Public Inquiry Recommendations

IHRD-1 Accepted Urgent

Hyponatraemia Inquiry (2018)

Statutory Duty of Candour

A statutory duty of candour should now be enacted in Northern Ireland so that: (i) Every healthcare organisation and everyone working for them must be open and honest in all …

- The available evidence indicates that this recommendation is not implemented. The February 2026 Being Open Framework expressly says that it does not create the …

IHRD-2 Accepted in Part

Hyponatraemia Inquiry (2018)

Criminal Liability for Candour Breach

Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.

- The Department of Health NI stated in March 2018 that criminal liability for breach of the duty of candour was under review (IHRD Implementation …

IHRD-3 Accepted in Part

Hyponatraemia Inquiry (2018)

Guidance on Statutory Duty of Candour

Unequivocal guidance should be issued by the Department to all Trusts and their legal advisors detailing what is expected of Trusts in order to meet the statutory duty.

- The Department of Health NI stated in March 2018 that guidance was being developed in conjunction with the statutory duty of candour legislation (IHRD …

IHRD-4 Accepted in Part

Hyponatraemia Inquiry (2018)

Trust Awareness of Duty of Candour

Trusts should ensure that all healthcare professionals are made fully aware of the importance, meaning and implications of the duty of candour and its critical role in the provision of …

- The Department of Health NI reported that work to raise awareness of the duty of candour among healthcare staff was being taken forward (IHRD …

IHRD-5 Accepted

Hyponatraemia Inquiry (2018)

Employment Contracts and Duty of Candour

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.

- The Department of Health NI reported that contractual obligations relating to the duty of candour were under development (IHRD Implementation Programme, Department of Health …

IHRD-6 Accepted

Hyponatraemia Inquiry (2018)

Support for Candour Compliance

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

- The Department of Health NI reported that support mechanisms for staff exercising the duty of candour were being developed (IHRD Implementation Programme, Department of …

IHRD-7 Accepted

Hyponatraemia Inquiry (2018)

Monitoring Candour Compliance

Trusts should monitor compliance and take disciplinary action against breach.

- The Department of Health NI reported that compliance monitoring for the duty of candour was being considered (IHRD Implementation Programme, Department of Health NI, …

IHRD-8 Accepted

Hyponatraemia Inquiry (2018)

RQIA Compliance Review Powers

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 …

- The Department of Health NI stated in March 2018 that expanded oversight powers for RQIA were under consideration (IHRD Implementation Programme, Department of Health …

IHRD-9 Accepted

Hyponatraemia Inquiry (2018)

Leadership Development

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.

- The Department of Health NI reported that leadership development programmes had been implemented across the HSC (IHRD Implementation Programme, Department of Health NI, March …

IHRD-10 Accepted

Hyponatraemia Inquiry (2018)

Age-Appropriate Hospital Settings

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.

- HSC Trusts reported that children are treated in age-appropriate settings with appropriately trained staff (IHRD Implementation Programme, Department of Health NI, March 2018). - …

IHRD-11 Accepted

Hyponatraemia Inquiry (2018)

Patient Transfer Protocol

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

- HSC Trusts reported that consultant-led ward rounds are conducted regularly on paediatric wards (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

IHRD-12 Accepted

Hyponatraemia Inquiry (2018)

Senior Paediatric Responsibility

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

- HSC Trusts reported that bedside name boards identifying the responsible consultant and named nurse are in place on paediatric wards (IHRD Implementation Programme, Department …

IHRD-13 Accepted in Part

Hyponatraemia Inquiry (2018)

Foundation Doctors in Children's Wards

Foundation doctors should not be employed in children's wards.

- HSC Trusts reported that care plans are available at each child's bedside for reference by parents and carers (IHRD Implementation Programme, Department of Health …

IHRD-14 Accepted

Hyponatraemia Inquiry (2018)

Clinician Competence Assessment

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

- HSC Trusts reported that fluid management protocols for children have been reviewed and updated (IHRD Implementation Programme, Department of Health NI, March 2018). - …

IHRD-15 Accepted

Hyponatraemia Inquiry (2018)

Consultant Notification on Admission

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 …

- HSC Trusts reported that specific protocols for the recognition and management of hyponatraemia in children have been implemented (IHRD Implementation Programme, Department of Health …

IHRD-16 Accepted

Hyponatraemia Inquiry (2018)

Bedside Display of Responsible Staff

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.

- HSC Trusts reported that Paediatric Early Warning Scoring systems are in use across paediatric settings (IHRD Implementation Programme, Department of Health NI, March 2018). …

IHRD-17 Accepted

Hyponatraemia Inquiry (2018)

Recording Changes in Accountability

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

- HSC Trusts reported that nurse-to-patient ratios on paediatric wards have been reviewed in line with professional standards (IHRD Implementation Programme, Department of Health NI, …

IHRD-18 Accepted

Hyponatraemia Inquiry (2018)

On-Call Consultant Display

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

- HSC Trusts reported that clinical handover processes on paediatric wards have been standardised (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

IHRD-19 Accepted

Hyponatraemia Inquiry (2018)

Senior Lead Nurse in Children's Wards

To ensure continuity, all children's wards should have an identifiable senior lead nurse with authority to whom all other nurses report. The lead nurse should understand the care plan relating …

- HSC Trusts reported that arrangements for paediatric consultant cover out of hours have been reviewed (IHRD Implementation Programme, Department of Health NI, March 2018). …

IHRD-20 Accepted

Hyponatraemia Inquiry (2018)

Consultant-Led Ward Rounds

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

- HSC Trusts reported that processes for escalation of clinical concerns about children have been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). …

IHRD-21 Accepted

Hyponatraemia Inquiry (2018)

Nurse Attendance at Clinical Interactions

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

- HSC Trusts reported that clinical documentation standards for paediatric care have been improved (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

IHRD-22 Accepted

Hyponatraemia Inquiry (2018)

Parental Knowledge in Care Plans

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

- HSC Trusts reported that discharge planning processes for children have been reviewed and strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - …

IHRD-23 Accepted

Hyponatraemia Inquiry (2018)

Care Plan Availability at Bedside

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

- HSC Trusts reported that arrangements for parent and carer involvement in clinical decision-making have been formalised (IHRD Implementation Programme, Department of Health NI, March …

IHRD-24 Accepted

Hyponatraemia Inquiry (2018)

Blood Test Result Documentation

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 …

- HSC Trusts reported that medication prescribing and administration protocols for children have been reviewed (IHRD Implementation Programme, Department of Health NI, March 2018). - …

IHRD-25 Accepted

Hyponatraemia Inquiry (2018)

Drug Prescription Documentation

All instances of drug prescription and administration should be entered into the main clinical notes and paediatric pharmacists should monitor, query and, if necessary, correct prescriptions. In the event of …

- HSC Trusts reported that laboratory turnaround times for urgent paediatric blood tests have been reviewed (IHRD Implementation Programme, Department of Health NI, March 2018). …

IHRD-26 Accepted

Hyponatraemia Inquiry (2018)

Recording Clinical Discussions

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.

- HSC Trusts reported that clinical audit programmes for paediatric care have been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

IHRD-27 Accepted

Hyponatraemia Inquiry (2018)

Electronic Patient Information Systems

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

- The Department of Health NI stated in March 2018 that electronic care record programmes were progressing (IHRD Implementation Programme, Department of Health NI, March …

IHRD-28 Accepted

Hyponatraemia Inquiry (2018)

Informed Consent Documentation

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

- HSC Trusts reported that clinical communication systems between primary and secondary care for paediatric patients have been reviewed (IHRD Implementation Programme, Department of Health …

IHRD-29 Accepted

Hyponatraemia Inquiry (2018)

Record Keeping Audit

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

- HSC Trusts reported that arrangements for transfer of children between hospitals have been formalised with standardised protocols (IHRD Implementation Programme, Department of Health NI, …

IHRD-30 Accepted

Hyponatraemia Inquiry (2018)

Confidential Reporting of Clinical Concerns

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

- The Department of Health NI reported that confidential reporting mechanisms had been established (IHRD Implementation Programme, Department of Health NI, March 2018). - A …

IHRD-31 Accepted

Hyponatraemia Inquiry (2018)

SAI Reporting Understanding

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

- The Department of Health NI reported that work to improve staff understanding of SAI processes and their purpose had been taken forward (IHRD Implementation …

IHRD-32 Accepted

Hyponatraemia Inquiry (2018)

SAI Reporting as Disciplinary Offence

Failure to report an SAI should be a disciplinary offence.

- The Department of Health NI reported that the SAI process had been redesigned to separate learning and improvement from disciplinary procedures (IHRD Implementation Programme, …

IHRD-33 Accepted

Hyponatraemia Inquiry (2018)

CEO Responsibility for Investigations

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

- The Department of Health NI reported that CEO accountability for SAI investigation quality and timeliness had been strengthened in revised SAI procedures (IHRD Implementation …

IHRD-34 Accepted in Part

Hyponatraemia Inquiry (2018)

Independent SAI Investigation

The most serious adverse clinical incidents should be investigated by wholly independent investigators (i.e. an investigation unit from outside Northern Ireland) with authority to seize evidence and interview witnesses.

- The Department of Health NI stated in March 2018 that independent investigation arrangements had been strengthened (IHRD Implementation Programme, Department of Health NI, March …

IHRD-35 Accepted

Hyponatraemia Inquiry (2018)

Non-Cooperation as Disciplinary Offence

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

- The Department of Health NI reported that SAI investigation teams now include members with appropriate clinical expertise for the incident under review (IHRD Implementation …

IHRD-36 Accepted

Hyponatraemia Inquiry (2018)

Separation of Investigation and Litigation

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

- The Department of Health NI reported that SAI investigation training for panel members had been developed and delivered (IHRD Implementation Programme, Department of Health …

IHRD-37 Accepted

Hyponatraemia Inquiry (2018)

Family Involvement in SAI Investigations

Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all …

- The Department of Health NI reported that standardised terms of reference for SAI investigations had been developed (IHRD Implementation Programme, Department of Health NI, …

IHRD-38 Accepted

Hyponatraemia Inquiry (2018)

Multi-Disciplinary Peer Review

Investigations should be subject to multi-disciplinary peer review.

- The Department of Health NI reported that timescales for completion of SAI investigations had been set and were being monitored (IHRD Implementation Programme, Department …

IHRD-39 Accepted

Hyponatraemia Inquiry (2018)

Investigation Team Reconvening

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

- The Department of Health NI reported that family engagement in the SAI process had been formalised through the SAI Engagement Platform (IHRD Implementation Programme, …

IHRD-40 Accepted

Hyponatraemia Inquiry (2018)

SAI Learning Informing Clinical Audit

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

- The Department of Health NI reported that SAI investigation reports are now shared with families in a timely manner (IHRD Implementation Programme, Department of …

IHRD-41 Accepted

Hyponatraemia Inquiry (2018)

Publication of External Investigation Reports

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

- The Department of Health NI reported that arrangements for families to provide input to SAI investigations had been strengthened (IHRD Implementation Programme, Department of …

IHRD-42 Accepted

Hyponatraemia Inquiry (2018)

Sharing New Investigation Information

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.

- The Department of Health NI reported that mechanisms for tracking implementation of SAI recommendations had been established (IHRD Implementation Programme, Department of Health NI, …

IHRD-43 Accepted

Hyponatraemia Inquiry (2018)

GP Notification of Death Circumstances

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

- The Department of Health NI reported that arrangements for sharing learning from SAI investigations across the HSC had been improved (IHRD Implementation Programme, Department …

IHRD-44 Accepted

Hyponatraemia Inquiry (2018)

Post-Mortem Limitation Authorisation

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.

- HSC Trusts reported that post-mortem communication procedures with families had been updated (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

IHRD-45 Accepted

Hyponatraemia Inquiry (2018)

Post-Mortem Documentation Checklist

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

- HSC Trusts reported that consent processes for post-mortem examinations had been reviewed and strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - …

IHRD-46 Accepted

Hyponatraemia Inquiry (2018)

Clinician Attendance at Post-Mortem Discussions

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

- HSC Trusts reported that mortality review processes for child deaths had been formalised (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

IHRD-47 Accepted

Hyponatraemia Inquiry (2018)

Post-Mortem Reporting Standards

In providing post-mortem reports pathologists should be under a duty to: (i) Satisfy themselves, insofar as is practicable, as to the accuracy and completeness of the information briefed them. (ii) …

- HSC Trusts reported that arrangements for paediatric pathology services had been reviewed (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

IHRD-48 Accepted

Hyponatraemia Inquiry (2018)

Mortality Meeting Recording and Audit

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

- HSC Trusts reported that processes for timely completion of death certificates for children had been reviewed (IHRD Implementation Programme, Department of Health NI, March …

IHRD-49 Accepted

Hyponatraemia Inquiry (2018)

Multi-Trust Mortality Meeting Engagement

Where the care and treatment under review at a mortality meeting involves more than one hospital or Trust, video conferencing facilities should be provided and relevant professionals from all relevant …

- HSC Trusts reported that quality standards for post-mortem reports had been reviewed (IHRD Implementation Programme, Department of Health NI, March 2018). - No independent …

IHRD-50 Accepted

Hyponatraemia Inquiry (2018)

HSCB Notification of Inquests

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.

- HSC Trusts reported that procedures for engagement with the coronial process had been updated (IHRD Implementation Programme, Department of Health NI, March 2018). - …