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Inquiry into Hyponatraemia related deaths


Health and Social Care Board response to Summary of Findings Report

The Health and Social Care Board (HSCB) notes the contents of the Inquiry’s summary report and will take some time to carefully consider the findings.

The HSCB is very mindful of the pain the families involved in the hyponatraemia inquiry have endured over a considerable period of time, and the potential for the latest findings to cause further distress.

Therefore, the HSCB welcomes the fact that no amendment to the essential findings of Sir John O’Hara’s Inquiry report as published in January 2018 is required.

We acknowledge that the summary report highlights a number of issues in relation to how the whistleblowing investigation was carried out and in respect of the findings of the panel.

Whilst the HSCB accepts there is scope for learning, it is also important to stress that the panel members carried out a very complex investigation within a constrained timeline with honesty, integrity and dedication. This was done in line with the whistleblowing policy which provides for anonymity of the whistleblower in accordance with relevant legislation.

The panel members were acutely aware of the seriousness of the whistleblower’s concerns, given the tragic circumstances which led to the Hyponatraemia Inquiry, and strived to consider the issues raised in a fair and impartial manner.

The HSCB is firmly committed to working with the wider healthcare system to ensure that any learning is fully taken on board.

There also needs to be a wider debate in relation to what evidential and investigative thresholds and training are required for future whistleblowing investigations.


A number of concerns were raised with the Chief Executive of the Health and Social Care Board under the HSC Whistleblowing policy on 2nd October 2017. The concerns were then considered by a three person panel (two of the members of which were external to the HSCB) under the Whistleblowing policy which provides for anonymity of the Whistleblower in accordance with relevant legislation (Public Interest Disclosure (NI) Order 1998).

The HSCB, through the Directorate of Legal Services, wrote to the Inquiry Chair on 9th October 2017 to notify the Chair of the concerns that had been raised and then kept the Inquiry informed of progress throughout the investigation process.

The investigation, as requested, was completed ahead of the publication of the hyponatraemia report, and the Inquiry Chair received the panel’s Investigation Report on 12th December 2017.