The wrong conclusions were reached following an investigation into how a whistleblower’s hyponatraemia concerns were handled by officials, an inquiry said.
Chairman Sir John O’Hara QC scrutinised the deaths of five children from the condition last year and heavily criticised a “cover-up” by some consultants, accusing some doctors of behaving “inadequately, evasively, dishonestly and ineptly”.
On Tuesday he published an update on the adequacy of searches in 2004 of what were then Western Health Board properties for documents relevant to the probe.
Sir John identified a failure at leadership level after the whistleblower raised concerns in the public interest.
He added: “However, there was a serious failure to address these concerns, whether to investigate them properly or judge them fairly.
“The wrong conclusions were reached.
“This was a failure at leadership level within the healthcare service.
“Not only was the whistleblower failed but so too was the service.”
He said confidence in the critically important systems of whistleblowing depended upon fairness and professionalism.
“These were absent. It is unsettling to be compelled to this conclusion given the many reassurances urged upon me by senior Health and Social Care Board officials.”
He added: “Whilst it is for others to determine why this particular whistleblower’s concerns were not accorded proper response, I reiterate my recommendation that the highest priority be accorded the development and improvement of leadership skills within the healthcare service.”
The High Court judge found three deaths from hyponatraemia, a lack of sodium in the blood, were avoidable and the youngsters received unacceptable care during the administration of intravenous fluids.
His update said an internal investigation by the Health and Social Care Board ought to have concluded that:
– There were gaps in the search for documents in 2004.
– The senior civil servant in the department of health was misled in 2004 as to the completeness of the searches undertaken within the board, for documentation relating to the deaths of Lucy Crawford and Raychel Ferguson.
– There was a failure by the health and social care board in 2013 to bring relevant information to the attention of the inquiry, leaving it misinformed.
The update said: “That the Western Health and Social Services Board should have failed to conduct appropriate searches, and misled as to the extent of those searches, is profoundly unsatisfactory and is to be criticised.”
The Health and Social Care Board welcomed the fact that no amendment to the “essential findings” of Sir John’s report as published in January 2018 is required.
It acknowledged issues raised in the summary report and accepted there was scope for learning.
“It is also important to stress that the panel members carried out a very complex investigation within a constrained timeline with honesty, integrity and dedication.
“This was done in line with the whistleblowing policy which provides for anonymity of the whistleblower in accordance with relevant legislation.
“The panel members were acutely aware of the seriousness of the whistleblower’s concerns, given the tragic circumstances which led to the Hyponatraemia Inquiry, and strived to consider the issues raised in a fair and impartial manner.
“The HSCB is firmly committed to working with the wider healthcare system to ensure that any learning is fully taken on board.”