Third Covention in London
Sunday 27th &
Monday 28th.November 2005
delighted to act as hosts to our colleagues and friends in the IEU
Alliance and were most grateful that the
Alliance members were willing to travel to London for the meeting.
27th November was a very successful meeting. The Alliance continued
to discuss the concerns of the iatrogenic patient and also to discuss
arrangements for presenting our Declaration to Downing Street coinciding
with Prime Minister Blair's occupancy of the Presidency of the EU;
and to the Department of Health to the Chief Medical Officer ( Sir Liam
Donaldson) and to the Minister for Patient Safety, Mrs. Jane Kennedy
on the following day.
Alliance were delighted to welcome as guests to their meeting: Mrs.
Susan Sheridan (USA) who founded CAPS ( Campaign for the Advancement
of Patient Safety) and Martin Fletcher, World Health Organisation
(Geneva). (See first photo below)
Sheridan shared with us the two great tragedies caused by serious medical
errors which had changed her life completely. Her young son Callum had
been left seriously physically impaired from birth because there was a
delay in diagnosing jaundice . Her husband died prematurely from cancer
because a diagnostic test result had been filed incorrectly. This cost
Susan's husband the chance of receiving cancer therapy which would have
prolonged his life. After her husband's death in 2002, she decided to devote
her life to the furtherance of Patient Safety and set up CAPS. All
present empathised with her and admired her great courage and perseverance.
Members of the IEU-Alliance
have all had personal experience of serious medical errors or else have
witnessed a family member suffer. Therefore, our experiences have been
similar to Susan's. Like Susan we have tried to put our bad experiences
to good use by being productive and trying to change the system so that
other families do not have to suffer as we have done.
IEU-Alliance handed to Susan Sheridan
( CAPS) & Martin Fletcher ( WHO Geneva) a copy of the
IEU-Alliance Declaration 2005: Patients' Rights in Statute.
Sheridan gave a recorded interview with Fergal Keane on Radio 4 on
Tuesday morning 17th January 2006 describing her experiences - thereby
confirming experiences of all iatrogenic patients as stated in our Declaration].
are photgraphs showing IEU-Alliance's Third Convention, London
Downing Street, Monday 28th November 2005
recognition of Prime Minister's Blair Presidency of the EU
28th November 2005 submitted to the Chief Medical Officer,
Liam Donaldson, and Mrs Jane Kennedy , Minister for Patient safety
Do the public
agree with our demands as stated in the IEU-Alliance Declaration?
26th January 2006
Our 'snap-shot' questionnaire
to see if the public agreed with our demands for Patients' Rights in Statute
- the result was unanimous agreement ( most of the public thought we had
these rights already) - except for one person . Guess what? - he was a
doctor ! He presumably believed that health professionals should not be
under any legal obligation to record medical errors that harmed patients;
that there should be no legal obligation to inform the patient of the damage
regardless of legal liability etc. etc. This certainly proves, we think,
the importance and the necessity for dialogue between health professionals
and iatrogenic patients.
SIN-UK & IEU
- Alliance Members at Patient Safety Summit
UK Presidency the EU 2005 Health Programme
Queen Elizabeth 11 Conference Hall
, Westminster, London
27th - 30th November 2005
glimpse of the Promised land?"
SIN was delighted to be invited
to attend this very prestigious Summit. It was held in conjunction with
the WHO, EU Commissioner for Health, Health Ministers, Chief Medical Officers,
top civil servants and consultants were present, from all round the world.
The WHO is promoting patient safety at the global level and has formed
a World Alliance for Patient Safety Committee. UK's Chief Medical Officer
is the Chair of this committee.Presentations were given from many countries
and experts in the field of medical mistakes, for the Conference's theme
was Medical Errors and the need to reduce the incidents and so improve
patient safety.Patients from the WHO World Alliance for Patient Safety
met at their own Forums, but on Sunday several were able to relate their
own iatrogenic experiences to the Summit.
Medical errors have been attracting the attention of health services in
the developed world for the last decade. As astonishing as it seems, there
had been little or no record of the occurrence of medical errors, indeed
no one had really any idea of their frequency or severity.
It was probably true to say that medical errors and their consequences
were considered of little interest. Confidence in the quality of health
systems was found to be unjustified. In the UK we have over 50 years
of accurate recording of car accidents but no systematic recording of medical
accidents. Various countries decided to do a 'spot check' using a sample
of medical records of patient admissions to hospital. These records
would determine how many medical errors had occurred and then
to extrapolate from the sample to the country as a whole. It was Prof.
Charles Vincent who did the research in the UK. According to official
Statistics from the NPSA the following results have been recorded:
ADVERSE EVENT RATE
(% of admissions)
is worth noting that the number in the sample varies, and it is difficult
to know whether there was a standard definition of what constitutes an
adverse incident or whether there was variation in the rigor of recording.
conclusion that can be drawn is that approximately 10% of patients
entering hospitals will be subjected to a medical mistake. This is not
an unreasonable expectation because the very complex systems are run by
fallible human beings. The majority of these incidents will be minor,
with short lived results. However, it is reckoned that 1% of medical accidents
result in very serious injury resulting in death or permanent disability.
In the UK it is estimated that 34,000 patients will die annually
because of a medical accident ( in the USA the figure is 100,000 )
and approx. 40,000 will be permanently and seriously damaged annually in
found the Summit very interesting and encouraging. It was obvious from
the presentations from several countries that a great deal of work over
the last seven years has been going on behind the scenes. Medical errors
are being documented and categorised for analysis. The NPSA ( UK)
being one of the first Agencies in the world to be given the task of recording
medical errors (anonymously). We were given examples of different
types of errors and the research from various studies gathered from
around the world to show what has been undertaken to ensure a reduction
of such incidents and so guaranteeing improvements in patient safety. There
had also been set up many Workshops in health institutions and discussion
Forums to educate and to change attitudes, mind-sets and hearts. In fact
to change the culture of the last 50 years which has prevailed in medicine:
the need for more openness.
was evident that political leaders at this Summit had made Patient Safety
a priority and that the World Health Organisation had made it a Global
Issue with the setting up of the WHO Alliance Steering Committee for Patient
Safety with the Chief Medical Officer ( UK) Sir Liam Donaldson as
Chair. It was noted with satisfaction that the UK government was spearheading
research and innovative pilot studies on how medical errors should best
be addressed to lessen the trauma to innocent patient victims. We were
also gratified that there was a universal recognition that patients
themselves are intrinsic to the work of improving patient safety, and
must be involved right at the heart of the matter. The fact that
the UK now has a Minister for Patient Safety, Mrs. Jane kennedy, demonstrates
the priority and seriousness with which the UK government views the whole
issue of medical errors and their impact on patients.
is with Patient Safety in mind that the IEU-Alliance
set up and produced its own Declaration for Patients' Rights in Statute,
one of them being the right to know if a patient has been seriously
damaged irrespective of legal liability and the right to remedial
care being guaranteed together with a Victim's Compensation
Fund set against a National Tariff.
was apparent that there was a clear political will to change matters for
the better and the local leaders were in place to implement the necessary
changes. However, we feel that there is still much work to be done to
ensure that such changes percolate downwards and are introduced at the
'front-line'. Dialogue between health professionals and damaged
patients not only would be mutually therapeutic but we also see this
as an essential tool to ensure that changes do occur and as rapidly as
last two presentations given by Prof. Ian Kennedy ( Chair of the Healthcare
Commission and of the Bristol Royal Infirmary Inquiry) and Sir Liam Donaldson
( Chief Medical Officer, UK)
truly inspirational and moving. SIN has campaigned for a more humane approach
to medical errors for seven long years, and for the first time we felt
that we have had a glimpse of the 'Promised Land'? The damaged patient
will no more be viewed as a'the hot potato' or 'a leper' , but will be
seen as a very traumatised human being in need of couselling and genuine
remedial care - in fact in need of some TLC!
Medical errors will always be with us. No system will ever be devised
to totally eliminate them. The question is : What do we do about them?
best we can do is to record them honestly and to learn
from them so that their incident rate can be reduced.
A great deal of work over the last seven years has been on this part of
the problem. But the other side of the equation MUST be addressed:
the effect that serious medical incidents have on the innocent victims.What
can be done about this?
Open and honest disclosure irrespective of legal
liability is essential and long over due. Legal liability should never
be a barrier to medical care, as it is at the moment.
we reached the banks of the River Jordan?
Return to Top
Why No Publicity?
26th January 2006
It is quite extraordinary
and very puzzling that the IEU - Alliance
demonstration outside the Department of Health & 10 Downing Street
received no publicity at all. Is any editor of a respected television channel
or newspaper willing to state in public that Patient Safety is not of major
Patient Safety relating to
medical errors is now thought to be SO important that it has been taken
up at the GLOBAL level by the World Health Organisation and indeed ironically
at the same time as we were delivering our Declaration
2005 on Patients' Rights to Downing Street and the Department
of Health the UK government as part of Mr. Tony Blair's EU presidency in
conjunction with WHO was funding a very prestigious Summit on patient safety
at the Queen Elizabeth Conference Hall.
The following TV Channels
and newspapers were contacted by email:
Not one acknowledged receipt
of the email and no one came to interview these public-spirited people
of the IEU- Alliance. These good
people had travelled from mainland Europe, some at their own not
inconsiderable expense, to make this powerful gesture on behalf of victims
of medical errors. WHAT IS THE PROBLEM? Is there some kind of censorship
NO ONE IS IMMUNE FROM A MEDICAL ERROR
This subject deserves
a widespread and mature public debate including
dialogue between the victims of medical errors and the health professionals.
of Email sent to the television & press from SIN:
Patient Support Group called 'Sufferers of Iatrogenic Neglect' (SIN)
was set up in Nov. 1998 to draw public attention to the trauma problems
of the innocent victims of medical errors.
has now joined forces with other similar Patient Support Groups from Europe
to form the 'Iatrogenic Europe Unite' (IEU)
Alliance and we are hoping that you may wish
to update the development of SIN particularly as medical errors is now
in the public arena for debate.
is meeting outside the D.o.H. Monday at 10.am 28th November to hand in its
Declaration and then will go over to Number 10 Downing Street, also
to hand in the Declaration.
the attachment is a copy of the IEU
DECLARATION 2005 FULL PRESS RELEASE
M Bean & Margaret MacRae Co-Directors & Founder Members SIN
firstname.lastname@example.org & email@example.com
( available Sunday 27th November)
at NPSA Patient Safety 2006 Conference Birmingham
was delighted to be invited to attend the above Conference. The NPSA
is to be congratulated for the amount of work it has covered in just a
few years and the many areas of Patient safety it has initiated and is
over-seeing. What is so admirable is that the 'patient experience' and
'patient (public) involvement' is central to all its work.
was impressive to see how active the NPSA has been behind the scenes in
promoting issues of 'Patient Safety' - its really big service has been
to start to change the medical profession's mind-set of 50 years: that
of denying the very existence of medical errors, and to wean them from
their limpet-like attachment to the notion of 'infallibility', to one of
accepting that even the best of doctors will make mistakes - to convince
the profession that the reporting of medical errors MUST become
an integral part of their professional life.
is aiming for full, open and honest disclosure irrespective of legal
liability and the waiving of anonymity in the interests of Patient Safety.
However, we do appreciate that the first stage in this process must be
to obtain the cooperation of the health professionals and for them to begin
a process of frank self-criticism and to understand the necessity of logging
and analysing medical errors in the first step towards understanding why
they occur, with the aim of reducing these incidents. We hope that during
this process they will begin to empathise with the iatrogenic patient and
understand this perspective of medical errors.
was particularly good at the Birmingham Conference is that the NPSA brought
together many different strands from the Health Service: health professionals;
administrators; risk managers; clinical governance managers; medical insurers
and - perhaps best of all - patients. This was a very good opportunity
to bring down the barriers by allowing DIALOGUE to take place and
so bring about a change of culture. As SIN circulated we were able to give
out IEU-Alliance leaflets and discuss our objectives. Most people were
very enthusiastic and supportive of the IEU-Alliance. It was surprising
how many people had their own stories to tell of seriously, iatrogenically
damaged relatives!! One delegate wished to know why no patient from
SIN had been on the Podium - why were they hearing form the USA & Ireland,
but not the UK?
to Our Comments
member meets WHO at Copenhagen
were delighted that our IEU-Alliance Co-Ordinator
Ms Sophie Hankes, was able to meet with Mr. G. Schmetz of the WHO
Regional Office, Copenhagen to hand in the IEU-Alliance 2005 Declaration
and to discuss the problems facing the iatrogenic patient. WHO has
a major initiative to make Patient Safety a top priority.