By Steven McCaffery
AN anaesthetist who treated a seriously ill child has told a public inquiry he believed he knew what ultimately caused her death, but did not take sufficient steps to make certain it was reported and acted upon because he believed others would do so.
Dr Thomas Auterson denied any reluctance to highlight potential failings by colleagues after realising 17 month old Lucy Crawford died as a result of the use of intravenous fluids in the former Erne hospital in Enniskillen, but believed the issue would be picked up by others because it was so obvious.
The consultant anaesthetist told the Hyponatraemia Inquiry there was no defence for this, but said there was no deliberate intent to mislead.
He apologised for the events and said it was the first time he had been faced by such circumstances and might otherwise have handled it differently.
“Lucy was not my patient. I did what I could for her,” he told the Inquiry yesterday (Friday, May 31).
“Unfortunately, she died, but the subsequent management of conveying information to her parents I believe was the sole responsibility of the paediatrician in charge of her case.
“It was tragic. In fact, it was the second time I saw Lucy.
“The first time I saw Lucy was on the day she was born because I anaesthetised her mother for a Caesarean section and it’s particularly tragic that I should see her again on the day that she basically died.
“I did my best for her. The subsequent events, I can only apologise for. “
The inquiry accepted he had done all he could to save the child, but chairman Mr Justice John O’Hara said his concern was for the events that followed her death, as a result of which the inquiry is questioning a string of senior medical figures.
The inquiry sitting in Banbridge courthouse is examining the deaths of three children, but is not investigating the circumstances of Lucy’s death at the request of her family.
It is, however examining any degree of failure to learn lessons from her death and what impact this may have had on the death of another child 14 months later.
The inquiry is focusing on concerns over the fluid management of Adam Strain (4), Claire Roberts (9) and Raychel Ferguson (9), whose deaths are being investigated.
Hyponatraemia is a condition which results in a low level of sodium in the blood stream causing the brain cells to swell with too much water and in some cases resulting in death
Mr Auterson said he was called to the hospital shortly after 3.30am on April 13, 2000 after Lucy had a fit.
He said a decision was eventually made to transfer her to Belfast’s Royal Hospital, but he says he suspected fluids administered in the Erne were linked to the rapid decline in her condition.
He confirmed she had received a large amount of so-called Solution 18 and saline.
He said: “The conclusion I reached was that in view of her neurological collapse, it was probably due to hyponatraemia induced cerebral oedema. That was my working diagnosis.”
But when he told Lucy’s parents of the planned transfer to Belfast, he did not think it appropriate at that time to inform them of his belief.
He said he believed it was the responsibility of a colleague more closely involved in the child’s care to discuss the issue with the parents or to pursue the issue.
He was asked: “Did you confirm with anybody that he had taken either of those steps?”
The answer was: “No.”
The chairman asked Mr Auterson to detail an exchange he said he had with his colleague during attempts to resuscitate Lucy in the Erne around 4 am.
He said it “wasn’t so much a discussion” as a short conversation where he suggested “maybe she got too much fluid”.
The chair interrupted and said: “Sorry, bring that out. Don’t say maybe she got too much fluid. Unless I misheard you, I think you were going to say `blah blah’, as if to say et cetera, et cetera. What is the et cetera, et cetera?”
Dr Auterson said: “This was in the midst of an extremely chaotic resuscitation scenario. This was not a head to head over a table discussion. Things were extremely difficult that morning.”
The chairman said: “When did the head to head over the table discussion take place?”
Mr Auterson answered: “It didn’t.”
Challenged on his failure to sufficiently highlight the issue, he was asked by the inquiry lawyer if he should not have “fully exposed the elephant in the room”.
Mr Auterson accepted that while he could be fairly criticised for failing to fully spell out the issue in sufficient detail in a review of the case – though he did say he highlighted related issues that should have been picked up – he believed others would have spotted the concerns over the fluids because it was “an obvious conclusion”.
He objected to this being characterised as “passing the buck”.
At the conclusion of his evidence to the inquiry, Mr Auterson said: “I was only partly involved with the treatment of Lucy. I had no previous experience of such an event and, had I had, I may have approached things differently with regard to the review and reporting matters. I cannot offer any defence as to why I didn’t. There was no deliberate omission on my part.”
The chairman said he accepted he had done all he could for Lucy, but that the inquiry was concerned with the aftermath and whether more could have been done for her parents and for parents of other children.
Mr Auterson said in his defence that “there were many other people who should have picked up on things”.
Earlier in the day’s hearing Dr Dara O’Donoghue of the Royal Belfast Hospital for Sick Children, who completed and signed Lucy’s delayed death certificate, was quizzed on the timing of the certificate’s release and whether the issue of fluids was properly picked up.
He said he had consulted with a senior colleague at the time, took his advice and that any question should be referred to him.
The chairman accepted that he was a relatively junior doctor at the time, though one of experience, and recognised he had referred the issues to a senior colleague.
But Counsel to the Inquiry Moyne Anyadike-Danes asked the doctor if the full sequence of events had been determined at the time.
Counsel added: “If that missing step is not in itself a natural event, then do you appreciate that there is a difficulty in signing a death certificate like that without referring the matter to the coroner?”
The doctor answered that he as a junior figure had sought advice, adding: “On reflection, it has become apparent that I should not have taken that advice so readily and that I should have stress tested it in more detail.”
The inquiry continues on Tuesday.