Dr Rob Hendry - Medical Protection Society

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6 HEADLINES AND DEADLINES UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk NHS awaits changes to NEWS IN BRIEF Constitution on reporting concerns Health Bill scrutinised Changes to the NHS Constitution and its Handbook are imminent following the closure of a consultation, which set about tackling the “fear and secrecy” inherent in the NHS. The amendments will tighten the system to ensure that all NHS staff can report concerns freely when concerned about threats to patient safety. The move was instigated by the health secretary Andrew Lansley to prevent isolated failures such as those investigated at Mid- Staffordshire NHS Foundation Trust. He said: “The NHS Constitution must be brought up to date to enshrine the rights of staff. Staff should be working in an environment where they feel able to voice “The prevailing presumption was one of safety rather than of risk,” said Professor Bren Neale, describing the tragic death of her husband Dr John Hubley at an Independent Sector Treatment Centre in 2007. Professor Neale was sharing her experiences of clinical negligence at a unique conference called Risky Business, organised by Dr Allan Goldman from Great Ormond Street Hospital and a team of international safety experts. The conference provides a forum for health professionals to explore risk by learning lessons from the successes and failures of those working in different industries and walks of life. A study conducted in the Netherlands has found that the use of a surgical safety checklist significantly reduces surgical morbidity and mortality. The study, published in the New England Journal of Medicine (NEJM) on 10 November, says that the World Health Organisation (WHO) Surgical Safety Checklist reduced surgery complications by more than a third, with deaths reduced by concerns and know that their concerns will be taken seriously. Staff will be expected to raise concerns and employers must support them and investigate where necessary. That means better patient care and better staff morale.” This consultation follows significant progress already made on whistleblowing. On 25 June 2010 new guidance was published for the NHS, developed through the Social Partnership Forum (SPF) with support from the independent whistleblowing charity Public Concern at Work. Access this guidance at: www.dh.gov.uk/en/ Publicationsandstatistics/Publications EVENT FOCUS: Risky Business 2010 One may ask what lessons could be learned from F1 team Principal Ross Brawn, or Dean Richards, former director of Harlequins rugby team? But both presenters delivered hard-hitting messages about teamwork – give individuals what they need to be the best – and making mistakes – hold your hands up if you make a mistake. Other highlights included a debate on whether litigation improves patient safety, and a session learning from defining moments such as the 7/7 bombings and the BP Deepwater Horizon. A recorded live stream of the conference is available at www.risky-business.com. Surgical checklist saves lives NICE GUIDANCE WATCH This is a selection of the guidance NICE is expected to publish over the next few months, although publication dates may be subject to change. almost half. The study was conducted from October 2007 to March 2009. The NPSA has led on the checklist’s implementation in England and Wales. Dr Suzette Woodward, Director of Patient Safety at the NPSA, said: “The Netherlands study clearly validates what we know about the use of a surgical safety checklist, that it significantly reduces surgical morbidity and mortality.” in Parliament January Aripiprazole for the treatment of schizophrenia in people aged 15-17 The Health Bill will begin to pass its way through Parliament this year. The Bill, published late last year following a lengthy consultation on the proposals, sets out the biggest change to the NHS in decades. The BMA estimates that the Bill will become an Act by July this year. GMC due to publish audiovisual guidance The GMC is due to update its guidance on using audio and visual recordings of patients. To access the updated guidance when it becomes available, visit www.gmc-uk. org/guidance/index.asp Watch out for ■ May – GMC fitness to practise stats published Changes for NICE The Department of Health has announced some changes to the role of NICE in assessing new medications for the UK. From 2014, a valuebased pricing system will replace NICE’s binding “recommends” or “does not recommend” notice to the NHS, although NICE will continue to appraise new drugs. This system means it is likely that the government will negotiate directly with the pharmaceutical industry on price, after receiving NICE’s assessment. Health minister Lord Howe, who announced the changes, stressed the ongoing importance of NICE. February A clinical guideline on alcohol use disorders: management of alcohol dependence The diagnosis and assessment of food allergy in children and young people in primary care and community settings March Golimumab for the treatment of rheumatoid arthritis (after failure of previous antirheumatic drugs) Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease. This is a review of existing NICE guidance April First ever national guidelines on the recognition and initial management of ovarian cancer
Images courtesy of The National Archives & Wikipedia Commons A potted history of medicine Throughout history, doctors have treated patients, and doctors have made mistakes. Casebook has delved deep into the past to see what doctors used to get away with These cases are based on publications within the 19th Century Poor Law Union and Workhouse Records and the Royal Navy Medical Officer’s Journals – recently opened by the National Archives in the United Kingdom. Acid attack – a case of vicarious liability? Thomas S Fletcher was a surgeon at the Bromsgrove Workhouse, Worcestershire. One of his patients, young Henry Cartwright, died in 1842 after being immersed in potassium sulphate – in an attempt to cure “the itch”, or scabies. The postmortem result described how his skin was inflamed and scalded. Dr Fletcher was found to have failed to supervise nurse Sarah Chambers, who placed the young boy in the acid. Was Dr Fletcher vicariously liable? Although the incident was investigated, Dr Fletcher was not struck off, owing to his “previous unblemished professional record, and kind attention to pauper patients”. Letter from Ralph Docker, Coroner for Worcestershire to the Poor Law Commission, 17 February 1842. National Archives: Ref MH 12/13905/153. Laudanum overdose – learning from adverse events Mrs Elizabeth Galloway of Newcastle was suffering from inflammation of the bowels. To aid her recovery, she was given a tincture of rhubarb, which was collected from the druggist, Mr Tinn, by her young daughter. Unfortunately, the druggist mixed up the wrong remedy; the cup contained laudanum rather than rhubarb. Mrs Galloway immediately worsened and the doctor was called. Her stomach was pumped, first with a mixture of brandy and ammonia, followed by water and strong coffee, but she later died. At the ensuing inquest, Mr Tinn was found to have administered the drug in an act of human error: “One of those mistakes to which all men were liable, however much they were to be deplored.” In an early example of learning from adverse events, the inquest recommended that in future, druggists should store poison separately from other medicines. BMJ Archives: Death from Laudanum: Given by Mistake, Prov Med Surg J, 1-1:334-335 (1841) Deadly nightshade In a similar case, Mary Ramshaw, from Northallerton, was knocked down and severely fractured her thigh. Dr Lumley was called, and prescribed both a mixture to take and an embrocation. Mrs Ramshaw’s daughter unfortunately administered the medicine from the wrong bottle and Mrs Ramshaw instantly began to convulse. Ten minutes later, she died. The embrocation she had accidentally been given contained belladonna (deadly nightshade). The inquest heard how Dr Lumley did not place any labels on the bottle to warn of its poisonous nature. The jury recorded in their verdict that “the medical attendant was not free of blame in the matter”, and stressed the importance of dispensing poisonous mixtures in roughened or fluted bottles, as well as ensuring appropriate labelling in future. BMJ Archives: Fatal Mistakes in Taking Medicine, 2:1120- 1132 (1885) Under the influence A woman died following childbirth in 1839. The postmortem revealed that the fatal injuries were caused by the unskilled use of “some instrument” during delivery. The surgeon was thought to have been intoxicated during the delivery and was charged with manslaughter – but was later acquitted. The Times, 12 April 1839. Ferner RE, McDowell S, Doctors charged with manslaughter in the course of medical practice, 1795-2005, Journal of the Royal Society of Medicine, Vol.99 (2006). Errors in time Medical negligence has been described as “a space, more than a thing” – a shifting, malleable interaction between time and place and, to varying degrees, society, law, ethics, medical practice, health professionals, and patients. 1 What is perhaps most interesting about the extracts from the medical archives is that the definition of medical negligence hasn’t shifted all that much. While the prescribed treatments and remedies mentioned may be different, the same high expectations of professional conduct, skill and integrity from doctors remain. Some of the issues are strikingly contemporary: vicarious liability, prescribing errors, significant event audits following adverse events, professional misconduct and, of course, human error. 1 Price, K, Towards a history of medical negligence, The Lancet, 375:9710, 192-193 (2010). Compiled by Sarah Whitehouse 7 ARTICLE UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk
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Page 17 and 18: Missed opportunities Daniel Miss R
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Dr Rob Hendry - Medical Protection Society

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