There will be no public enquiry

I am two months away from the fifth anniversary of Ruby's death.
Claire and I received the final decision from legal entities involved in investigating the circumstances around that fateful day in Scotland- the final legal decision is that there will be no public enquiry.
There will be no public enquiry.

This side of Ruby's death- the investigation of what happened before, during and after her death- is an aspect of grief I have found too hard to bear. Claire has lead and managed this throughout our grief with the help of her family (this is one of many unexpected aspects of grief- how personal it is and how each of us vary in our resilience and coping strategies from one incident to the next) and I have remained very much on the side, observing and occasionally contributing, but generally finding it too painful to grasp all the details about these investigations.
There have been three major aspects- the NHS Trusts involved in her care from birth to death, the education board that manage her school and the legal powers in Scotland that support the police at the scene and the subsequent management of all investigations.
As usual the NHS were as efficient as they could be and were transparent and exemplary in their actions. All carers for Ruby throughout her short life- cardiac surgeons, consultant paediatric cardiologists and others- convened and reflected on every detail of her medical history from Claire's 20 week scan when she was pregnant with Ruby, Ruby's major heart surgery at four days old (transposition of the great vessels) and thereafter her yearly follow-up appointments with cardiologists keeping an eye on her progress in London and then here in Northern Ireland. The medical team, with agreement from Claire and I, concluded that they had done everything they knew at the time was possible to do to look after her as best as medical research knew how. Some changes, new tests, have now been implemented for other children having similar cardiac follow-up to reduce the risk of this ever happening again (after Ruby's death the pathologist discovered that Ruby had been slowly developing a very unusual, and nearly undetectable, heart condition as a result of her surgery as a baby- it was this that caused her fatal heart attack). In other words, the medical staff reflected and reassssed their approach and implemented the findings. This happened within a few months. An apology was offered and accepted, counselling was offered and accepted and Claire and I continue to hold up that team, and the NHS in general, as being a sentinel guiding us through these extraordinary times.
The police that investigated Ruby's death were intensely thorough and diligent (and mercifully brief) and the protracted legal process kept us informed of all processes and developments.

The dissatisfaction I feel is aimed squarely at the education board who runs the school she attended. I have deflected my anger over the last five years which could have been (rightfully) directed at her school and the education board because to not do so could have destroyed me. I will continue to deflect and mange this as best as I can.
There is no one individual to blame for Ruby's death, this is true. There were no suspicious circumstances surrounding her death, this is true. What is true is that more than one person made a mistake in her care on the night she died which resulted in her not being given the opportunity of survival. Her death was barely avoidable, as was agreed by the pathologist and others, but due to lack of thought, management skills and appropriate risk analysis we, her parents, will never be able to know whether she might have survived that night and thereafter had subsequent surgery to allow her to live and thrive.
It was a heart attack, incompetently managed, that allowed her to die.

We wanted a public enquiry to show the world that mistakes were made. We wanted to show that her school were not as blameless as everyone thought and that may other parents, who were relying on Ruby's school to look after their children and keep them safe, were misguided in their beliefs.
One year after her death the school went on another week-long trip. And the parents, who know of little else, let their children go. These trips continue even now, after little change in policy.
We wanted a public enquiry to clarify, with absolution, the potential for avoidance of such a tragedy again.
We wanted a public enquiry so that certain people and organisations involved would apologise. And would apologise unequivocally after reflecting on their poor practice, learning from their mistakes, knowing how they went wrong and then unambiguously say sorry without exception before changing policy and actions.
We wanted a public enquiry to give us some closure. But, as is the way with grief, there is of course no closure, just a series of small doors closing an exit to a dark corridor.