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| Case number 11 STEPHEN | Return to Case Studies |
-
14th April
2003
- Sub standard care by GP
- Symptoms ignored
- Cursory physical examination
- Refused request for remedial antibiotic medication
- Mis-diagnosis
- Appalling
lack of care and poor procedures at A& E
- Resulting in unnecessary death - one of the 34,000 per yr
in the UK
- Procedures set up to deal with NHS complaints fail family
This case came in from Scotland. Scotland
is about to re-appraise its NHS Complaints Procedure, so anyone reading this
coming from Scotland and wishing to contribute should contact the following
website:http://www.scotland.gov.uk/library5/health/
SIN is receiving contacts from all over the United Kingdom. The cases
coming in illustrate the sub-standard medical care and abuse being received
by patients resulting in unnecessary patient suffering. There is a total
lack of accountability.
Stephen had made very few demands on the NHS throughout his 73 years of life except for a minor operation in 1961. Yet when he had desperate need of the NHS - it totally failed him and this failure cost him his life.
Stephen had made very few demands on the NHS throughout his 73 years of life except for a minor operation in 1961. Yet when he had desperate need of the NHS - it totally failed him and this failure cost him his life.
The account below is written by his
son.
This is to draw attention to the sudden
and unexpected, but avoidable death of my father, Stephen,
over four years ago. The various NHS bodies concerned: the
NHS Complaints Procedure, the Ombudsman, and the GMC have not satisfactorily
dealt with the questions and concerns that his family have raised about
his NHS treatment. It is because there are no more
options available to pursue, that I am providing details of our experience
to the SIN website in the hope that someone will be able to make
use of them to improve the relevant public services and to assist my family
in getting full and accurate information and explanations concerning the
circumstances of my father's death.
The First Signs of Illness
Stephen was 73 years old, always in good health and up to that point had suffered no serious illness, rarely visited doctors, and had last been in hospital in 1961, 40 years ago, for a hernia operation. It was therefore, an indication of the severity of his condition that he agreed to his first and only home visit by a GP one evening in January 1998. His symptoms, over the previous two days were: an initial earache followed by a painful throat that prevented him swallowing or speaking normally, elevated temperature and difficulty breathing in any other position than an upright or sitting one.
GP Fails- lack of duty of care - clinical negligence
The GP who visited him at home confidently and incorrectly dismissed his illness as a viral infection .[55% of medical errors are misdiagnoses] She made a cursory and ineffectual physical examination that failed to see any sign of a cyst or infected epiglottis, completely ignored my mother's account of his clinical history, refused his reasonable request for antibiotics, provided no treatment whatsoever, and left him, after her brief visit with nothing to alleviate his pain and discomfort. [ This GP missed adult epiglottitis. This is a life threatening emergency and requires urgent endotracheal intubation and intravenous ampicillin ref. 'Clinical Medicine' by PJ Kumas & ML Clark - textbook for medical students and doctors p.575]
Admitted as an emergency the next day
The following morning he was admitted to hospital in an ambulance by his own GP and, shortly after arrival at A & E, developed breathing difficulties followed by respiratory and cardiac arrests and died.
Hospital Staff - clinical negligence - lack of duty of care - death
No A&E staff were aware that in the ambulance he had received oxygen therapy . Oxygen was inexplicably discontinued on arrival at hospital.
His abnormal physical signs :
The First Signs of Illness
Stephen was 73 years old, always in good health and up to that point had suffered no serious illness, rarely visited doctors, and had last been in hospital in 1961, 40 years ago, for a hernia operation. It was therefore, an indication of the severity of his condition that he agreed to his first and only home visit by a GP one evening in January 1998. His symptoms, over the previous two days were: an initial earache followed by a painful throat that prevented him swallowing or speaking normally, elevated temperature and difficulty breathing in any other position than an upright or sitting one.
GP Fails- lack of duty of care - clinical negligence
The GP who visited him at home confidently and incorrectly dismissed his illness as a viral infection .[55% of medical errors are misdiagnoses] She made a cursory and ineffectual physical examination that failed to see any sign of a cyst or infected epiglottis, completely ignored my mother's account of his clinical history, refused his reasonable request for antibiotics, provided no treatment whatsoever, and left him, after her brief visit with nothing to alleviate his pain and discomfort. [ This GP missed adult epiglottitis. This is a life threatening emergency and requires urgent endotracheal intubation and intravenous ampicillin ref. 'Clinical Medicine' by PJ Kumas & ML Clark - textbook for medical students and doctors p.575]
Admitted as an emergency the next day
The following morning he was admitted to hospital in an ambulance by his own GP and, shortly after arrival at A & E, developed breathing difficulties followed by respiratory and cardiac arrests and died.
Hospital Staff - clinical negligence - lack of duty of care - death
No A&E staff were aware that in the ambulance he had received oxygen therapy . Oxygen was inexplicably discontinued on arrival at hospital.
His abnormal physical signs :
- tripod posture ( upright))
- inspiratory stridor
- R.R.36 ( Respiratory Rate)
- BP 220/130,
- pulse 132 bpm
- Temp 38.4C
...........caused no concern.
The ambulance report and his GP's referral
letter were unread. He was not triaged [compulsory assessment by duty nurse to establish severity
of condition and therefore speed of access to doctor and treatment],
and it was not until a nurse realised that there was something seriously
wrong with his breathing that concern was shown for the severity of his
condition. He was then taken to the Resuscitation Room
where , we understand , that after transfer from a wheelchair to a trolley,
he started gasping for breath and suffered respiratory and cardiac arrest.
[It must be
remembered that Stephen had great difficulty in speaking and would have found
it impossible to express his need to be kept upright. Imagine his fear and
panic as he was put onto his back knowing he would be unable to breathe.]
The Resuscitation Room:
The events that occurred in the Resuscitation Room are unclear since my mother was not present at this point and the accounts from the hospital are confusing and incomplete. With some difficulty he was intubated and resuscitated but he never regained consciousness. I am of the opinion that his transfer from a sitting position in which he had maintained for the previous two days, to a recumbent position on a trolley in which he was unable to maintain a patent airway due to obstruction from epiglottitis swelling and accumulation of secretions caused some degree of asphyxiation, which resulted in subsequent respiratory and cardiac arrest.
This aspect of his treatment has never been investigated properly. I believe that, had the correct airway protocol for upper airway obstruction been applied, and that his arrival at hospital been better organised, his death might well have been avoided.
The Avenues for Complaints :
The various NHS bodies involved treated my requests for an investigation as 2 separate complaints. The attitude of the various NHS staff and organisations throughout has been of denial and secrecy in which I have identified instances of misinformation, deception, contradiction and selective disclosure of the facts. There has been obvious bias in favour of the medical establishment and a great deal of selectivity of evidence by medical investigators and assessors to support their arguments and assumptions. Every assessor/examiner /investigator/screener displayed incorrect knowledge of adult epiglottitis [There is no excuse for this because the so called 'clinical assessors' should avail themselves of the medical facts - however, these 'clinical assessors' have been given Crown indemnity]
General statements that they made about this illness in their efforts to support the NHS, were factually wrong and my protestations about this to the Ombudsman were ignored. I cannot see how there can be a proper investigation if those who do the investigating do not have a proper understanding of the illness? [ These clinical assessors are usually nameless. SIN believes that unless there is a signed statement form the clinical Assessors used by the Trust, Health Authority, Ombudsman's Office or GMC - all statements issued by these investigative bodies should be considered null and void!]
Conclusions of the Ombudsman's Office re:the Hospital
At first, the Ombudsman refused to investigate the complaints but later agreed, after my family had petitioned the Scottish Parliament to review and improve the NHS Complaint Procedures. The Ombudsman did not uphold either complaint ( against the GP or against the hospital staff) although, in the case of the hospital, he made the following recommendations:
The Resuscitation Room:
The events that occurred in the Resuscitation Room are unclear since my mother was not present at this point and the accounts from the hospital are confusing and incomplete. With some difficulty he was intubated and resuscitated but he never regained consciousness. I am of the opinion that his transfer from a sitting position in which he had maintained for the previous two days, to a recumbent position on a trolley in which he was unable to maintain a patent airway due to obstruction from epiglottitis swelling and accumulation of secretions caused some degree of asphyxiation, which resulted in subsequent respiratory and cardiac arrest.
This aspect of his treatment has never been investigated properly. I believe that, had the correct airway protocol for upper airway obstruction been applied, and that his arrival at hospital been better organised, his death might well have been avoided.
The Avenues for Complaints :
The various NHS bodies involved treated my requests for an investigation as 2 separate complaints. The attitude of the various NHS staff and organisations throughout has been of denial and secrecy in which I have identified instances of misinformation, deception, contradiction and selective disclosure of the facts. There has been obvious bias in favour of the medical establishment and a great deal of selectivity of evidence by medical investigators and assessors to support their arguments and assumptions. Every assessor/examiner /investigator/screener displayed incorrect knowledge of adult epiglottitis [There is no excuse for this because the so called 'clinical assessors' should avail themselves of the medical facts - however, these 'clinical assessors' have been given Crown indemnity]
General statements that they made about this illness in their efforts to support the NHS, were factually wrong and my protestations about this to the Ombudsman were ignored. I cannot see how there can be a proper investigation if those who do the investigating do not have a proper understanding of the illness? [ These clinical assessors are usually nameless. SIN believes that unless there is a signed statement form the clinical Assessors used by the Trust, Health Authority, Ombudsman's Office or GMC - all statements issued by these investigative bodies should be considered null and void!]
Conclusions of the Ombudsman's Office re:the Hospital
At first, the Ombudsman refused to investigate the complaints but later agreed, after my family had petitioned the Scottish Parliament to review and improve the NHS Complaint Procedures. The Ombudsman did not uphold either complaint ( against the GP or against the hospital staff) although, in the case of the hospital, he made the following recommendations:
- GPs should notify the duty ENT Officer of any potential supraglottis patients [but did not Stephen's GP do just that in his referral letter which was ignored by the A & E staff?]
- administration of oxygen to be continued if possible from ambulance to the hospital [Surely this is standard procedure, anyway? The patient should have the oxygen mask on for the duration of time he experiences breathing difficulties requiring oxygen therapy]
- Ambulance Service and Hospital should review their procedures for handing over patients [ We cannot believe that it was standard practice at this hospital or at any other, for GP referral letters to be unread; and that it is acceptable and usual practice for there to be no communication between ambulance staff and A & E staff. Such communication is vital. - It seems obvious to us there this was an example of careless or badly trained staff not following established procedure]
- Patients arriving at the hospital should be triaged
[ patients are always triaged when
arriving at the A & E - it is long standing practice - this time the
staff negligently omitted to follow protocol with disastrous consequences
for Stephen]
- Recording system at A & E should be reviewed
[ It was negligently missing]
I also draw attention to the following:
- the hospital's own earlier internal review recommended a more formal protocol for receipt of patients at A & E
- The hospital, sometime after my father's death, surreptitiously changed its protocols on airway obstruction and epiglottis for adults
- In 2000 the hospital announced a £1.3m upgrading of the A & E Department.
- The hospital did not report my father's death to
the Procurator Fiscal as required by Law [In England this would
be the Coroner - this would appear to be unlawful and considering the Procurator
Fiscal & Coroner come under the jurisdiction of the Home Office,
this was possibly a criminal omission]
Ombudsman's Conclusions re: the GP
The Ombudsman did not uphold the complaint against the GP either, and his clinical assessors showing unacceptable ignorance of adult epiglottis, accepted every single instance where the GP's account differed from my mother's account. The GP's account was accepted without any question or evidence and was accepted on nothing other than assumed, presumed and unsubstantiated probabilities. [ Isn't this always the case? The evidence presented by the patient is ignored, but whatever is stated by the doctor even if it is fabricated or complete nonsense is accepted? Why is it that patients' memories are always deficient; that patients tell lies - when 9 times out of 10 - it is the doctor who is at fault?]
The GP's inaccurate story was that Stephen appeared normal at the time of her visit but deteriorated after she left - was readily believed - even though her description - which conveniently omitted all the diagnostic symptoms - of my father's condition is not typical of what one might expect to see in an adult suffering from such severe epiglottitis, that was to cause his death in less than 24 hours. They accepted without evidence or corroboration the GP's convenient explanation that Stephen deteriorated after her visit , even though my mother said that his condition remained unchanged.
The Arrogant GP Who Has Leant Nothing :
One month after my father's death , my mother met this GP and found her unapologetic and unwilling to accept that she had made any mistakes and the GP further commented that, given the same circumstances in the future she would do nothing differently! [ Should she not be dismissed / struck off for admitting to this?]
Her defence argued that epiglottitis is rare in adults, usually occurs in children, and on the day of her visit she claimed that she had admitted a child with epiglottitis to hospital. To demonstrate her ignorance of this illness I provided statistics to the Ombudsman regarding the incidence of epiglottitis in Scotland and other countries to show that although epiglottitis is uncommon is is by no means rare and it is actually more common in adults than in children. The GP should similarly have been aware that the symptoms of epiglottitis in an adult are different from that of a child.
I am unsure whether this GP has learnt anything from her mistakes. She had the opportunity to save my father's like but instead, through lack of concern, incorrect and presumptuous diagnosis, apparent disinterest in his clinical history, ineffective physical examination and incomplete knowledge of this specific illness, gave my parents mistaken assurances that effectively delayed medical attention for my father until it was too late.
Convenient Autopsy Result:
The Post Mortem revealed that Stephen suffered from heart disease. [ We would suggest that any 73 year old at Post Mortem would reveal some degree of 'heart disease' In fact we would go further and say that it would have been remarkable if a 73 year old has suffered no degree of 'heart disease'] The GP, Hospital, Ombudsman's Clinical Assessors etc. have all found it convenient to imply that my father's heart condition, discovered at autopsy, was the cause of his death. Whilst the family does not dispute that he may have had some degree of heart disease, this condition was unknown to them before the Post Mortem and it had never before given him any problems. I feel that this discovery had provided an expedient alibi that obstructed a more thorough investigation of the circumstances that caused his death. Where fatality occurs in patients ( of all ages) with epliglottitis, death is most commonly attributed to cardiac arrest brought on by respiratory failure following some degree of asphyxiation and airway obstruction. Since my father appeared to follow this well documented sequence of events, I believe that this possibility should have been considered.
Contradictions in reports from the Ombudsman's Office:
The Ombudsman's Clinical Assessors accepted the GP's description of my father that :
" His general appearance was of a well rather than an ill man.." ! At the time of the home visit] Yet the Clinical Assessors dealing with the complaint against the Hospital defended the hospital and the fact that my father died very shortly after being admitted to A & E, that "... he had been unwell over the previous 2 days..." The Clinical Assessors of both complaints have interpreted the same evidence in converse ways in their respective need to defend the respective actions of the GP and the hospital staff. On the one hand the fact that my father appeared 'well' when the GP visited him, obviously protected her from any charges of negligence to provide medication or to admit him to hospital. The fact that my father had been (very?) unwell for two days before being admitted to hospital meant that this gave extenuating circumstances to explain why he died shortly after being admitted. One lot of Clinical Assessors had agreed that my father had been "well" at the time of the GPs visit, the other set argued that he had been "(very ?) unwell" when she visited,and indeed had been so for the previous two days.
The Ombudsman's Clinical Assessors volunteered a favourable report of the action of my father's own GP who had admitted him to hospital as an emergency. This however, was not part of our complaint. We had raised no criticisms of the performance of this GP. [ This is typical of the muddle and confusion which charaterise official reports produced by the NHS Complaint Procedure ] It was not part of the remit of the Ombudsman's Office to pass judgement on the second GP, nor were they aware of the conclusions reached by the GMC
GMC Assessors at odds with Ombudsman's Assessors:
The GMC described the performance of the first GP against whom the complaint was made as:" somewhat sub-optimal..." and wrote to her about the need to keep "accurate records" and the need to do a " thorough examination". [ These are basic requirements and very vital when it comes to providing medical care to a sick and vulnerable patient. In our opinion these criticisms constitute a ' lack of duty of care' which is a disciplinary offence and surely amount to clinical negligence]. For the Clinical Assessors (doctors) of the Ombudsman's Office to give a favourable opinion, without any criticisms, on a 'colleague' without reference to the full facts, demonstrates prejudice and raises doubts whether our complaints receive a fair assessment from the professional Clinical Assessors at the Ombudsman's Office, who I suspect are not completely independent nor unbiased.
Challenge to Ombudsman:
I raised the matter of the contradictory reports of the Hospital's and the Ombudsman's own Clinical Assessors and he told me that he would not comment about the many recorded statements made during the complaint procedures by the 2 senior medical staff of the hospital.
The Ombudsman disregarded published medical literature that I referred to him to advise that some explanations and suppositions of his assessors did not correspond with similar documented cases and current expert opinion of this particular illness. The Ombudsman kept asking me to provide evidence but accepted neither published medical opinion nor the recorded statements of the 2 senior hospital staff. His interpretation of what constitutes evidence is selective and prejudiced.
We noticed , especially in the case of the complaint against the hospital that information was provided piecemeal and usually incomplete so that by the time the Ombudsman became involved we still did not have all the details and were, therefore, unable to ask the questions that the Ombudsman's Clinical Assessors should have asked.
Conclusion:
The stress, frustration, time, expense and unhappiness in pursuing the truth behind my father's death has taken its toll on our family and we would prefer to put this episode behind us and get on with what has been left of our lives. We have no motive other than the pursuance of truth and some degree of justice. My family has nothing to hide and nothing to gain by deception. On the other hand, the GP and the hospital have possible mistakes to hide, litigation to evade, reputations to protect, accountability to avoid. There is, therefore, no question about who have most to lose by disclosure of the facts. The GP does have a sub-optimal performance or worse to try to hide from investigation. The hospital had a number of unsatisfactory or imperfect procedures to try to cover up.
My father suffered a series of errors ( misjudgement, misdiagnosis, incorrect procedures) by the GP, ambulance and hospital's A & E and ENT ( Ears, Nose & Throat Department) that did not prevent, and perhaps contributed to my father's sudden and unexpected death. There has never been any demonstration of concern by those involved other than to try and extricate themselves from blame or responsibility. The complaint procedures were always on their side. We have never seen any openness or accountability nor received any apology. My father's condition was never diagnosed as critical, yet he left the hospital in a coffin. Why should it require complaint procedures in order to get information and honest explanations?
My father's death, and the mistakes contributing to it, has been covered up by inefficient and biased complaint procedures.
The Ombudsman did not uphold the complaint against the GP either, and his clinical assessors showing unacceptable ignorance of adult epiglottis, accepted every single instance where the GP's account differed from my mother's account. The GP's account was accepted without any question or evidence and was accepted on nothing other than assumed, presumed and unsubstantiated probabilities. [ Isn't this always the case? The evidence presented by the patient is ignored, but whatever is stated by the doctor even if it is fabricated or complete nonsense is accepted? Why is it that patients' memories are always deficient; that patients tell lies - when 9 times out of 10 - it is the doctor who is at fault?]
The GP's inaccurate story was that Stephen appeared normal at the time of her visit but deteriorated after she left - was readily believed - even though her description - which conveniently omitted all the diagnostic symptoms - of my father's condition is not typical of what one might expect to see in an adult suffering from such severe epiglottitis, that was to cause his death in less than 24 hours. They accepted without evidence or corroboration the GP's convenient explanation that Stephen deteriorated after her visit , even though my mother said that his condition remained unchanged.
The Arrogant GP Who Has Leant Nothing :
One month after my father's death , my mother met this GP and found her unapologetic and unwilling to accept that she had made any mistakes and the GP further commented that, given the same circumstances in the future she would do nothing differently! [ Should she not be dismissed / struck off for admitting to this?]
Her defence argued that epiglottitis is rare in adults, usually occurs in children, and on the day of her visit she claimed that she had admitted a child with epiglottitis to hospital. To demonstrate her ignorance of this illness I provided statistics to the Ombudsman regarding the incidence of epiglottitis in Scotland and other countries to show that although epiglottitis is uncommon is is by no means rare and it is actually more common in adults than in children. The GP should similarly have been aware that the symptoms of epiglottitis in an adult are different from that of a child.
I am unsure whether this GP has learnt anything from her mistakes. She had the opportunity to save my father's like but instead, through lack of concern, incorrect and presumptuous diagnosis, apparent disinterest in his clinical history, ineffective physical examination and incomplete knowledge of this specific illness, gave my parents mistaken assurances that effectively delayed medical attention for my father until it was too late.
Convenient Autopsy Result:
The Post Mortem revealed that Stephen suffered from heart disease. [ We would suggest that any 73 year old at Post Mortem would reveal some degree of 'heart disease' In fact we would go further and say that it would have been remarkable if a 73 year old has suffered no degree of 'heart disease'] The GP, Hospital, Ombudsman's Clinical Assessors etc. have all found it convenient to imply that my father's heart condition, discovered at autopsy, was the cause of his death. Whilst the family does not dispute that he may have had some degree of heart disease, this condition was unknown to them before the Post Mortem and it had never before given him any problems. I feel that this discovery had provided an expedient alibi that obstructed a more thorough investigation of the circumstances that caused his death. Where fatality occurs in patients ( of all ages) with epliglottitis, death is most commonly attributed to cardiac arrest brought on by respiratory failure following some degree of asphyxiation and airway obstruction. Since my father appeared to follow this well documented sequence of events, I believe that this possibility should have been considered.
Contradictions in reports from the Ombudsman's Office:
The Ombudsman's Clinical Assessors accepted the GP's description of my father that :
" His general appearance was of a well rather than an ill man.." ! At the time of the home visit] Yet the Clinical Assessors dealing with the complaint against the Hospital defended the hospital and the fact that my father died very shortly after being admitted to A & E, that "... he had been unwell over the previous 2 days..." The Clinical Assessors of both complaints have interpreted the same evidence in converse ways in their respective need to defend the respective actions of the GP and the hospital staff. On the one hand the fact that my father appeared 'well' when the GP visited him, obviously protected her from any charges of negligence to provide medication or to admit him to hospital. The fact that my father had been (very?) unwell for two days before being admitted to hospital meant that this gave extenuating circumstances to explain why he died shortly after being admitted. One lot of Clinical Assessors had agreed that my father had been "well" at the time of the GPs visit, the other set argued that he had been "(very ?) unwell" when she visited,and indeed had been so for the previous two days.
The Ombudsman's Clinical Assessors volunteered a favourable report of the action of my father's own GP who had admitted him to hospital as an emergency. This however, was not part of our complaint. We had raised no criticisms of the performance of this GP. [ This is typical of the muddle and confusion which charaterise official reports produced by the NHS Complaint Procedure ] It was not part of the remit of the Ombudsman's Office to pass judgement on the second GP, nor were they aware of the conclusions reached by the GMC
GMC Assessors at odds with Ombudsman's Assessors:
The GMC described the performance of the first GP against whom the complaint was made as:" somewhat sub-optimal..." and wrote to her about the need to keep "accurate records" and the need to do a " thorough examination". [ These are basic requirements and very vital when it comes to providing medical care to a sick and vulnerable patient. In our opinion these criticisms constitute a ' lack of duty of care' which is a disciplinary offence and surely amount to clinical negligence]. For the Clinical Assessors (doctors) of the Ombudsman's Office to give a favourable opinion, without any criticisms, on a 'colleague' without reference to the full facts, demonstrates prejudice and raises doubts whether our complaints receive a fair assessment from the professional Clinical Assessors at the Ombudsman's Office, who I suspect are not completely independent nor unbiased.
Challenge to Ombudsman:
I raised the matter of the contradictory reports of the Hospital's and the Ombudsman's own Clinical Assessors and he told me that he would not comment about the many recorded statements made during the complaint procedures by the 2 senior medical staff of the hospital.
The Ombudsman disregarded published medical literature that I referred to him to advise that some explanations and suppositions of his assessors did not correspond with similar documented cases and current expert opinion of this particular illness. The Ombudsman kept asking me to provide evidence but accepted neither published medical opinion nor the recorded statements of the 2 senior hospital staff. His interpretation of what constitutes evidence is selective and prejudiced.
We noticed , especially in the case of the complaint against the hospital that information was provided piecemeal and usually incomplete so that by the time the Ombudsman became involved we still did not have all the details and were, therefore, unable to ask the questions that the Ombudsman's Clinical Assessors should have asked.
Conclusion:
The stress, frustration, time, expense and unhappiness in pursuing the truth behind my father's death has taken its toll on our family and we would prefer to put this episode behind us and get on with what has been left of our lives. We have no motive other than the pursuance of truth and some degree of justice. My family has nothing to hide and nothing to gain by deception. On the other hand, the GP and the hospital have possible mistakes to hide, litigation to evade, reputations to protect, accountability to avoid. There is, therefore, no question about who have most to lose by disclosure of the facts. The GP does have a sub-optimal performance or worse to try to hide from investigation. The hospital had a number of unsatisfactory or imperfect procedures to try to cover up.
My father suffered a series of errors ( misjudgement, misdiagnosis, incorrect procedures) by the GP, ambulance and hospital's A & E and ENT ( Ears, Nose & Throat Department) that did not prevent, and perhaps contributed to my father's sudden and unexpected death. There has never been any demonstration of concern by those involved other than to try and extricate themselves from blame or responsibility. The complaint procedures were always on their side. We have never seen any openness or accountability nor received any apology. My father's condition was never diagnosed as critical, yet he left the hospital in a coffin. Why should it require complaint procedures in order to get information and honest explanations?
My father's death, and the mistakes contributing to it, has been covered up by inefficient and biased complaint procedures.
.......from his son
Comments by SIN:
The lack lustre performance of the Ombudsman's Office:
The Ombudsman's Office, assuming it is the same as in England, is forbidden by Law to investigate any complaint which has a legal remedy. In other words, Stephen's death undoubtedly raised questions of clinical negligence which is a legal matter. This probably explains why the investigation was so muddled and ineffectual. An honest approach would have been to have informed the family that if they wanted accountability they must go to the GMC and if they wanted compensation they must go to Law.
With regards to the Hospital Inquiry, it is not clear whether this was internal or done under a so called 'Independent Review'. Certainly if it is the latter, and follows the English model, the Clinical Assessors cannot deal with clinical negligence or disciplinary matters. Furthermore, the NHS Complaints Procedure does not apportion blame i.e. establish accountability. It is utterly useless and the fact that so many thousands of medical errors proliferate unchecked in our NHS is verification to this ineffectual mechanism, and is a disgraceful state of affairs.
The GMC did very mildly criticise the first GP. We would challenge the use of the adjective "somewhat" in reference to her sub-optimal performance. Not to keep accurate notes, not to record the symptoms and not to carry out a thorough physical examination was a lack of duty of care and would amount, in the public eyes, to a disciplinary offence and clinical negligence. A physical examination would have told her immediately the seriousness of Stephen's condition. Prompt action then could have saved his life. However, we do not have enough doctors and so we must keep these poorly performing doctors, who put lives at risk, on the NHS pay-roll.
What should have happened to this GP? We believe she should have been severely reprimanded by the GMC and that this would be kept on her record. All nurse and doctors should have a 'licence' to work and, rather like a driving licence, 'points' for sub-standard behaviour can be added. Sanctions of fines, demotion or being struck off to follow atuomatically if 'points' continue to be recorded. This GP should have been obliged to write an abject apology to the family.Since we do not have enough doctors to weed out those who are sub-standard, then perhaps it would be a good idea to introduce fines, when performance is found to be seriously below par. Such fines could be graded according to the severity of the offence, and could amount to several thousand of pounds, to be paid out of the doctor's own pocket - the money to go into a central compensation fund for victims of medical errors and medical abuse. If this could happen with this doctor, we believe she would never again be so cavalier in her attitude to the next patient who put themselves in her care. What was so appalling is that this GP remains arrogant, unrepepentant, recalcitrant, - utterly refusing to acknowledge that she in anyway failed in her duty of care to Stephen.
Clinical Assessors: All clinical Assessors whether at the Hospital, Primary Care Trusts, the Ombudsman's Office, the GMC or CHI must be named and their qualifications given. Furthermore, all their ' medical opinions' must be given in their own signed statements and they must not be covered by Crown indemnity.
How sad, that the GP and the hospital staff have been unable to express any remorse or sorrow for Stephen's premature death or to give the family an apology.
The lack lustre performance of the Ombudsman's Office:
The Ombudsman's Office, assuming it is the same as in England, is forbidden by Law to investigate any complaint which has a legal remedy. In other words, Stephen's death undoubtedly raised questions of clinical negligence which is a legal matter. This probably explains why the investigation was so muddled and ineffectual. An honest approach would have been to have informed the family that if they wanted accountability they must go to the GMC and if they wanted compensation they must go to Law.
With regards to the Hospital Inquiry, it is not clear whether this was internal or done under a so called 'Independent Review'. Certainly if it is the latter, and follows the English model, the Clinical Assessors cannot deal with clinical negligence or disciplinary matters. Furthermore, the NHS Complaints Procedure does not apportion blame i.e. establish accountability. It is utterly useless and the fact that so many thousands of medical errors proliferate unchecked in our NHS is verification to this ineffectual mechanism, and is a disgraceful state of affairs.
The GMC did very mildly criticise the first GP. We would challenge the use of the adjective "somewhat" in reference to her sub-optimal performance. Not to keep accurate notes, not to record the symptoms and not to carry out a thorough physical examination was a lack of duty of care and would amount, in the public eyes, to a disciplinary offence and clinical negligence. A physical examination would have told her immediately the seriousness of Stephen's condition. Prompt action then could have saved his life. However, we do not have enough doctors and so we must keep these poorly performing doctors, who put lives at risk, on the NHS pay-roll.
What should have happened to this GP? We believe she should have been severely reprimanded by the GMC and that this would be kept on her record. All nurse and doctors should have a 'licence' to work and, rather like a driving licence, 'points' for sub-standard behaviour can be added. Sanctions of fines, demotion or being struck off to follow atuomatically if 'points' continue to be recorded. This GP should have been obliged to write an abject apology to the family.Since we do not have enough doctors to weed out those who are sub-standard, then perhaps it would be a good idea to introduce fines, when performance is found to be seriously below par. Such fines could be graded according to the severity of the offence, and could amount to several thousand of pounds, to be paid out of the doctor's own pocket - the money to go into a central compensation fund for victims of medical errors and medical abuse. If this could happen with this doctor, we believe she would never again be so cavalier in her attitude to the next patient who put themselves in her care. What was so appalling is that this GP remains arrogant, unrepepentant, recalcitrant, - utterly refusing to acknowledge that she in anyway failed in her duty of care to Stephen.
Clinical Assessors: All clinical Assessors whether at the Hospital, Primary Care Trusts, the Ombudsman's Office, the GMC or CHI must be named and their qualifications given. Furthermore, all their ' medical opinions' must be given in their own signed statements and they must not be covered by Crown indemnity.
How sad, that the GP and the hospital staff have been unable to express any remorse or sorrow for Stephen's premature death or to give the family an apology.
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