Inquiry into Hyponatraemia-related Deaths

Trusts should review their contracts of employment, policies and guidance to ensure that, where relevant, they include and are consistent with the duty of candour.

Support and protection should be given to those who properly fulfil their duty of candour.

Trusts should monitor compliance and take disciplinary action against breach.

Regulation and Quality Improvement Authority ('RQIA') should review overall compliance and consideration should be given to granting it the power to prosecute in cases of serial non-compliance or serious and wilful deception.

The highest priority should be accorded the development and improvement of leadership skills at every level of the health service including both executive and non-executive Board members.

Health and Social Care ('HSC') Trusts should publish policy and procedure for ensuring that children and young people are cared for in age-appropriate hospital settings.

There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.

Senior paediatric medical staff should hold overall patient responsibility in children's wards accommodating both medical and surgical patients.

The experience and competence of all clinicians caring for children in acute hospital settings should be assessed before employment.

A consultant fixed with responsibility for a child patient upon an unscheduled admission should be informed promptly of that responsibility and kept informed of the patient's condition, to ensure senior clinical involvement and leadership.

The names of both the consultant responsible and the accountable nurse should be prominently displayed at the bed in order that all can know who is in charge and responsible.

Any change in clinical accountability should be recorded in the notes.

The names of all on-call consultants should be prominently displayed in children's wards.

Children's ward rounds should be led by a consultant and occur every morning and evening.

The accountable nurse should, insofar as is possible, attend at every interaction between a doctor and child patient.

Clinicians should respect parental knowledge and expertise in relation to a child's care needs and incorporate the same into their care plans.

The care plan should be available at the bed and the reasons for any change in treatment should be recorded.

All blood test results should state clearly when the sample was taken, when the test was performed and when the results were communicated and in addition serum sodium results should be recorded on the Fluid Balance Chart.

Clinical notes should always record discussions between clinicians and parents relating to patient care and between clinicians at handover or in respect of a change in care.

Electronic patient information systems should be developed to enable records of observation and intervention to become immediately accessible to all involved in care.

Consideration should be given to recording and/or emailing information and advices provided for the purpose of obtaining informed consent.

Record keeping should be subject to rigorous, routine and regular audit.

Confidential on-line opportunities for reporting clinical concerns should be developed, implemented and reviewed.

Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').

Failure to report an SAI should be a disciplinary offence.

Compliance with investigation procedures should be the personal responsibility of the Trust Chief Executive.

Failure to co-operate with investigation should be a disciplinary offence.

Trust employees who investigate and accident should not be involved with related Trust preparation for inquest or litigation.

Investigations should be subject to multi-disciplinary peer review.

Investigation teams should reconvene after an agreed period to assess both investigation and response.

Learning and trends identified in SAI investigations should inform programmes of clinical audit.

Trusts should publish the reports of all external investigations, subject to considerations of patient confidentiality.

In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the same should be shared promptly with families.

A deceased's family GP should be notified promptly as to the circumstances of death to enable support to be offered in bereavement.

Authorisation for any limitation of a post-mortem examination should be signed by two doctors acting with the written and informed consent of the family.

Check-list protocols should be developed to specify the documentation to be furnished to the pathologist conducting a hospital post-mortem.

Where possible, treating clinicians should attend for clinico-pathological discussions at the time of post-mortem examination and thereafter upon request.

The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.

The Health and Social Care ('HSCB') should be notified promptly of all forthcoming healthcare related inquests by the Chief Executive of the Trust(s) involved.

Trust employees should not record or otherwise manage witness statements made by Trust staff and submitted to the Coroner's office.

Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.

Professional bereavement counselling for families should be made available and should fully co-ordinate bereavement information, follow-up service and facilitated access to family support groups.

Trust Chairs and Non-Executive Board Members should be trained to scrutinise the performance of Executive Directors particularly in relation to patient safety objectives.

All Trust Board Members should receive induction training in their statutory duties.

Specific clinical training should always accompany the implementation of important clinical guidelines.

HSC Trusts should ensure that all nurses caring for children have facilitated access to e-learning on paediatric fluid management and hyponatraemia.

There should be training in the completion of the post-mortem examination request form.

There should be training in the communication of appropriate information and documentation to the Coroner's office.

Clinicians caring for children should be trained in effective communication with both parents and children.

Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident, which training should include communication with grieving parents after a SAI death.

The practice of involving parents in care and the experience of parents and families should be routinely evaluated and the information used to inform training and improvement.

Parents should be involved in the preparation and provision of any such training programme.

Training in SAI investigation methods and procedures should be provided to those employed to investigate.

Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.

Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should be informed.

Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.

Trusts should appoint and train Executive Directors with specific responsibility for: (i) Issues of Candour. (ii) Child Healthcare. (iii) Learning from SAI related patient deaths.

Effective measures should be taken to ensure that minutes of board and committee meetings are preserved.

All Trust Boards should ensure that appropriate governance mechanisms are in place to assure the quality and safety of the healthcare services provided for children and young people.

All Trust publications, media statements and press releases should comply with the requirement for candour and be monitored for accuracy by a nominated non-executive Director.

General Medical Council ('GMC') 'Good Medical Practice' Code requirements should be incorporated into contracts of employment for doctors.

Likewise, professional codes governing nurses and other healthcare professionals should be incorporated into contracts of employment.

Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters and deal with them independently of professional bodies.

Clinical standards of care, such as patients might reasonably expect, should be published and made subject to regular audit.

Trusts should appoint a compliance officer to ensure compliance with protocol and direction.

Implementation of clinical guidelines should be documented and routinely audited.

Trusts should bring significant changes in clinical practice to the attention of the HSCB with expedition.

Trusts should ensure health care data is expertly analysed for patterns of poor performance and issues of patient safety.

Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.

Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.

Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding year and particularise the learning gained therefrom.

All Trust Boards should consider the findings and recommendations of this Report and where appropriate amend practice and procedure.

The Department should appoint a Deputy Chief Medical Officer with specific responsibility for children's healthcare.

The Department should now institute the office of Independent Medical Examiner to scrutinise those hospital deaths not referred to the Coroner.

The Department should engage with other interested statutory organisations to review the merits of introducing a Child Death Overview Panel.

The Department should consider establishing an organisation to identify matters of patient concern and to communicate patient perspective directly to the Department.

The Department, HBSC, PHA, RQIA and HSC Trusts should synchronise electronic patient safety incident and risk management software systems, codes and classifications to enable effective oversight and analysis of regional information.

The Department should review healthcare standards in light of the findings and recommendations of this report and make such changes as are necessary.

The Department should review Trust responses to the findings and recommendations of this Report.

Given that the public is entitled to expect appropriate transparency from a publically funded service, the Department should bring forward protocol governing how and when legal privilege entitlement might properly be asserted by Trusts.

The Department should provide clear standards to govern the management of healthcare litigation by Trusts and the work of Trust employees and legal advisors in this connection should be audited.