Hyponatraemia inquiry: Royal patient care 'lacked structure'
A public inquiry into the death of a four-year-old boy at the Royal in Belfast has heard that his care lacked structure which resulted in serious and numerous omissions.
Adam Strain died following a kidney transplant in 1995.
The hyponatraemia inquiry is investigating the deaths of five children in Northern Ireland.
The inquiry also heard on Tuesday that Adam's mother requested a surgeon not take part in her son's procedure.
The inquiry is examining the deaths of three children - Adam, Claire Roberts and Raychel Ferguson.
But it is also investigating the events following the deaths of Lucy Crawford and Conor Mitchell. All of the children died in hospital.
In relation to four of the deaths hyponatraemia is said to be a contributing factor.
Hyponatraemia describes an abnormally low level of sodium in the blood which occurs when fluid is not administered properly.
A nursing expert appointed by the inquiry team raised very serious concerns about how staff at the Royal Belfast Hospital for Sick Children cared for Adam.
The nursing expert, Sally Ramsey, said that record keeping fell below the expected standards. There was also no nursing care or dialysis plan.
She said: "As a child in chronic renal failure about to undergo major surgery - the care given to Adam pre-operatively lacked structure which resulted in omissions in his care. "
It has been revealed that prior to Adam's operation his mother requested that one of the surgeons should not be involved in his surgery as she had no faith in him.
As there was no plan in place that instruction was ignored.
The inquiry has also heard that handwriting was misread which could mean that Adam received the wrong amount of fluids.
Counsel for the family, David McBrien, said the family still had many questions.
This included why a leading doctor did not play a more active role in the operating theatre, why it took a different doctor 16 years to recognise he had made so many mistakes and why there was such poor communication between clinicians?
In summing up, an expert witness said: "Adam's death was an avoidable tragedy - it's a shame it has taken so many years for the lessons to be learned in this case."
The inquiry will resume on 16 April and is expected to last until November.