In October 2004, UTV broadcast a documentary called When Hospitals Kill, which examined the deaths of Raychel Ferguson, Adam Strain and Lucy Crawford.
he programme claimed the children died from hyponatraemia because they had been given too much of the wrong type of fluid while in hospitals in Northern Ireland.
The following month, the then minister with responsibility for health in Northern Ireland, Angela Smith, announced a public inquiry into the allegations made in the UTV documentary and appointed Mr John O’Hara QC as chair of the inquiry.
Claire Roberts was then added to the remit of the inquiry after her parents viewed When Hospitals Kill and raised concerns over the circumstances of her death.
Following Claire’s death, her parents were told she had died as a result of a viral infection which spread to her brain, but they never fully understood what had happened to their only daughter.
Mr O’Hara then made a decision to also examine the death of 15-year-old Conor Mitchell.
Hyponatraemia is a shortage of sodium in the blood that can be fatal.
The condition can occur when fluids are not administered properly.
It can lead to catastrophic swelling of the brain.
Publishing his findings in January 2018, Mr Justice O’Hara said that four of the five deaths he had examined were preventable.
In a scathing assessment of the health service, he said that “doctors and managers cannot be relied upon to do the right thing at the right time” and that some witnesses to the inquiry “had to have the truth dragged out of them”.
In total, he made 96 recommendations, including a call for a statutory duty of candour. The issue is currently under consideration by the Department of Health, although it has been opposed by a number of unions, including the British Medical Association.
Following Mr Justice O’Hara’s comments that he believed a cover-up had occurred after Claire Robert’s death, the Attorney General ordered a fresh inquest.
The original inquest, which took place in 2006 after concerns were raised following When Hospitals Kill, found she had died from a brain virus.
A second inquest took place in June 2019. It found Claire’s death was caused by treatment she received at the Royal Belfast Hospital for Sick Children.
The coroner, Joe McCrisken, ruled she died from cerebral oedema due to hyponatraemia, which was due to inappropriate infusion of fluids in combination with the effects of a viral illness and toxicity from treatments she had been given.
In parallel, the General Medical Council has been investigating the conduct of a number of doctors criticised by the Hyponatraemia Inquiry.
An investigation team within the PSNI’s legacy investigation branch has also been set up following a referral from the Attorney General.
It is working to identify any areas of potential criminality with regards to the deaths of the children examined by the Hyponatraemia Inquiry.