Reader, please remember that all the activities and the effort below has been made on behalf of the innocent victim of medical errors. The aim is to protect these patients, to improve patient safety by changing the NHS system to one of openness & honesty. SIN believes that patients have a right to know  when they have been medically damaged and the full extent of this damage irrespective of the legal liabilities of the Trust/Health Authority.  The damaged patient also  has the right to genuine remedial medical care.To do otherwise is unethical and amoral and intrinsically inhumane.   Remember, too, that SIN is completely voluntary - it has no funding. SIN is funded by ourselves and  the generosity of our members - most of whom are very ill and unable to work and so unable to give much. We know that the D.o.H. reads what we write and uses our ideas - one senior civil servant told us that SIN's documents are widely distributed and widely read ! Remember, too, that Gillian is an iatrogenic patient & Margaret has had two sons who were iatrogenically damaged - one sadly has died - so we have experienced personally the unnecessary trauma and sufferings of iatrogenesis.

no one is immune from a medical error

• Even when very comphrehensive and detailed complaints with evidence, some from expert witnesses, were submitted - still the complaints were not upheld - a dossier/file was shown to illustrate this point.
• Letters from the NCN Fitness to Practice Dept.were very short simply stating that complaint was not upheld-no detailing of complaint or evidence given-this was not considered as satisfactory
• One Patient who had complained about treatment to her husband had sent in a very extensive well written dossier but her complaint was not upheld and furthermore when she asked for the dossier to be returned she was told it had been destroyed within a week of the letter dismissing complaint being sent. It was suggested that all evidence submitted should be listed and signed for and detailed comments written.
• Reference was made to the recent television documentary programmes showing nurses behaving badly. It was asked why the NCM was not pro-active - it was obvious who the nurses were and why had they not been called to the NCM to be held to account? The NCM said they could and have been proactive with regards to the nurses on the television programme. However, afterwards it was disclosed that the only nurse who had been called before them for disciplinary procedures was the under-cover nurse who had helped to expose the bad nursing. If this is the case, then it is disgraceful for this nurse was being very public -spirited.
• A case was raised where the nurses had given very bad/negligent care to a patient and when the relative announced they were to make a formal complaint the nurses issued a letter the next day accusing the relative of 'aggressive and verbal abusive behaviour and if this did not stop she and the family would be refused admittance.' The relative now had 'Zero Tolerance' written in her notes. This was considered appalling that nurses could misuse 'Zero Tolerance' Orders in this way in order to bully and intimate patients and their families. The NMC said this would not come under their remit.
• It was emphasised that patients did not wish for severe sanctions but if standards were to be improved it was vital that any complaint or criticism was taken seriously and acted upon and poorly behaving nurses should be reprimanded/disciplined in some way.

September 12th: Important Teleconference with Patients For Patient Safety ( PFPS) World Health Organisation - see 'Our Comments'

March:
SIN-UK visited Brussels with other members of the IEU-Alliance to meet with  Karl-Heinz Florenz Chair of the Commission for  Public Health, Environment & Food Protection  European Parliament. The IEU Declaration was  delivered. More details + photos see 'our comments'

SIN-UK  attend Fourth Convention of the IEU-Alliance in Strasbourg. Meetings were arranged with the Directorate General III - Social Cohesion Depart. of Health  of the Council of Europe and and with Mr. John Bowis MEP, former Minister for Health UK, of the European Parliament and member of the Health Commission when the IEU Declaration was delivered. More on these meetings + photos can be seen in 'our comments' in the menu.

February:
SIN-UK invited to attend Patient Safety Conference in Birmingham organised by NPSA (National Patient Safety Agency ) Wednesday & Thursday 1st. & 2nd. February 2006.

January:
SIN-NL ( Netherlands) meeting with WHO representative in Copenhagen.
Discussion on the need for dialogue with health professionals,  government officials and politicians to change the system. Presented with copies of IEU-Alliance Declaration. 

Delegate from the SIN- NL ( Netherlands)  branch of the IEU-Alliance attended Conference on Medical Ethics in Copenhagen. She was invited to give a 15 mins power-point presentation on the consequences of medical errors on the patient and the need to improve the system by dialogue with health professionals. This presentation was well received.

Translations of the IEU-Alliance Declaration into several languages: German, Dutch, French,  Italian, Norwegian, Russian, Turkish etc. The IEU - Alliance's  influence is now European and Global. Medical errors and the traumatic consequences to patients  are  universal. The World Health Organisation has recognised this and has set up a Patient Safety Alliance Committee. Copies of the IEU-Alliance Declaration  distributed at Conference.

Monday afternoon, 28th November,  members of the IEU-Alliance  had meeting with IAPO ((International Association of Patient Organisations)

Monday morning 28th November, Delivered signed copies of the IEU-Alliance Declaration to Downing Street ( Prime Minister Blair as President of the EU)  and to Department of Health ( Minister for Patient Safety, Mrs. Jane Kennedy and the CMO, Sir Liam Donaldson) Photos etc.  in 'Our Comments' and on IEU-Alliance website.

Third IEU-Alliance Convention took place on the Sunday 27th November in London. To view photos and more information connect to www.ieu-alliance.org

Meeting with Ms Pauline Philip, Head of the WHO Alliance for Patient Safety, Department of Health SIN was delighted to have this opportunity to be  able to discuss its ideas on how Patient Safety can be improved.  A copy of the  IEU-Alliance Declaration was handed to Mrs. Philip, stating that Patients' Rights should now be in Statute.

Workshop at NPSA , London for presentations by: NCAS ( Clinical Assessment Service- only used by health institutions & health professionals) COREC ( Central Organisation for Research Ethics Committee). The conclusion after discussions was that the patients' voice  had a part to play in all of these organisations.

Invited as guests to Health Service Journal Awards Evening at the London  Hilton.

Attended evening meeting in London organised by AVMA to discuss the Redress Bill which is having its first reading. SIN believes this is very disappointing and is a wonderful opportunity which has been missed to bring in a realistic Victim's Compensation Fund. A capping of £20,000 is much too low and the 'status quo' remains. The law courts are no place for ill patients to haggle over what has gone wrong with their care. Especially when the hospitals/ health authority lawyers are all too aware of what has actually happened.

Banner for IEU-Alliance purchased
Finalising arrangements for the Third Convention of the IEU Alliance in London on 27th November, 2005.
The IEU -Alliance website  is now operating: www.ieu-alliance.org

October:
Invited to Workshop run by the HealthCare Commission in London." What do Patients Want?"
Not surprisingly patients wanted the following: Cleanliness; good clinical care; short waiting lists; confidentiality; privacy ( an end to the mixed bed wards); accurate record keeping. SIN was able to add coming from the perspective of the damaged patient: when an error occurs there should be open, honest and full disclosure irrespective of  legal liability, the patient should be involved in the investigation into the medical error and  genuine remedial care should be assured. Such workshops have real value : the patients are allowed their 'say' and this is real empowerment if the patients' suggestions are acted on.

Meeting with the President of ESQH ( European Society for Quality Healthcare). SIN explained our 'Aims & Objectives'  in order to protect and improve patient safety, and the need for Patients' Rights in Statute ( IEU - Alliance)
 .
Attended the AGM of the NPSA. The NPSA is the first Agency to begin to record and categorise medical errors in a systematic way. This is the first and most important step to  establishing  the cause of medical errors and how incidents can be reduced.This, unfortunately , is anonymous at the moment. [ Read SIN's publication "The Removal of anonymity in the  Recording of Adverse Medical Incidents in the Interests of Patient Safety] The NPSA is to be congratulated for involving patients & the public with their related experience  in their work and the support given to patients

Arrangements for next IEU Convention in London

September: 
Attended Centre For Public Policy Seminar on : "Patient Led NHS" . Representatives from the Department of Health, the National Patient Safety Agency, Which, clinicians and other interested parties. Various topics were discussed : CHOICE  - ideally this is a laudable aim to give patients choice of consultant and hospital etc. ( The iatrogenic patient has little or no choice for care is often withheld because of potential litigation). MEDICAL RECORDS: -  acknowledged they are not free from errors, therefore problem will increase if transferred to Electronic Data  Base.( Errors in medical records are a particular problem with iatrogenic patients - transference to Electronic Data Base without corrections would be disastrous). Two major foci within the health service: the health professional & the medico-legal bods ( Risk Managers). ( Iatrogenic patients fall between the two - no protection - no or little care because seen as potential litigants).

Minutes of July Convention

July:Second Convention of IEU Alliancein Utrecht , Netherlands. In all six countries were represented. Declaration was signed, future plans were discussed.

June:
Preparing for  the second convention of IEU ( Iatrogenic Europe Unite) - meeting of European Patient Support Groups to take place in July. ( Read November 2004 & see 'Our Comments' )

APRIL: 
Attended Conference in London on:
"Understanding Clinical Negligence In the NHS - getting it right when things go wrong" 

This was a very interesting Conference and there is an awareness that there is a need for the NHS  to be more open  & honest when medical mistakes happen. Certainly, there are support systems in place for health professionals who require counselling after a serious medical error. SIN raises the question about the need for the damaged patient and bereaved relatives to receive counselling. Usually, the innocent iatrogenic victim is left in trauma and finds themselves caught up in an inhumane  'denial & cover-up culture', can  be 'blacklisted' when genuine  specialist medical care is withheld and receives no counselling whatsoever.

SIN raised the question as to whether a Risk Manager at a hospital Trust if  it were discovered that the Trust were liable for serious damage - would the patient be informed or would the Trust insist that the patient starts legal proceedings? ( In our view this a total waste of money and time and  is unethical ). SIN was told that permission would be sought form the Executive of the Trust and possibly the NHS Litigation Authority. SIN suspects that if the amount of justifiable compensation was large - then the Trust would be unlikely to release this information.

SIN also made the point that the capping of £20,000 on the 'Victim's Compensation Fund', which is likely to be introduced this parliament was much too low. In the CMO's consultative document 'Making Amends'  a capping of £30,000 was suggested - SIN dismissed this as being to olow and suggested sums in the region of several hundred thousand up to £1 mill for the most serious cases . Although the mantra is that 'everyone must have a right to go to court' - the actuality is that extremely few people can afford to go to court.  SIN understands that AVMA suggested the capping was reduced to £20,000. 

SIN maintains that health professionals & the Risk Manages ( lawyers) are perfectly aware of the truth of the situation and damaged patients have a right to be informed of the damage sustained. SIN also refutes the idea that serious damage ( i.e. large compensation) is necessarily complex and therefore such cases MUST go to law. Actually, the cause of serious damage can be extremely simple. If the £20.000 cap is kept then most patients will have no alternative than to go to law to prove they have been damaged and that the cause was negligence. The status quo will prevail. Obviously the legal bods will be very keen to keep the capping at a low level - more work for them.

What must be remembered is that as long as the patient is perceived as being a potential litigant and has a price tag of compensation around his/her neck - that patient will be unable to access genuine medical care. Once a potential litigant - always a potential litigant.This is unacceptable and must surely  be unlawfu?

Attended Patient's Forum at NPSA in London
Discussion on the best  means of indentifying patients in hospital. The wrist band is the most obvious one and the discussion then moved to the data that should be on the wrist band and ways of encouraging patients not to remove them.

SIN submitted a full page statement in the House Magazine. This was promoting the need for a 'Victim's Compensation Fund' and demanding that patient's rights must be in staute.

March:
SIN was delighted to be invited to give a one hour PowerPoint Presentation to a Forum of NHS personnel. The Forum consisted of Clinical Governance Officers, Risk Managers and health professionals. The title of the  presentation was : "The ( iatrogenic) Patient's Perspective" The main title of the event was: " Patient Safety" there were several other talks and the Forum lasted for the whole day.

After SIN had finished there was spontaneous applause. One delegate came up afterwards and said: "That was absolutely brilliant! I agree with everything you are saying. You must keep on saying it". another delegate said that" Gillian & Margaret are speaking to the 'converted' " .

It was gratifying that health professionals are being encouraged to come forward when mistakes have been made. The needs of the damaged patient must be paramount.

February & 
January
Tried to help a badly  damaged iatrogenic patient in Europe whilst she was in hospital . She was unable to obtain any diagnostic tests. Mysteriously she was under the care of a Cancer specialist although her problems were neurological. Inexplicably, the Cancer specialist wrote a statement that she had had a colonoscopy ( untrue) - which was negative. Presumably, this was showing that the hospital was giving her  (imaginary ) tests and also this test, that never took place, was to explain why she was under an oconologist when she should have been under the care of a neurologist. The patient protested that she was not getting the care to which she had a right and SIN tried to speak with the Chief Executive. This was at first agreed and a time arranged, however, the C.E. was never available. Eventually the patient was removed from the hospital by the police.!!! ( Gillian & other members of SIN have been escorted off the premises of British hospitals by hospital security guards and have been refused access to specialist advice or care. One has even been informed by a doctor that they will not be getting medical care BECAUSE they are involved in legal action. This doctor made sure there were no witnesses to this statement. We believe that this was a criminal offence on the part of this doctor.)!!
European countries appear to be no better than the UK in facing up to the problem of medical errors and ensuring that iatrogenic patients are given the care to which they have a right. This is why there has been a coming together of patient support groups  in Europe- see month of November 2004

November:
A momentous meeting took place in North Germany on 21st. of this month. This First Convention of Patient Groups was professionally and generously hosted by our North German colleagues & friends, allowing  a coming together of Support Groups for the Victims of Medical Errors. There were six countries represented. Each group spoke about similar experiences and trauma.
There was a remarkable unity of purpose and empathy between the groups. It was decided to meet again and to produce a Declaration for the protection of damaged patients.. Iatrogenic Europe Unite (IEU) came into being.( see report in 'Our Comments')

October:
Meeting at NPSA, London, to discuss the Electronic Data Form ( E-Form) for logging in medical errors over the internet. SIN had had a previous  meeting in March 2003 when we had gone into this subject in detail.

SIN has always maintained that the E-Form for patients should be just as structured as it is for health professionals. The time/day/month on which the error occurred. The grade of doctor/ health professional; the exact speciality  of medicine; whether it was a physician /surgeon; and the  types of medical error should  be categorised. There should always be room left  for patients to add their comments. We also advised that the questions about medical records should be available e.g.. have  you been able to obtain all your medical records? if not- then what is missing? etc./ have documents /test results been changed to you knowledge?

At this particular meeting it appeared that all the 'advice' SIN had given in March 2003 had been ignored. A new group of young people were working on this topic.  Whilst the E-Form for health professionals to complete ( optional) would be very structured - the patient's E-Form was 'unstructured' and patients were encourage to 'write their story',. We believe that , because the experience of iatrogenic patients becomes very long & tortuous - often deliberately confused by health professionals - the 'story' (we prefer an 'account') will easily degenerate into a long 'rigmarole'. We believe this would not lend itself to analysis - and would be virtually useless. (We hope this is not the real purpose). One so called patient representative at the discussion was determined to leave the patient's E-Form as a blank series of pages. Any attempt by SIN to introduce a structured layout was met by - 'Too prescriptive'. &  ' Joe public would not understand the question' . This was a nonsense. No one objected to the health professional's E-Form   being structured. Common sense dictates that to enable meaningful data to be extracted - a structure is required. SIN continues to vigorously advocate: "The Removal of Anonymity in the Recording of Adverse Medical Incidents in the Interests of Patient Safety. Please read our document on this topic - found in 'publications'.

August:
Meeting at NPSA , London to discuss progress.  SIN again reiterated the importance of the removal of anonymity in the recording of Adverse Medical Incidents in the Interests of Patient Safety. Handed in a second copy of our document to the NPSA - this time to the Deputy Director of PEPI ( Patient Experience & Public Involvement). Also, again raised the problem of seriously damaged patients being 'blacklisted' for genuine specialist medical care.

A number of interesting presentations were given to us. Again we challenged the concept of the 'no blame culture' -  SIN believes that the medical profession has had a 'no blame culture' for 50 years. Sensible acknowledgments of mistakes with sensible accountability MUST be brought in.  SIN also refuted once again the analogous comparison with the aviation industry where no one is forced to report errors or incompetence but a very high level of  reporting is done  voluntarily. It is obvious that when one's own life is at risk one will report on oneself and one's colleagues as well as on faulty equipment. Heath professionals' lives are not at risk. They  have the option of walking away when a medical error has left someone dead or badly maimed - this is analogous to a 'hit & run' motorist. This cannot be acceptable. Only  3% of errors are being reported, although, at least 10% would be expected according to research. SIN is concerned that Patient reporting of medical errors is not given the same importance as those that come from health professionals and Trusts.

July :
BBC Radio Five Live . Gillian took part in a discussion programme with Lord Hunt , a doctor from Doctors Net, a GP from BMA & Mr. Tony Maude who has developed a computer programme for diagnosing illness from symptoms. The title of the programme was 'Mis-Diagnosis'. We hope to have a pre-recording of Gillian answering questions put to her by Radio 5 Live before the programme, on the website shortly.

June:
SIN's statement in "The Parliamentary Monitor" appeared on the same page as an article on  the previous  Secretary  of State for Health, Mr. Alan Milburn and the present Secretary for Health , Mr. John Read: "The Plight of the Iatrogenic Patient."

April:
Full page statement of SIN appears in "The House Magazine", arguing for a  "A Victim's Compensation Fund".

March:
Paper 7  eleven pages: " Reforming the NHS Complaints Procedure : Consultation upon Draft Regulations" submitted to the Department of Health. In August 1999 SIN had produced a critique on the 1996 NHS Complaints Procedure and came to the conclusion that it was a total  farce and was a confidence trick played on the patient at the tax-payers expense. Please read " The Emperor Has No Clothes".

We are sorry to say that the new Complaints Procedure seems just as bad, if not worse. There now appears to be no 'clinical assessor' - anyway it is not apparent at what point he/she is brought in. This makes sense to those who do  not wish to have accountability, because if a doctor does not assess the patient's claim of sub-standard care -  no conclusion can be made. The Health Service Commissioner seems to be still the final arbiter - and by law (1993 Act) he is unable to deal with anything that is serious eough to go to law i.e. serious iatrogenic damage.This is against the Human Rights Act Article 6

Please, read Paper 7 . At the conclusion we asked  SEVEN pertinent questions paragraphs 20. 1 to 20.7. We have received no answers from the Department of Health!. In our conclusion we wrote: 
" It must be recognised that, with an estimated 100,000 iatrogenic deaths and injury occurring every year in  the UK, it is reasonable too assume that the vast majority of complainants who engage in he NHS Complaints Procedure will have been subjected to some kind of iatrogenic damage. These are some of the most vulnerable and traumatised people in the NHS system. These innocent victims must not be regarded by the Health Care Providers as potential litigants and so categorised as adversaries.

" The question must be asked: what is the new NHS Complaints Procedure devised to achieve?  Is it constructed to give honest and transparent  disclosure of iatrogenic damage regardless of  any potential liability of the Health Care Provider? Or is it created to obstruct and conceal the results of medical errors and substandard care in order to protect the health professional and the system? If it is the latter, then there has been no change in policy towards innocent victims of iatrogenic damage. It is our opinion that the public is demanding an open and honest culture of accountability , where mistakes are acknowledged and given a thorough causal analysis; where priority is given to caring for and counselling of the iatrogenically damaged patient....."
 

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SIN is not in favour of the TORTS continuing to dominate  medical errors, in particular the illogical Bolam  Tort  & Sideway ( causation) . One example of how illogical and unjust these torts are is that in one case heard at the Royal Courts of Justice within the last two years, there were 5 instances of clinical negligence that had affected the patient ( Bolam Test)- anyone of which could have caused the death. However, it was impossible to prove causation - i.e. to prove which one of the  incidents of clinical negligence actually  caused the death of the young patient. In fact the court was spoilt for choice - incredibly the litigant lost the case!!!. SIN believes that the British public would be shocked to hear of such inconceivable injustice.

If openness & honesty prevailed the Courts would not be needed. Who is in favour of the  'Courts &  Torts' ? - well not surprising - the MDU ( Medical Defence Union ) The Medical Protection Society ( MPS)  & all the medical- legal lobby.Lord Woolf, in his inaugural lecture ,17th January 2001, heavily critised the medico- legal route.( Read 'Bye, Bye Bolam in 'Our Comments')

SIN  believes that the capping for a Victim's Compensation Fund case that  can be decided out of Court should not be as low as £20,000 /£30,000 - this is much too low. THis will mean that the status quo will continue and most cases will have to go to the useless & unnecessary adversarial  legal dispute. The Trusts , the health professionals, the Risk Managers & indeed the NHS Litigation Authority are all aware of the truth and their legal liability -for these institutions  hold all the medical evidence. SIN believes that the Victim Compensation Fund should go as high as £250,000 - £500,000 in the most serious cases of disability (  e.g. paralysis & lack of economic livelihood)  A lump sum should be given & then any disability payments should be made to which the iatrogenic patient has a right. We believe in truth , honesty & mediation. The only people who gain from the legal cases are the lawyers. Obviously, if someone wishes to go to law, then that would be their right. We believe that  given (i)) the Truth about their medical condition ( ii) causal analysis of what went wrong (iii) genuine remedial medical care (iii) reasonable compensation- then most people would  wish to choose this and to get on with their lives, than be involved in a along, expensive, legal wrangle involving unjust Torts.

SIN believes that compensation should be paid against a National Tariff - as it is done in the case of car accidents.

SIN does not believe that a Victim's Compensation Fund would prove any more expensive in the long term than the present inequitable system. At least the money would be going into the pockets of the iatrogenic patients and not into the lawyers' pockets. SIN has been told that from the £billions spent annually on medical litigation and only a tiny proportion of seriously damaged patients receive a fraction of this huge amount - about 10%!!.

SIN also believes that the committee that was looking at  the Victim's Compensation Fund was dominated by medico-legal people . It appears that 75% were from the Legal -lobby. Since medical litigation is a £billion annual industry it is unlikely that the legal lobby will wish to change the status quo. SIN also believes that AVMA ( Arnold Simonovitch ) does not represent damaged patients - he  represents and supports the LEGAL ROUTE. He is himself a barrister.

Please read this Paper & the preceding one " Balancing the Scales"

September:
Meeting with the Director of Patient Experience & Public Involvement, NPSA London,  to discuss  progress and new initiatives.

June:
Paper 5: " Case for the Removal of Anonymity in Recording of Adverse Medical Incidents in the Interest of  Patient Safety". At the moment the NPSA ( which has a large number of senior consultants acting as advisers)   records medical errors voluntarily given by health professionals and from patients - but all of this is done anonymously. Therefore, it would be impossible to stop another Shipman,Ledward or Neale. Nor is the NPSA able to help the patient who had been seriously damaged and ensure they received remedial care - these patients could not be identified. Nor could the incompetent or negligent doctor be identified  - so no help could be given.  Remember, the dangerous plight of the iatrogenic patient - once seriously damaged,  these patients are deliberately blacklisted -  it is unlikely they will be able to access further genuine specialist care!

SIN believes that this is unacceptable - please read this Paper, to be found in 'Publications'. It is time to put the needs of the patient FIRST.

Request from the Chief Medical Officer to comment on his consultative document : "Making Amends". The Department of Health is considering setting up a victim's compensation fund.

March:
Meeting with Director of Patient Experience and Public Involvement at NPSA, London with six members of SIN to discuss the construction of an Electronic Data Form for logging in medical errors over the internet. We believe that the idea of compiling a data base of medical errors came form SIN's Paper 2 submitted in June 2000 to BRI Inquiry. 

There was a very good team form the NPSA who discussed such matters  with  SIN for the whole day. Our members stressed that the E-Form must be structured:
Date on which medical error occurred, the time, day , month and whether it was a weekend or holiday. The rank of the health professional involved. Place of medical error Name of Trust, ward, A&E ,ambulance  etc). Medical  Specialty. Type of medical error ( misdiagnosis, wrong surgery, wrong drugs ,wrong dosage, wrong test, equipment failure etc. etc. )  The reaction of health professionals/ Trust  to being informed about the medical error), the state of medical records ( changed? missing? not available ?), the treatment of iatrogenic patient - were they told the truth ? were they given remedial care? etc.

SIN believes that it is essential to collate this information. The distress, trauma and abuse received by the innocent victim of a medical error MUST STOP!

February:
Meeting with the Director of Patient Experience & Public Involvement (PEPI) National  Patient Safety Agency (NPSA) London. To discuss if SIN could have any in-put into the work of the NPSA. Discovered that all logging of medical errors must be 'anonymous'

January:
Newspaper article appeared in The SUN, January 3rd, 2003. It was about the victimisation of 'whistle-blowers' in the NHS - both doctors & patients. its heading was : "Victimised" . SIN maintains that patients who complain about sub-standard care are some of the best whistle-blowers. In the article there were three doctors: an anaesthetist  ( Stephen  Bolsin )who exposed the scandal of the substandard  cardio-thoraxic surgery of babies in Bristol Royal Infirmary; a General Practitioner ( Phil Hammond) and a female surgeon. All had problems because they had whistle-blown  & the anaesthetist had  lost his job and had been unable to find another post in the UK and had been forced to go to Australia and the surgeon had been suspended. 

The patient was Gillian from SIN who had complained ( whistle-blown ) against her substandard cardiac care , in fact her total lack of specialist cardiac care.  SIN believes that all whistleblowers - health professionals and patients receive the same appalling treatment: health professionals get a character assassination and lose their jobs; patients get a character assassination and put their health care in jeopardy.

There is now an Act that is supposed to protect whistl-blowers. SIN believes that the Act states that a doctor must not 'whistle-blow'  out of  malice. How on earth can you prove that you are not being malicious?  Anyway, whether someone is being malicious or not, is totally irrelevant -  the important point is - is the doctor(s) who is being reported  dangerously  incompetent or negligent i.e. doing patients harm? 
 
 

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November:
Attended BMA/BMJ Conference in London : " The way forward after the BRI Inquiry"Spoke out on behalf of damaged patients. 

Apparently some consultants do not wish for any medical information to be given out over the Internet.!! One can only surmise that such consultants have little confidence in their own abilities and do not wish to be challenged by the patients. Also of course, if medical information was withdrawn from the internet there would be greater difficulty in proving that a medical error had occurred. SIN has noticed that there are more and more 'extracts not available' on the Pubmed site and many internet sites are for 'subscribers only'.

SIN pointed out that there may at times be a 'Systems failure'  that causes  serious iatrogenic damage, but most times the medical errors occur because of a human failure on the part of a medical professional(s)  SIN believes that :" personal responsibility is a moral obligation"

SIN was assured that the medical profession was changing - but 'You ( the patients) must keep up the pressure'. It would seem that everyone forgets that we, the patients, are indeed patients and we are ill, some of us very seriously.  Would that more doctors would speak out and support us openly.

September:
Half page statement in the "House Magazine" to coincide with the Labour Party Conference September 30th 2002. Article entitled: "SIN Rife  in the  NHS"

June:
Attended public consultation of the " Organ Retention Commission" meeting in Nottingham. Heard many harrowing stories from mothers  whose dead babies had had their reproductive organs removed and their tongues cut out for research purposes - without their  permission or knowledge. The question that must be raised is,  that in addition to research,  are organs being removed from bodies in order to cover-up medical errors and negligence? In other words , evidence is  being deliberately removed. Is not this  thwarting justice?

April:
Statement appeared in "The House magazine" - The Lord's Picture Guide- April 28th 2002.

Statement appeared in the House magazine entitled : "The Plight of the Iatrogenic Patient" in issue dated April 22nd 2002 which was concerned about Public Health. This magazine is distributed amongst MPs civil servants, Secretaries of State & Ministers.

Statement of SIN's Demonstration also appeared on " Net Doctor" (www.Netdoctor.co.uk)

Record of SIN's Demonstration appeared in BBC TV Archives 15th April  2002

SIN's London Demonstration outside the Department of Health & delivered a statement & petition to Prime Minister Blair and to the Chief Medical Officer. Mr. Blair's Office wrote to say that all our papers were sent over to the Department of Health, although they were instructed to retain them. So, Mr. Blair remains in ignorance  of the abuse of patients under his priministerial watch! No wonder he can go on smiling! Please see website for photos & other information.

SIN's London Conference. See photos on website.

Paper 4 " The Consequences of Presumed Consent: Organ Retention". The problem seems to be that the state acts as though it owns the body. SIN believes that no organ/tissue  can be removed from a body ( dead or alive) without the consent of the patient or relatives. Please read this Paper - on our section'Publications'

March:Commission for Health Improvements (CHI) consultative meeting in Leeds. About 13 members of SIN were down to attend this meeting. however, only about four were officially registered by CHI. Why was this? SIN was the largest patient group there. 

There were many representatives of CHCs .  Many of these were aware that iatrogenic patients were having problems in accessing  specialist medical care,  and yet nothing was reported. There were a few health professionals. CHI officials seemed very uneasy with SIN. SIN is very, very disappointed with CHI. It has, in our opinion  been largely a  waste of money.

Many brave patients have come forward to describe what amounts to abuse and denial of medical care. In fact we know that some of the accounts were recognised by the CHI recorders as being criminal. Although CHI is bound to report anything criminal to the police - none of the cases were reported. In fact SIN realises that none of the appalling accounts of patient abuse were ever read by the Clinical Assessors - presumably because lawfully they, the clinical assessors, would have been obliged to report their malpractising  colleagues to the GMC or the police. Obviously,not one of them  wished to do that. So patients who were being denied care were just left in that position.

 We believe that  CHI has totally failed the damaged patient and the public and many of their reports are, in our opinion,a waste of the paper they are printed on.

February:
Responded to government consultative paper: "Clinical Negligence : what are the issues and the options for reform?"  Submitted Paper 3: "Balancing the Scales : the case for a Victim's Compensation Fund" Please read Paper on website under "Publications"
 
 

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December:
Attended meeting for improvements of paediatric cardio-thoracic surgery in London.

September:
Attended meeting for discussion on improvements for paediatric cardio-thoracic surgery in Sheffield.

July:
BRI Inquiry findings published in London.  The recommendations are very good.

However, SIN believes that  here was a huge opportunity missed. The Second Phase of  the Inquiry - dealing with the  whole of the NHS - was in our opinion just as important as the original Inquiry, if not more so. 

SIN believes that there should have been an opportunity for damaged patients to come foreword and relate the flaws and abuse they had received at  the hands of the system. Just as the Health Select Committee had received the reports in June/July 1999 of the abuse of iatrogenic patients in the UK. This would have been a wonderful chance to explode  the  scandal of the 'denial & cover-up culture '  endemic  to the  NHS which has caused so much unnecessary sufferings and has been the cause of the lowering of medical standards in this country. Perhaps the truth was too unpalatable?

June:
Received unsolicited a £50 donation from a journalist because the work of SIN is considered so important.

May:
Successfully obtained for a sick member a consultation with a TB specailist and TB drugs.( See Anne's Case)

April:
Attended news conference for the report of the Brompton & Harefield Inquiry into paediatric cardiac surgery in London. In our opinion this was a complete whitewash - please see wbesite - photos & report of demonstration .

Visited sick patient in London hosptial. Took photos of TB skin Test ( Anne case see website)

March:
SIN appeared in TV programme Channel 4 "Power House" to advocate for a victim's compensation fund for patients who have been damaged through no fault of their own.

February:
Attended BMA/BMJ Conference in London : "Ensuring Quality Care". Spoke out on behalf of iatrogenic patients.
 

Return to Activities

November &
October 
Writing letters re: sick member. Contacted CHI, Health Authority, & MP. Wrote many letters.

Newsletter produced

August:
SIN's Paper 2 submitted on behalf of the damaged patient was published on the BRI Website.

July:
SIN's website launched 10th July : www.sin-medicalmistakes.org

Submitted Paper 2 entitled : "The patient's Voice For Equity" to BRI Inquiry.

June:
SIN was represented at a protest meeting in London with a number of other patient groups.

SIN submitted a letter to Department of Health re: seriously ill patient ( see Anne's case on website).

Attended one of the CHI Road shows in Leeds and again spoke out on behalf of iatrogenic patients. There were several CHCs present - what have they ever done to safe guard the damaged patient, although  they are officially known as the 'patient's watchdog'? They have little power, and in our experience are not confidential since they are under the authority of the Regional Office. One Medical  Director asked Dr Peter Homa, Director of CHI, would any of the doctors lose their jobs because of a CHI 'inspection' They were assured that this would not happen. However, it was pointed out to Dr Homa by SIN, that many  seriously damaged patients lose their economic livelihoods - their jobs -  because of medical errors, but none of the medical profession seems to be concerned about this, or willing to accept any responsibility.

There was a great deal of hostility shown to SIN by some of the professionals and regional administrators.SIN pointed out to one doctor that surely it would have been better for Ledward to have been reported to the GMC many years ago, it having taken  18 years before he was struck off. Many of his colleagues were aware of his incompetent surgery during this time. If this had happened, perhaps Ledward would have been retrained, would have become a reasonable surgeon . Just think how many women would not have had their lives ruined because of  this one man ?

Meeting  at CHI in London Offices. Presented the awful trauma of the sufferings of the iatrogenic patient. Told it would take at least 5 years to change the culture, SIN replied that patients could not wait that long - we need care NOW!  Did not gain the impression that anyone at CHI was particualry bothered about the situation of damaged patients and that they were not able to access  genuine specialist medical care.

May:
Attended meeting at Brompton & Harefield Inquiry into poor standards in paediatric cardio-thoracic surgery - patient submission.

Article in 'Break Away' magazine - Gillian & misdiagnosis of cardiac condition. received many letters of similar complaints from women whose chest pains were routinely ignored.
 

March:
First letter ( and only letter) published in National Newspaper - the Express! over the years SIN has written many letters in particular to the Telegraph, the Times & the Sunday Times,. In spite of 'medical errors' and the resulting effect of patients being such  an important topic - not one of letters was published. Why not?  Judge for yourselves - some of these unpublished letters appear on our website. Does the topic 'medical errors & patients' have a D-notice attached to them? Or are 'D -notices' just a myth in our democratic society?

Attended BMA/BMJ conference on 'Medical Errors' and spoke on behalf of the iatrogenic patient. Asked Prof. Charles Vincent ( recent research into Medical Errors and their frequency) whether he would like to be informed if he had been seriously damaged by a medical error. His answer was a most emphatic 'Yes'!

SIN also met Prof. Lucien Leape from the USA who is spearheading the cultural change necessary for the medical profession to be open & honest  to the patient. about serious medical errors in the USA. He tapped Gillian on the shoulder and said: " Are you the SIN lady? Because I ,too, am a SINNER! How are we going to get the culture to change - that is the problem?". It was great to know that SIN has an ally in Prof.Leape who is sympathetic to what we are trying to achieve.

'Aims & Objectives' published on the BRI Inquiry website. These were first submitted in October 1999 - it took much  argument to get them put on the website! Why?

Attended the last public Seminar of the Bristol Royal Inquiry which was held in Bristol. SIN, with several members, travelled all the way down to Bristol to be there, incidentally at our own not inconsiderable cost!

Previously, SIN and two whistle-blowing doctors who had contacted SIN for assistance - Prof. Peter Dawson & Dr. Anil Jain - had written independently  to the Seminar requesting that SIN & the two doctors should make up part of this 'public' seminar. Obviously SIN & the two doctors were well qualified to take part in such a Seminar.  This request was refused by the BRI Committee.

In the event the Seminar consisted of people who had obviously had very little personal experience of the trauma of medical damage. Michaela Willis represented such patients but obviously had a very narrow experience being  only involved with the BRI Inquiry - she in fact said very little. The seminar was chaired by a man from the BBC - he would have left totally ignorant of the real nature and state of medical errors in the UK. SIN & its members considered the Seminar to be a farce - we wished we had all stood up and denounced it there and then - but we were too polite!

 The Committee at the Seminar  invited  questions from the public. We spent the lunch break formulating  several  questions and submitted them. In the afternoon  we were informed  that the questions would now  not be  taken. The civil servants seemed very nervous of our presence & we were not allowed to make any contact with the members who had formed the seminar. In fact civil servants trailed around after us as we tried to make contact. This was altogether very disappointing.The authentic voice of the damaged patient was not heard!

February:
Support for two whistle-blowing doctors. Two doctors  had made contact with SIN and gave their support to the aims of SIN. Both doctors had been  suspended from their posts after alerting their Line Managers, in accordance with protocol, to the fact that patient's were in jeopardy because of incompetence of a colleague and inadequate procedures.. In both cases the Trust was hostile to them. One Chief Executive actively encouraged colleagues to submit written derogatory remarks. The Regional Offices were also hostile and in one case spent over £100,000 taking (un)lawful action in the High Courts - actions were lost - a profligate waste of public money! Both doctors lost their positions and worked on 6 monthly contracts. SIN, on request, wrote a letter to the Health Select Committee on their behalf and to the MP. ( Both doctors received publicity in the media: newspapers, Radio & TV ).

January:
National newspaper made contact ( Telegraph). Spent week discussing cases - sent in information. No follow-up.

Contact made from 'File on Four' BBC Radio 4 - subject was the NHS Complaints Procedure - no cases used! This in spite of the fact SIN had produced the most comprehensive critique of this Procedure!
 
 

Return to Activities

Meeting with Stephen Thornley, Chief Executive of the Confederation of the NHS Managers at HQ London.

BMA/BMJ ( British Medical Association & British Medical Journal) held conference : " Whistle-blowers" . SIN went as delegates. Doctor after doctor stood up and said they had experienced difficulty in 'Whistleblowing' ( complaining) about sub-standard care for patients and claimed that their careers had been put in jeopardy. SIN claimed that patients were also Whistleblowers and like the doctors they had a character assassination and had their medical care put in jeopardy!. SIN also said that they did not understand 'a no blame culture' . SIN wanted a culture of responsibility and accountability. SIN was applauded by the doctors and many came up to offer their congratulations.

November:
Meeting at Wakefield for members.

Major Scottish newspaper spent day discussing SIN and patient cases. The promise of a two page spread was aborted at the last minute - no explanation.
 

At member's request SIN wrote seeking a meeting with the patient & his medical team to discuss his concerns at the ambiguities of his test results. Meeting was offered by the Trust.

BBCRadio 4 'Woman's Hour' invited SIN to take part in discussion on the NHS Complaints Procedure with Mr Alan Bedford, Chief Executive of an Health Authority and spokesman for the Confederation of NHS managers. SIN listed on BBC Data Base for patient support groups.

October:
Meeting with Chair of Health Select Committee & MPs. Submitted the Critique of the NHS Complaints Procedure & SIN's 'Aims & Objectives'

Article promoting SIN appeared in the prestigious Sunday newspaper the 'Observer' 24th. October 1999 entitled : "Doctors blacklist dissatisfied patients" - quote from the Health Select Committee after their Inquiry into Adverse Medical Incidents & their Outcomes.

Paragraph in the GP's magazine 'The Pulse' described SIN as a new patient 'watchdog'

BRI Inquiry requested permission for SIN's critique on NHS Complaints Procedure " The Emperor Has No Clothes" to be published on BRI Inquiry website: www.bri-inquiry.
org.uk

September:
Launching Conference of SIN in Birmingham. For the first time six Patient Support groups met together.

August:
Paper on critique of the NHS Complaints Procedure entitled: The Emperor Has no Clothes" was submitted to the BRI Inquiry ( Bristol Royal Infirmary) into the high deaths rates of babies in the cardio-thoracic surgery unit. This Inquiry was Independent and set up the government.

June:
Supported patient litigant in court.

Submitted statements to the Health Select Committee which was holding an Inquiry into Adverse  Medical Incidents & their Outcomes.  Nearly 300 submissions were made by patients, showing widespread abuse of the innocent victims of medical errors. SIN also presented its 'Aims & Objectives'.