| 1. SIN was the first group courageous enough
to make public the unthinkable truth that doctors are capable of deliberately
and systematically denying damaged patients, who are seriously ill, the medical
care to which they are entitled by law. In SIN's Manifesto, first made public
in Nov. 1998 SIN said:
"....there is evidence that doctors subsequently deny patients
appropriate treatment to cover-up their colleagues' incompetence and or/
negligent mistakes. One theory is that appropriate treatment to remedy iatrogenic
damage could lead to a successful complaint and/or disciplinary
action and/or in extreme cases, [successful] medical negligence litigation".
2. In June 1999 the Health Select Committee held an Inquiry into
"Adverse Medical Incidents and their Outcomes". There were almost 300 submissions
to the Committee and SIN was pleased that it was able to inform quite a few
iatrogenic patients about this Inquiry and so gave them an opportunity to
be involved.
On October 24th 1999 there was an article in The Observer which
promoted SIN and also contained quotes from the Health Select Committee following
the above Inquiry. The heading of the article was " Doctors 'blacklist'
dissatisfied patients: NHS close
s ranks
against sick who dare to complain about treatment" A
quote from the Health Select Committee following on from their findings said:
"It is certainly true that patients are
blacklisted by consultants and GPs"
To be blacklisted by consultants means that
a sick patient is effectively denied specialist care.
NOT ONLY IS THIS DISGRACEFUL, BUT IT IS
ALSO UNLAWFUL
"If you cannot trust your doctor, who then can you trust?"
In the article SIN was described as : "...a group of patients have formed a campaign to fight
back........there is a 'not in my backyard syndrome' because doctors are
frightened of being brought into a case that often involves very senior members
of their specialist discipline...."
3. The most recent public acknowledgement of this unpalatable
truth was in Lord Woolf's Lecture on 17th January, 2001 when he conceded
:"...where, if a patient unfortunately had an unsatisfactory outcome, the
medical carers ........needed to recognise that because patients felt that
they had been a victim of medical malpractice, this did not justify withdrawing treatment. [rather] It meant that those who had a responsibility
for treating the patient were under a particular duty to achieve the best
result possible for the patient".
We sincerely hope the Medical Profession will take heed
of Lord Woolf's wise words.
The
Health Select Committee regularly investigates and takes evidence from the
public on a range of health issues. SIN will endeavour to draw attention to
any Press Notice received in order to keep the public informed and to give
interested parties an opportunity to participate in any forthcoming debate
by submitting written evidence and thereby exerting democratic
pressure to improve standards in the NHS
GUIDE TO SUBMITTING WRITTEN EVIDENCE
- It is open to any organisation or individual to submit evidence
to the Committee
- Written evidence should contain, if appropriate, a brief introduction
to the persons or organisations submitting it [perhaps stating their area
of expertise, etc.], and any factual information they have to offer from
which the Committee might be able to draw conclusions [ or which could be
put to witnesses fro their reactions]. It is also helpful to include
any recommendations for action by the government or others which the
witnesses would like the Committee to consider for inclusion in its Report.
- Written evidence should be as concise as possible and in the form
of a self-contained memorandum. Unless memoranda are extremely short, they
should be prefaced by an executive summary.
- Memoranda should have numbered paragraphs and pages. If possible,
colour printing should be avoided.
- Memoranda and other communications should be addressed to
the The Clerk of the Health Committee, House
of Commons, 7 Millbank , London, SW1P 3JA
- Unless indicated otherwise, it will be assumed that those submitting
written evidence have no objections to it being made public by the Committee.
If witnesses give oral evidence, copies of their written evidence will usually
be made available to the press and public at the hearing and treated as being
in the public domain their after. Written submitted by those not giving oral
evidence will usually be made public by the Committee at the end of the Inquiry,by
publication or other means.
|
The text of the Committee
Reports, minutes of evidence and Press Notices can be accessed through the
Internet at Parliament's website:
www.parliament.uk/commons/hsecom.htm
FOR INQUIRIES TELEPHONE FRANK McSHANE ON 02072195466
1. INQUIRY INTO THE SAFETY OF BREAST IMPLANTS,
Thursday March 22nd : oral evidence to be taken.
TERMS of REFERENCE:
- The
role of the Medical Devices Agency
- The process whereby information relating to risks is disseminated
- The information provided by the Department of Health directly
to the public and action taken in response to concerns raised.
- Guidance to health care professionals.
- 2. NEW INQUIRY : NATIONAL INSTITUTE OF CLINICAL EXCELLENCE
(NICE)
- Organisations or individuals
wishing to submit written evidence to do so no later than Friday 4th January,
2002
- TERMS OF REFERENCE
- The Committee will consider
the progress NICE has made in achieving the key goals envisaged in A
First Class Service and as such:
- is providing clear and
credible guidance
- has ended confusion by
providing a single national focus
- is providing guidance
that is locally owned and acted on in the right way
- is actively promoting
intervention with good evidence of clinical and cost-effectiveness so that
patients have faster access to treatments known to work
- The Committee will
also specifically examine the independence of NICE
- 3.
NEW INQUIRY: INTO THE ROLE OF THE PRIVATE SECTOR IN THE
NHS
- The Committee has arranged
the following meetings to be held in public during November and December:
- Thursday 29th Nov.
10.30am: Oral evidence from NHS Alliance, BMA and partnerships UK
- Thursday 6th. Dec.
10.30am: Oral evidence from: Medway Maritime NHS Trust; Channel Primary
Care Group ( East Kent Health Authority); Federation of Independent Practitioners;,
General Healthcare Groups; IndependenH health Care Assoc. ; Assoc. Community
Health Councils; Royal College of Nursing; & NHS Confederation.
- Wednesday 12th. Dec.
4.00pm: Rt. Hon. Alan Milburn MP, Secretary of State for Health(NB. THIS MEETING POSTPONED UNTIL NEW YEAR)
4.. NEW INQUIRY: SEXUAL HEALTH
The health Committee will undertake an inquiry into the above
subject.
- The Committee will examine the effectiveness of the Government's
strategy for sexual health in the context of the consultation document 'Better
Prevention, Better Services, Better Sexual Health: The National Strategy
for Sexual Health and HIV'
- Organisations and individuals wishing to submit written evidence
are invited to do so no later than Wednesday 5 June 2002. Evidence sessions
are likely to commence in June and a later press notice will give details
of these.
- For Inquiries about the work of the Health Committee telephone
Frank McShane on 0207 195 466
SIN is very concerned
about the experiences of patients who are victims of a medical error
(iatrogenic patients) and their difficulties in obtaining genuine second opinions.
We have received
a very critical report of one member's attempt to obtain a second opinion
at Guy's & St. Thomas' Trust, London. We, therefore, thought it necessary
to establish the procedures/protocols already in place at this Trust to ensure
that patients receive a good standard of medical care, and have written today
, 19th February, 2001 a letter to the Chief Executive:
Re: Clinical Governance:Second Opinions
"We are writing to
request the documented procedures/protocols which Guy's & St. Thomas'
Trust has in operation which will govern the standards which an individual
patient can expect to receive after being referred to a Consultant Physician
at your Trust by the patient's GP for a full reappraisal of their medical
condition with a fresh comprehensive range of tests.
We look forward
to a rapid response to this request, and should be most grateful if your
reply is faxed through .........
This
letter will be posted on the WWW, and your reply will be of great interest
to patients in general and to iatrogenic patients in particular.
Yours
sincerely, "
[As soon as we receive the reply we shall
post it on the web]
We received
prompt reply from the Chief Executive, dated 21st. February, in which he wrote:
"In common with other parts of the NHS
Guy's & St. Thomas' respects the rights of individual patients to a seek
second opinion.
"Where one of the consultants of this trust is asked by a general
practitioner for a second opinion then that consultant will make their own
clinical judgement as to the extent of the re-assessment particularly with
regarded to the repeating of the investigations previously performed elsewhere.
Unnecessarily repeating tests that have been satisfactorily performed elsewhere
and that have produced a clear result may not be in the patient's best interest.
That is however a matter of individual clinical judegement.
"The Trust does not have specific
documented protocols covering the provision of second opinions at the request
of general practitioners.All clinical care
within this Trust is covered by a code of conduct to which all members of
the Trust particularly those with direct involvement in clinical care, are
expected to abide."
SIN
replied to this letter dated 22nd February :
" We should be most grateful if you would furnish SIN with details
of this code of conduct"
We have
not yet received a reply!
Last updated 17th March, 2001 Last updated 25th April,2001
| SIN'S COMMENTS ON THE INQUIRIES REPORT AND
THOSE ISSUES RAISED WHICH ARE OF PARAMOUNT IMPORTANCE TO PATIENTS IN
GENERAL |
Return to Our Comments |
Updated & completed
4th July, 2001
1. How Independent is an "Independent " Inquiry such as this?
Can the
following be seen as a conflict of interests?:
Dr. Stewart
Hunter was asked to verify statistics at both hospitals following the concerns
voiced by an anonymous whistle blower at the higher than average death rates
at the Royal Brompton and later to verify the statistics from
the BRI Inquiry which pointed to Harefield having a paediatric
surgical death rate only higher than the BRI. Was Dr.
Hunter an appropriate person to verify the statistics considering that he
had acted as an expert witness in a recent court case ,two years previously,
defending a legal action against clinicians at the Trust?
Mrs.Ruth Evans, Chair of the Inquiries is at present a Lay
member of the GMC. Surely, all such Independent Inquiries should
be independent from any of the Statutory Bodies established to regulate and
discipline members of the medical profession. The presence of
any member of the GMC must surely be prejudicial to any family who may have
wished to have their case heard by the GMC at any future date and would have
pre-empted any such action. Unbeknown to parents who were participating
in this Inquiry, expert evidence was solicited from two further members of
the GMC, namely: Ms. Isabel Nisbet, Director of Fitness to Practice,
GMC ( former Deputy Ombudsman), and Mr Anthony Townsend, Director of Standards
of Education . Could this strong
presence of the GMC at this Independent Inquiry , be construed by the parents
as a an iniquitous conflict of interest?
Dr. Barry Keeton was the cardiologist used by the panel
to advise the Brompton families. He is presently a Consultant in Paediatric
Cardiology at Southampton General Hospital, but was, however, formerly
employed at the Royal Brompton as a Paediatric Cardiologist. Can this be seen as a conflict of interest to the families
concerned, would it not have been wiser to have called in someone
who was not a former employee of the Trust?
The location of this "Independent" Inquiry was: 40,
Eastbourne Terrace, Paddington London, which happens to be the Regional
Offices of the North Thames NHS Executive.This
venue hardly suggests independence from the NHS, of which
the Trust is an integral part.
The Chief Executive of the Trust was allowed an advanced
copy of the Report one week before the Press Conference and was able to prepare
a written response. However, Josephine Ocloo, Chair of BHHCAG, only received
her copy 36 hours before, although she had signed a confidentiality agreement.
One family reported that a copy of the Report had been dumped on the front
doorstep and was discovered there on Sunday morning, 24hrs. before the Press
Conference. Since this Report was supposed to be
"independent" from the Trust should nor both participants: the families and
the Trust, have received the Report at the same time? To have
allowed the Trust prior disclosure is surely a conflict of interests, since
the families were not allowed an equal amount of time to put together their
considered responses?
Medical Records
2. Medical Records: The keeping of good medical records
is essential for accurate diagnosis and medical care. The Royal Brompton
& Harefield are two of our top hospitals, yet there was severe criticism
at the standard of the medical record keeping at these hospitals. (Section
24 "medical records" p253 - 264)
GMC GOOD PRACTICE GUIDE: Duties & Responsibilities of Doctors:
Good Clinical Care : In providing good care you must
:
3 (d) Keep clear, accurate, and contemporaneous patient records
which report the relevant clinical findings, the decisions made, the information
given to patients and any drugs or other treatment prescribed.
Families and the Panel had great problems
when trying to access medical records and a significant number of families
found that crucial documents were missing (para 24.10 p. 255/6) and "rarely
was there any record of what was said to parents, what concerns they
expressed and what were the views of the clinicians concerned" (para
24.24 p.260)
Quotes of families: "If we dealt like that we would
be sacked immediately in our job.....but these guys, who are looking after
peoples lives are allowed to bin it.." (para. 24.10 p. 255)
The parents of a child who had died confirmed that her records
were missing "literally one month after she died..." (para.
24.11p256) ...Four cases experienced unacceptable delays with parents of
one child experiencing a delay of three years : "I had been asking for
those (notes) since a month after she died ( 3 years ago). (para.24.17
p258). " It has been dreadful. It has taken 5 people in my family to try
and sort these notes out, trying to put them where they are supposed to go"
( 24.28 p259)
SIN endorses the Brompton & Harefield Heart Children's
Action Group's that "failure to keep proper medical records be made a criminal
offence".
It is clear that SIN's proposal to put medical records under the
control of the patient i.e. for a copy set to be held by the patient or parents
in the case of a child; and that summaries of consultations to be signed
and checked for accuracy by the patient, is essential for
patient safety.
It should be compulsory that a patient's medical records be kept
at the bedside in all hospital wards.
Stenographer: the best way of recording interview transcripts?
3.
Stenographer: She was there to provide a verbatim transcript of the hearing.
Parents who received copies of these "verbatim " transcripts found that these
contained numerous and very serious errors. For example statements made in
the negative were transcribed as in the affirmative, which would have
totally misled any reader of the transcript e.g...........
(a) One family discovered that several crucial clinical statements
made by the Panel's cardiologist had been wrongly transcribed and were
attributed to the parent, thereby negating the significance of these critical
medical opinions.
(b) In one transcript, the statement of the Panel's cardiologist
, when he clearly stated that he would not
have continued with the surgery because....., was wrongly transcribed
without the negative, thereby giving the reader the totally wrong impression
that he would have gone ahead with surgery.
Surely the time has come in the 21st. Century that full
use is made of modern technology. SIN suggests that all such inquiries are
tape recorded /videod in future , all primary participants getting copies.
[This should surely apply to court hearings too?]
All Access to Natural Justice Thwarted
4.
(a) Legal Route
To quote from Report: " Early on in our
Inquiry, a request for legal representation at hearings was raised with us
by the BHHCAG ( Parents' Action Group), and by some clinicians. The
Panel concluded that none of the parties, including the Panel itself should
be represented by lawyers as this would have made our proceedings disproportionately
adversarial , time consuming and costly." [p13]
This statement is confusing for those who participated in the
Inquiry and misleading to the reader, for a top medical litigation
lawyer, MS Sarah Leigh, was available to the panel throughout the course
of the Inquiry and, indeed, was present at many of the parents' Panel
hearings. If she were not providing legal advice to the panel,
then what was her role in this Inquiry? MS Leigh is a senior
medical litigation lawyer at Leigh Day & Co., and is also secretary of
the NHS Clinical Disputes Forum.
SIN can find no mention in the Report of any reference to
the Panel clearing the cases heard of clinical negligence, and indeed the
Report states: " A few wanted us to attribute blame to particular individual
for what happened to their child. That was not within our remit, not least
because we did not have the legal powers to act in that way." [p395]
Astonishingly, at the Press Conference Mrs Evans claimed that
the Inquiry could find no evidence of clinical negligence. This clearly contradicted
her comments in the Chairman's Forward when she claimed that the Inquiry
she chaired was not:"....a substitute for the courts. We directed parents
towards these avenues where appropriate." The ensuing media coverage
from the Press Conference, not suprisingly, quoted her as stating that no
clinical negligence had been exposed, as though it had been
recorded as an official finding in the Report . Should she not be obliged
to publicly retract this grossly misleading statement?
Following the Press Conference Gillian challenged MS Caroline
Langridge, Secretary to the Inquiry, and asked her, since Mrs Evans had
claimed publicly that no medical negligence had been found, did this mean
that Ms Sarah Leigh, the medical litigation lawyer, sitting on the panel,
had cleared all the cases of clinical negligence? Ms Langridge replied that
that was not the case because the Panel were not looking for clinical negligence.
IN THAT CASE, GILLIAN POINTED
OUT, IF THE PANEL WERE NOT LOOKING FOR CLINICAL NEGLIGENCE, HOW COULD
MRS EVANS STATE THAT NONE HAD BEEN FOUND?
(b) The GMC Route
The Report claims that Panel members did: "....not encounter
actions or issues at the RBH or Harefield Hospital which, on the basis
of our inquiries and the information which we have obtained, should in our
views have been reported to the GMC or the UKCC [p20] [What about the
poor medical record keeping? see Section 2 above]
Only after the publication of this Report were the parents made
aware that there were 22 "expert witnesses" involved behind the scenes
with this Inquiry. These included two experts from the GMC namely:
Ms Isabel Nisbet, Director of Fitness to practice & Mr Anthony Townsend,
Director of Standards and Education. The inference can be drawn that
these individuals, drafted in from the GMC, proffered their advice to the
panel. To all intent and purposes this was surely a "quasi investigation
" of the GMC under the guise of the "independent inquiry" which effectively
precludes any family from taking their case to the GMC. It was an affront
to the families that this quasi investigation took place without their knowledge
and consent and they were unable to make personal representation to these
members of the GMC. So much for informed consent which was promoted
as one of the recommendations of the Report. [ Recommendations, main Report
p.71 & 72, in addtion to these, see also p169 which are the recommendations
re: consent for Harefield].
Apparently, the Panel members : " interviewed or received
written submissions from" these expert witnesses. [Chair's Forward].
Should not the ensuing documentation voicing the opinions of these
experts have been included with the final Report?
(c) CHI Commission For Health Improvements
CHI is a relatively new Agency set up to improve standards in
the NHS and the Chief Executive, Dr Peter Homa, was another expert witness
called in to give advice behind the scenes. Again precluding the BHHCAG from
using this organisation to look collectively at their cases.
(d) NHS Complaints Procedure
Mrs Evans had no hesitation in recommending the NHS Complaints
procedure as a means of redress, even though the Panel members had obtained
copies of SIN's critique of the NHS Complaints Procedure, which clearly shows
that '...the NHS Complaints System is a confidence trick played on the
trusting patient at the tax-payer's expense.' [ Click here to read "The Emperor Has No Clothes"] The paper proves that the NHS Complaints Procedure does
not:
- apportion blame
- consider clinical negligence
- consider disciplinary matters
- allow the Ombudsman's Office to investigate any complaint
which could have a legal remedy
- allow patients an impartial hearing, which is a denial of
our human rights and, as of October 2000, following the introduction of the
Human Rights Act, it is now officially unlawful [see Conclusion para.11.2 in SIN's Paper click here to read" The Patient's
Voice For Equity]
Whistle Blowers
5.
As a result of Private Eye being contacted by an annonymous whistle blower,
a three day review of paediatric cardiac surgery was carried out at the Royal Brompton Hospital in
August 1999. This Review looked into the allegations of poor outcomes in
paediatric cardiac surgery with particular reference to Downs Syndrome children.
The Review makes reference to the whistle blower's allegations being 'unfounded
and malicious'. This review did not allay parents' fears, and
several other families brought their concerns to the attention of the
media, following its publication. In view of the parents' misgivings, an
Independent Inquiry was recommended by the ReviewTeam - although the Review
records that the motives and allegations of the whistle blower had been denigrated.
This Review congratulated the Trust on their structures set up
since 1998 to allow whistle blowers to raise their concerns internally. However,
the Evans' Report was more critical and identified a number of weaknesses
in the Trust's speaking up policy. (page 285, para.26.15)
Statistics
6. The Report fails to mention that the Harefield
Hospital was included in the Inquiry because statistics obtained via
the BRI Inquiry showed that Harefield had the second highest paediatric surgical
death rate for children over one year, after the Bristol Royal Infirmary
itself. Dr. Stewart Hunter & associates were asked to validate the Harefield Hospital data. Although
their findings were published on 8th. March 2001, the analysis
of this data was not included even as an appendix, in the Evans' Report.
A decision was made to merge the findings of these two separate inquiries
into one Report: "The Report of the Independent Inquiries into Paediatric
Cardiac Services at the Royal Brompton Hospital and Harefield Hospital April
2001"
Down Syndrome Discrimination?
7. None of the 7 families involved in the Harefield Inquiry
had a Down Syndrome child. Of the 42 Brompton families, only 14 cases involved
a Down Syndrome Child. Although fewer than a third of the cases reviewed
affected families alleging discrimination on the grounds of Down Syndrome
disability, all media coverage seemed to focus on this issue, in doing
so effectively by-passing the concerns of the majority of the families. Were
the Down Syndrome children discriminated against for cardiac surgery at the
Brompton Hosptial? The conclusion is ambiguous. Following are some
of the more pertinent comments made by the Panel with regards to this issue:
- "Some of the families alleged discrimination in the treatment
which was delivered to their child. We found no child who presented from
1990 onwards who did not receive appropriate treatment. We accept that
in some cases surgery was delivered by other centres after a second opinion
had been sought by the parents." [p347]
- "The doctors are insistent that such insensitive remarks or inappropriate
attitudes would not have been made or occurred. This area of parent concern,
and the intensity with which it was expressed to us does ,however, suggest
that there may have been a breakdown in communication between some doctors
and these families and these consultations may, in some cases, have lacked
the sense of partnership that parents reasonably expected." [p349/350]
- "The majority of the families we saw felt that communication
in their child's case was at some time either inappropriate or insensitive.
Remarks alleged to have been made by staff carried for parents the implication
that children with Down Syndrome were of less value to society, or were less
suitable recipients of scant NHS resources, than other children. The doctors
are insistent that such insensitive remarks or inappropriate attitudes would
not have occurred or have been made."
- "We are unable to conclude whether the impression of the families
that some doctors at the RBH during these years were insensitive and displayed
inappropriate attitudes towards children with Down Syndrome was well founded.
From the consistency of oral evidence we have heard, it is at least
clear that there was a serious break down in trust and communication at the
RBH between some clinicians and these families, which gave rise to a belief
by parents that discrimination took place."
- "Finally, we wish to state that, in presenting our conclusions,
we believe that throughout the period of review the doctors acted
in good faith believing that their actions were in the best interests of
the children concerned. Although we found no evidence of discrimination in
the treatment delivered, it is essential for the RBH to take steps to assure
the public that its services for all children are open, transparent, and
free from discrimination." [The above 3 quotes
are from the Summary report p 42].
The
panel appears to have had some difficulty in ascertaining whether any discrimination
against these particular children took place.
Recommendations
8. Recommendations:
The fact that 119 recommendations were made, most of which applied to
the Trust, indicates that all was not well at both hospitals. All of these
recommendations are welcome, and if applied should lead to an improvement
of standards at the Trust and, indeed, throughout the NHS. A few are highlighted
below:
- (3) " The Trust
considers providing tape recordings of key consultations about diagnosis
and treatment options , with a detailed follow up letter being sent out in
20 days confirming what was said."[SIN's comments:
This should be standard practice throughout the NHS for all patients
participating in key consultations regarding diagnosis and treatment options.
This would protect both doctors and patients and prevent any future
misunderstandings .]
- (4)" The Trust ensures that letters to GPs are
copied to parents so that they can see any changes in the diagnosis or planned
treatment." [Sin's comments: this too should
be standard practice throughout the NHS for all patients - after all, the
illness belongs to the patient!]
- (12)" The Trust should, in addition to the existing comprehensive
consent procedure, prepare succinct and explicit guidelines making clear
to all medical staff that:
(a) "
Consent must be real and informed
(b) Consent
must be obtained by the consultant or a senior doctor familiar with the child's
case, who is competent to undertake the preferred treatment option
- (c)
Consent should be sought, except in an emergency , at a pre-arranged
time and in a place where reasonable and quiet can be provided." SIN's comments: Should not these Consent Guidelines be provided
to all patients and their families? Surely these additional guidelines should
already be standard practice?
- (27)" The Trust reviews its policy of excluding parents
from Ward Rounds and ensures that, as a matter of general policy, parents
who are present in the hospital when a Ward Round takes place are welcome
to attend." [SIN's comments: it is shocking
that parents have ever been excluded from Ward Rounds, since they are responsible
for the child and should be involved in all decision making. Also, SIN believes
that adult patients should have the option of requesting that a friend or
relative is present during a Ward Round. A sick patient is very vulnerable
and can easily be intimidated when outnumbered by medical staff.]
- (53)" The Trust puts in place arrangements for parents
to be given access to a computer and helped to use the Internet for the purpose
of obtaining further information on their child's condition. This should
include guidance on how to find and evaluate medical information." [SIN comments: this suggestion is applauded and should be
introduced throughout the NHS. Knowledge is a major source of patient
empowerment with one proviso: that the information gained from the Internet
by the patient is respected by the consultant responsible for that individual's
care].
- (55) " The Trust ensures that all cases of children requiring
surgery at Harefield Hospital are fully discussed by the surgeon with other
members of the clinical team prior to a decision being made to proceed with
surgery."[ SIN's comments: Although
Harefield's paediatric surgical unit was closed in the Spring of this year
(2001), it would be hoped that this would be a basic requirement for any
surgeon, whether paediatric or not.]
- Conclusion
(9)SIN agrees with Josephine Ocloo's analysis of the Evans' Report,
that it was indeed an "institutionalised cover-up" . Although the
Panel purported to carry out an independent investigation into the serious
concerns of the parents, behind the scenes, unknown to these families,
representatives from several other agencies which have a major role to play
in maintaining standards within the NHS, were involved. The parents
had no opportunity to liaise personally with these representatives
, to present tthem with their evidence or to challenge their opinions,
having had no sighting of their input to this Inquiry. This is considered
by SIN to be a major dis-empowerment of the families involved in the Inquiry.
At the very least, surely, their written submissions should have been published
as part of this Report? The involvement of these individuals, together with
evidence of the Trust's clinicians appears to have allowed the Panel in the
Report to down grade the evidence submitted by the families. This has
meant that other avenues for redress in theory have been precluded.
[ See section 4 above "The Thwarting of Natural Justice].
At the Press Conference on 2nd. April, 20001, Ruth Evans pointed
out that the Panel had found evidence of paternalistic attitudes. SIN is
concerned by the Panel's attitude to parental evidence
as revealed by the following quoted statement from the Report :" We
treated what the parents told us not as *prima facie evidence
but as sincere and genuinely felt expressions of concern about what went
wrong with their child's care and treatment. While what parents told us was
not attributable, that does not mean it was inaccurate."
This rather muddled statement appears to insinuate that
the parents' evidence, even when backed up with the child's medical records,
was given less credence and indeed, would have been disregarded if
such evidence were rebutted by the Trust's clinician. If the panel
did not treat parents' (accurate) evidence as prima facie evidence,
then all written and verbal statements to the effect that no case should
be submitted to the GMC, or that none had grounds for medical negligence
, would appear to be null and void. In SIN's opinion, such statements should,
in order that natural justice prevails, be publicly retracted.
*"prima facie" evidence means that on the face of it the evidence
suggests that there is a case to answer.
For those interested, further information can be obtained
from the Trust's website:www.rbh.nthames.nhs.uk
*******************************
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