Hyponatraemia inquiry hears how transplant broke guidelines
One of the children at the centre of the hyponatraemia inquiry in Northern Ireland may have received a kidney transplant that broke recommended medical guidelines.
Adam Strain was four years old when he died in 1995.
The public inquiry into the deaths of five children while being treated in hospital has finally got under way in Banbridge.
Established in 2004, the inquiry has been postponed on several occasions.
It will also investigate the deaths of Claire Roberts, Raychel Ferguson, Lucy Crawford and issues arising from the treatment of Conor Mitchell.
The common thread linking four of the children is a condition called hyponatraemia, which occurs when there is a low amount of sodium in the blood stream.
The children died between 1995 and 2003. Their cases are being dealt with in chronological order.
The issue of how fluid was managed by hospital staff was central to Monday's evidence.
In her opening address, senior counsel to the inquiry, Monye Anyadike-Danes QC, said that the length of time which lapsed between the donor kidney being retrieved and transplanted appeared to be unusually long.
In the UK all other renal transplant centres have a maximum time of 22 hours but in Adam's case it was 32 hours before the transplant was completed.
It was revealed that during the inquest into his death a doctor described the state of the kidney at the time of transplant "as good as dead".
The inquiry also heard that the consultant paediatric anaesthetist at the Royal Victoria Hospital for Sick Children, Dr Robert Taylor, now admitted that he gave the required fluids at a rate which was higher than that which Adam could physically cope with.
It was also revealed that insufficient records mean that it is not clear which medical staff actually attended Adam's transplant operation.
In the morning session, the inquiry heard evidence from Adam's mother that he had endured more in his four short years than most people go through in a lifetime.
Ms Anyadike-Danes QC said it was important to remember that at the heart of this was a child who his mother described as being "an adored little boy, but a little boy who had endured numerous operations".
The inquiry also heard how some of the nurses and doctors involved in Adam's case had not received the proper training in fluid management and record keeping.
The inquiry continues.