The findings in this report followed a 14-year inquiry into hyponatraemia-related deaths in five children in Northern Ireland.
The inquiry was set up in 2004 to investigate the deaths of Adam Strain, Claire Roberts, Raychel Ferguson, Lucy Crawford and Conor Mitchell. The chairman said that the deaths of Adam Strain, Claire Roberts and Raychel Ferguson were the result of "negligent care".
In his report, Mr Justice O'Hara found that:
- While investigating the death of Adam Strain, the inquiry had been met with "defensiveness and deceit" and that "information was withheld" about what happened to Adam in the operating theatre.
- There "was a cover up" in the death of Claire Roberts, whose death was not referred to the coroner immediately to "avoid scrutiny"
- Poor care was "deliberately concealed" in the death of Lucy Crawford.
- There was a "reluctance among clinicians to openly acknowledge failings" in the death of Raychel Ferguson.
- In the death of Conor Mitchell, there was a "potentially dangerous variation in care and treatment afforded to young people at Craigavon Hospital".
In total, the inquiry made 96 recommendations including the establishment of a duty of candour on medical professionals "to tell patients and their families about major failures in care and to give a full and honest explanation".