Coroner says ‘human errors’ resulted in death of young girl following operation

The death of a young girl following an appendix operation was due to “a series of human errors” and not “systemic failure”, a coroner has found. Raychel Ferguson, nine, from Coshquin, Co Londonderry, died on June 10 2001 at the Royal Belfast Hospital for Sick Children after the procedure at Altnagelvin Hospital in Derry city. She was one of five children whose hospital treatment was examined in the long-running Hyponatraemia Inquiry. Inquiry chairman Mr Justice O’Hara found in 2018 that Raychel’s death, and the deaths of Adam Strain and Claire Roberts, were the result of “negligent care”. The deaths of Lucy Crawford and Conor Mitchell were also examined during the inquiry. His report found four of the five deaths could have been avoided An inquest into her death was ordered in January 2022 by the Attorney General for Northern Ireland. During inquest hearings, John Coyle, representing the Ferguson family, had argued the case is “not mere negligence” but “utter systemic failure”. Delivering his findings at Belfast Coroner’s Court on Monday morning, Coroner Joe McCrisken expressed his condolences to Raychel’s parents Ray and Marie, who were present in court, saying their grief at the death of their daughter “shall continue to weigh heavily on them for the rest of their lives”. “This has been compounded by knowing that Raychel’s death was avoidable,” he said. He noted Mr Justice O’Hara’s report that errors were made by those charged with caring for Raychel, and lessons that should have learned following the death of Adam Strain were not. “Friends and family have spent the best part of the last 22 years attending various legal hearings and fighting to get answers which they deserve to have,” he said. Reading his findings to the court, Mr McCrisken said: “I am satisfied that a series of individual human errors resulted in Raychel’s death rather than serious systemic structural failures”. Mr McCrisken recorded Raychel’s death as cerebral edema (swelling of the brain), and hyponatraemia. He said there were three factors in the hyponatraemia, but said the most significant was the inappropriate administration of a type of saline known as solution 18. “I am completely satisfied that an inappropriate infusion of hypertonic saline, in other words solution number 18, played the most significant part in Raychel developing hyponatraemia which led to her death,” he said. The coroner added that he is satisfied that following both the inquiry and this inquest lessons have been learned. “I am satisfied, as was Mr Justice O’Hara, that as far as possible, both because of the inquiry and this inquest, the full facts of Raychel’s death have been brought to light, that the potentially dangerous practice of giving hypotonic fluids, solution 18, to children have been brought to public notice,” he said. “I’m also satisfied that significant lessons have now been learned following the deaths of Raychel, Adam, Conor, Claire and Lucy. The inquiry made several recommendations which the Department of Health is progressing.” Speaking outside court, Mrs Ferguson said she feels she has left no stone unturned as she had promised her daughter. “We want to see the establishment of Raychel’s Law, a statutory duty of candour for the medical profession,” she said. “The truth is all we ever wanted and we should not have been involved in dragging the truth out for over 22 years.”

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