SUCH was the level of concern about the condition of a nine-year-old girl just hours before her death that her father felt "comfortable enough" to leave her hospital bedside and watch A Question of Sport in a nearby ward.
The lack of communication with the parents of Claire Roberts - who was deteriorating "in plain sight" of doctors - was singled out as an "extraordinary failure" and one that was "profoundly unsettling" by Sir John O'Hara in his public inquiry into the hyponatraemia-related deaths of five children.
This extended to all cases, the high court judge found, noting: "Fundamental failures in communication with families was one of the most repeated, basic, depressing and serious deficiencies encountered by this inquiry."
Hyponatraemia is a medical condition that occurs when there is a shortage of sodium in the bloodstream.The investigation examined whether fatal errors were made in the administration of intravenous fluids.
First ordered by former NIO minister Angela Smith in 2004, it would another 14 years for the damning findings to published due to a string of setbacks and police investigations.
On January 31, Mr Justice O'Hara stood at a podium in a Belfast hotel and delivered a withering assessment of a system in which doctors did not admit their failings for the "obvious reasons of self-protection" and where parents "were deliberately misled".
"A fundamental concern is on some occasions some doctors and managers worked against the principles in inquests. It is time that the medical profession and health service managers stop treating their own reputations and interests first and put the public interest first," he said.
He concluded that the eight-year period of the children's deaths was one in which the Northern Ireland health service had been "largely self-regulating and unmonitored" and praised the work of a UTV team of journalists who in 2004 broadcast a programme that was central to the inquiry being ordered.
The 684 page report, which is separated into three volumes, focuses on each of the children, Adam Strain (aged four), Claire Roberts (aged nine), Raychel Ferguson (aged nine) 17-month-old Lucy Crawford and Conor Mitchell, who was 15.
The deaths took place between 1995 and 2003 at the Royal Belfast hospital for Sick Children in Belfast.
Acknowledging that the findings would be "difficult and emotional reading" for the families, the inquiry chairman said four of the five deaths could have been avoided and that the medical care provided "fell far below acceptable standards"
He referred to correspondence sent by the health trust to the Roberts family in 2005 - a year after the inquiry was ordered - describing it as "inaccurate, evasive and unreliable".
"Efforts to protect the trust's reputation was apparent again even after the inquiry was established," he added.
