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Where have many patients
gone,
Where have damaged patients
gone,
Where have many patients
gone,
Where have all the good docs
gone,
Where have all the good docs
gone,
*"somatised" comes from the word "psychosomatic" and means that patients are imagining their physical symptoms. Almost every iatrogenic patient will at some time have had the suggestion made that they should see a psychiatrist; particularly if the damage is serious and a "cover-up" has started. ** Dr. Stephen Bolsin who was the doctor with courage and integrity who exposed the poor standards of paediatric cardiac surgery at the Bristol Royal Infirmary, thereby saving the lives of babies and children. It is understood that he was effectively blacklisted in the UK having unsucessfully applied for posts at the City Hospital, Nottingham and Southampton hospital, he found he was unable to obtain another post. Hence, he had to emigrate to Australia with his family where he has been highly appreciated. Ironically, as Britain lost to Australia one of its best and finest doctors because of the ***blame heaped on him by his fellow doctors for having dared to break ranks and put patient protection before allegiance to his colleagues; so Britain imported from Australia a paediatric cardiac surgeon to take over at the Bristol Royal Infirmary. Presumably, there was no other such surgeon suitable in this country! Since this surgeon has been at the BRI the death rate in the unit has been reduced to very low single figures. ***We were appalled to hear the comments reported to have been made about Dr. Bolsin by British doctors on a Radio 4 programme. Apparently an Australian colleague of Dr. Bolsin had been attending a medical conference in Europe, and when British doctors understood he was working with Dr. Bolsin, asked this doctor if he were aware that he was working with the most hated doctor in Britain. When Dr. Bolsin heard what had been said, he replied, that all he had wished to do was to save the lives of babies and children. If that caused British doctors to hate him then, surely, there must be something wrong with the mentality of these doctors! SIN
suggests that Dr. Bolsin's name appears in the next New Years Honours
list. Gillian wrote to her MP with this suggestion in 1998, and received
a letter from Mr. Alan Milburn stating that
Return to Our Comments20 th August, 2001 THE LAUNCHING OF THE NHS " NO BLAME CULTURE" - So what's new, pussy cat? For more than a year there
has been promotion of the idea of establishing a "No Blame Culture"
in the NHS which appears to have had the full backing of the Medical
Profession. Eventually , on Wednesday, 27th June 2001 a joint statement
was issued signed by Mr. Alan Milburn, Secretary of State for Health
for the Department of Health , the Chief Medical Officer, representatives
of the Royal Colleges, the BMA, the Chief Executive of the
NHS and the GMC, to quote:
SIN
has had difficulty in defining "honest failure ". What is "honest
failure" as opposed to "dishonest failure" ?
SIN believes that for the last 50 years a "no blame culture" has been endemic throughout the NHS. For patients, who are the best whistle blowers when things go wrong, have found that their justifiable concerns have not been addressed nor have they been able to establish any accountability or the truth as to the medical damage sustained, and many have been left without genuine specialist care. The present system has always protected the doctor at the expense of the patient:
The Chief Executives
of Trusts and Health Authorities have always had the necessary sanctions
at their disposal to discipline a poorly performing doctor ;or to
send such a doctor to the GMC for clinical negligence; or to instigate
a criminal investigation; or to set up a Formal Independent Inquiry
into an adverse medical incident whenever a patient lodges a serious complaint
against a health professional. Rarely, if ever, is any of these options
taken.
Patients attempt to go to
the Department of Health itself in order to ask the Secretary of
State to set up an Inquiry if they believe that their medical care
has been seriously substandard and that indeed medical care has been denied,
which is unlawful. Such requests are sent to the Regional Offices
and here, civil servants, simply rely on what the Trusts and the Health
Authorities state. Never is the patient allowed to make personal
representation and in the experience of the damaged patients no one, either
at the Trusts, Health Authorities or Regional Offices are prepared to undergo
a thorough, impartial and accurate investigation of patients' serious complaints.
In
fact the evidence suggests that the Trust/ Health Authorities and the Regional
Offices have only one aim and that is to put as many secure lids
as possible on serious medical errors, because as Lord Woolf conceded
in his lecture: the major goal of the NHS since its
inception , was to keep down compensation paid to patients through
poor medical practice, regardless of this being a gross injustice
to damaged patients.
A few patients attempt to
use the GMC to expose sub-standard and malpracticing doctors but with very
little success, since the percentage of doctors having sanctions taken
against them is extremely low (e.g. in one year 13 doctors out of
the 2000 complaints received were struck off (0.65 %), and then for
only 10 months when they could re-apply for registration). This is
a disgracefully low figure when one considers that 68,000 unnecessary deaths
are occurring per year and 170, 000 patients are left permanently
damaged annually by medical errors. It would be naive, taking these
figures into account, to believe that this tiny proportion of 13
in one year reflected the true number of negligent and malfunctioning
doctors. Certainly, the GMC has lost credibility and public confidence.
Surely, what has been
described above, to all intents and purposes, has amounted to a NO BLAME
CULTURE FOR THE MEDICAL PROFESSIONS , NHS MANAGERS & CIVIL SERVANTS.????
********
SIN takes exception to the
use of emotive words such as "blame" and "retribution". The use of such
words serves no useful purpose, in our opinion.
Are the Secretary of State for Health, the BMA, the GMC and the D.o.H. really advocating that they want a culture of no responsibility and no sanctions when things go seriously wrong in the NHS? What role would the GMC have in such a culture? This document was signed without any consultation with patients. How can this be squared with the Sec. of State for Health's repeated statements of the need for patient empowerment and patient participation?? Nor was there any mention of the obligation to inform the patient who had been a victim of a medical mistake. Sin and, we believe, most patients wish to see a culture of personal responsibility and accountability with sensible remedial actions/ sanctions when things go seriously wrong, with patients being fully informed. Sensible sanctions can be an effective way of encouraging people to conform to a code of conduct. According to Prof. Alberti, President of the Royal College of Physicians, a report from Chesterfield showed 150% increase in error reporting by threats of disciplinary action! Although Prof. Alberti said: "apparently effective, but perhaps not the best approach", the damaged patient may think otherwise. SIN believes
that when an individual health professional is unwilling to report
a medical error or is unaware that an error has occurred, and
when informed continues to be unwilling to acknowledge it,
then it should be mandatory that
all other health professionals,
aware of the error, report it immediately.
********
1.To continue to show a commitment from the top to implementing the programme of quality assurance and quality improvement. 2. To take every opportunity to involve patients (sic)and their representatives in decisions about their own care and in the planning and design of services. 3. To work towards providing valid, reliable, up to date information on the quality of health services. 4. To work together in determining clinical priorities. 5. To create a culture within the NHS which is open and participative, where learning, and evaluation are prominent and which recognises safety and the needs of patients as paramount 6. To recognise that in a service as large as the NHS things will sometimes go wrong. Without lessening commitment to safety and public accountability of these services, to recognise that honest failure should not be responded to primarily by blame and retribution, but by learning and by a drive to reduce risks for future patients. . 7.To recognise that the professions and the Government share a common interest and commitment to improving the quality of services for patients. Minor disagreements on points of details must not be allowed to obscure this common goal. SIN believes that there should be two additional pledges: 8. To ensure that the patient is fully informed if an error has occurred, and given an accurate assessment of any damage sustained..[ see SIN's "Aims & Objectives no.5] 9. To recognise the rights of patients themselves to report medical errors to the new national system of reporting mistakes and near misses [ The National Patient Safety Agency] This Agency , as reported in both the Guardian & the Independent, 18th April, began work in July 2001. SIN hopes that the long standing "no blame culture" which has existed until now, will be replaced by one of openness and honesty, underpinned by accountability and personal responsibility throughout the Heath Service. Certainly this pledge suggests that, in spite of some couched language, the stage is set for a change of approach to medical mistakes and near misses. The proof of the pudding, for the iatrogenic patient, will be in the eating!
CULTURE OF COVER-UP IN THE NHS A culture of cover-up IS a "no blame culture" without accountability. What follows is verbal confirmation that this was the case pre-Bristol Babies Scandal. "TODAY" PROGRAMME,
RADIO 4, THURSDAY 22ND. OCTOBER 1998, 7.18AM
Sue MacGegor interviewsWinston Peters, President of Hospital Consultants & Specialists Association Sue Mac:.....Winston Peters, who is President of the Hospital Consultants & Specialists Association. Mr Peters, you know that there are, and obviously from people who are related in some way to the victims - heart felt hopes that there will be a culture change. What can you say about that? Winston P..... The Profession has a very positive desire to see patient care improved. A few years ago *"whistle Blowers" were condemned by managers, by doctors and by government. **Now they are being heard early, action is being taken. But you have to remember that THERE WAS A PREVIOUS CULTURE WHERE THESE PEOPLE WERE SUPPRESSED [Unfortunately, our members are finding that nothing has changed post - Bristol] Sue Mac: Well, there was a culture where the medical Profession policed itself, wasn't there? And lay people who had an interest in matters like this were often pushed to one side? Winston P: THAT IS TRUE.*** The profession is working with the government to develop institutes which produce guidelines for clinical excellence - these will be policed by another organisation that has wide ranging powers and directly reports to the Secretary of State.......there is a 10 year programme starting now, in fact it started a year or so ago, to regulate the way the profession is monitored and the profession is taking steps itself....... Footnotes:
** This is simply not true eg.1999 & 2000 Prof.Peter Dawson,& Dr. Anil Jain. Whistle blowing doctors ( & nurses) are still suffering and are not being heard ***Many statements are being made, but few are being implemented on the ground! ********
With the need to report and record adverse incidents within the medical profession comparisons have been drawn with the aviation industry where such reporting of adverse incidents is standard practice. However, the pilots and aviation personnel have much more incentive to report such incidences given that their own lives are as much at risk as the passengers who fly with them. This is obviously not the case with the medical profession. And indeed, the past scandals of Rodney Ledward, Richard Neale the Bristol paediatric cardiac surgeons revealed that many of their colleagues and nurses were fully aware for years of adverse incidents relating to these doctors and yet failed to report these matters of grave concern to the appropriate body, thereby colluding with and being responsible for the unnecessary deaths and damage of many patients. It is estimated that 68,000 deaths per year occur in our hospitals due to medical errors. It is claimed that half of these patients would have died anyway because they were terminally ill, however, that still leaves 34,000 who die each year unnecessarily! This amounts to two jumbo jets crashing every week ( not to mention the 170,000 estimated permanentlly damaged patients per year). If this were to happen in the aviation industry people would be in the streets and demanding an overhaul of this industry!. Therefore, the analogy with the aviation industry has limited usefulness. Perhaps a better analogy would be with the car repair business. Certainly if 68, 000 people were loosing their lives on the roads every year because of errors made by car mechanics, then would the victims' families and the Dept. of Transport be condoning and signing up for a no blame culture? ( There are between 3000 and 4000 deaths on our roads annually, very few being reported as due to poor or incompetently carried out mechanical repairs).However, great efforts are made in advertising etc. to reduce this number and a proper investigation, with all witnesses' testimonies carefully logged, is carried out every time one occurs, to establish accountability, with action being taken where appropriate against the responsible parties. This would include any mechanic whose faulty repair was judged to have caused the accident. ******** |
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