robust action is taken, families are engaged, and relevant learning is shared and disseminated across the wider HSC.

"The HSCB is firmly committed to continuing this work, alongside the wider HSC, to minimise the risk of such tragic events occurring again. We are confident that the recommendations in the report will play a key role in further embedding and enhancing learning across the whole system.

"The HSCB notes the decision of the Inquiry’s Chair to further investigate the issues involved in and surrounding the whistle-blower’s complaint. The HSCB will co-operate fully with the Inquiry and will provide whatever assistance is required.

"A number of concerns were raised with the Chief Executive of the Health and Social Care Board under the HSC Whistleblowing policy and as a result, the HSCB formed a three person panel (two of the members were external to the HSCB) to conduct an investigation.

"A full and thorough investigation was carried out by the panel which found no evidence to support the claims of any ‘deliberate attempt to remove evidence’ or any ‘deliberate attempt to destroy evidence or equipment contrary to the instructions regarding the need to preserve evidence for further consideration by the inquiry’.

"As the Inquiry will now investigate the matter further it would be inappropriate to comment further on this issue."