Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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The criminalisation of fatal medical mistakes
- Kieran A McCaul (14 November 2003)
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Increasingly negative environment for doctors in the UK
- David A.C. Maclachlan (14 November 2003)
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A further sad reflection on our society?
- Peter J Davis (14 November 2003)
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The Indian Story: Neck that fits the noose
- Sujay K Shad (14 November 2003)
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Only Junior Doctors to the 'Slaughter House'?
- Jay Ilangaratne (14 November 2003)
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Does racism motivate prosecution of fatal medical mistakes?
- Caroline L Litman (15 November 2003)
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Criminalisation of doctors - does it encourage defensive medicine?
- Shehnaaz Jivraj (15 November 2003)
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Who are the real criminals?
- Himanshu Patel (16 November 2003)
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Criminalisation of Medical Errors or Decriminalisation of Racims?
- Umesh Prabhu (16 November 2003)
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Is there a solution for medical errors?
- Giusto Giusti, Università di Roma "Tor Vergata" (16 November 2003)
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why just them?
- archana desurkar, Melrose, Roxburghshire, TD6 9BS (17 November 2003)
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Penalties bear a cost
- Stan Goldstein (17 November 2003)
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Criminalisation of fatal medical mistakes: who is the real offendant?
- Jonathan Punt (17 November 2003)
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works both ways
- manan vasenwala md, mrcp (uk) (17 November 2003)
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Re: works both ways
- Jayaprakash Gosalakkal (17 November 2003)
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What about the patient
- Janet M Pinder (17 November 2003)
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Society should stop this trend before it is too late!
- Satyanarayan Hegde, London W12 0RE (17 November 2003)
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A solicitor responds
- Paul Balen (17 November 2003)
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Defensive General Practice
- Francesco Carelli (18 November 2003)
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Media and Mass Run Criminalisation Needs Ending
- Anil Pandit (18 November 2003)
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The criminalisation of fatal healthcare mistakes
- Anthony R Cox (18 November 2003)
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Fair and Just Blame?
- Jeffrey C McILwain (19 November 2003)
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Re:A solicitor responds--is this true?
- Jay Ilangaratne (19 November 2003)
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Re: Re:A solicitor responds--is this true?
- Penny Mellor (20 November 2003)
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Litigation and criminal proceedings do not improve outcome
- Richard G Fiddian-Green (20 November 2003)
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What's in a name?
- Kamal Kumar Mahawar (20 November 2003)
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Stop the grizzling
- Gurli Bagnall (21 November 2003)
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In Defence Of Lawyers 'Touting For Business'
- Joseph . C . Obi (21 November 2003)
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Code for Crown Prosecutors determines prosecutions
- Nigel Dudley (21 November 2003)
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Negligence, rashness, malpractice or misadventure?
- Dr BR Pal (21 November 2003)
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Re: What about the patient
- Declan P Fox (21 November 2003)
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Re: Stop the grizzling
- Anthony R Cox (23 November 2003)
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Re: Increasingly negative environment for doctors in the UK
- Jenny L Robertson (23 November 2003)
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Re: Stop the grizzling
- CA Johnson (24 November 2003)
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Re: Re: Stop the grizzling
- Gurli Bagnall (24 November 2003)
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Look to the System
- Simon P Kelly, on behalf of NPSA Clinical Specialty Advisers - see list below (24 November 2003)
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Don’t hurt the individuals to change the system
- Christopher I. Price (24 November 2003)
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Re: In Defence Of Lawyers 'Touting For Business'
- Peter Morrell (25 November 2003)
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Fatal medical mistakes - is there a genetic predisposition?
- Jai Shankar (26 November 2003)
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Criminalization of medical errors
- Ediriweera B.R., Desapriya (27 November 2003)
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Doctors losing Image of Goodness
- Dr. S. K. Roy Chaudhary (28 November 2003)
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Pull up your socks, or have them pulled up for you!
- Russell D. Lutchman (29 November 2003)
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Legal mania
- Andrew D Beggs (29 November 2003)
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Re: Pull up your socks, or have them pulled up for you!
- Jay Ilangaratne (30 November 2003)
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Re: Pull up your socks, or have them pulled up for you!
- Alex Psirides (1 December 2003)
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A solicitor gloats
- Andrew Al-Adwani (1 December 2003)
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Re: Legal mania
- Gurli Bagnall (2 December 2003)
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Suck my socks
- Hari D Maharajh (2 December 2003)
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The long drop (aka. a medical career)
- Steven Ford (3 December 2003)
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Re: Suck my socks
- Gurli Bagnall (3 December 2003)
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let there be no cerebrovascular accidents
- Vadivelu Vasanthakumar (3 December 2003)
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I would prefer not to suck anyone's socks...
- Alex Psirides (4 December 2003)
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Re: Re: Suck my socks- Racial profiling, shame and medical criminalization sucks.
- Hari D. Maharajh (4 December 2003)
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In dubio contra medicum
- Giuseppe Vetrugno, Achille M. Luongo, Massimo Volpe, Fabrizio Celani, Fabio De Giorgio, Fidelia Cascini, Leonardo Scorcelletti, and Ernesto D'Aloja (4 December 2003)
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Re: The long drop (aka. a medical career)
- Mark Struthers (4 December 2003)
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In response to Alex Psirides
- Gurli Bagnall (4 December 2003)
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Re: Pull up your socks, or have them pulled up for you!
- Catherine Clarke (4 December 2003)
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Re: Erratum
- Theo H Fenton (5 December 2003)
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There but for the grace of God go all of us
- Damian Conway (5 December 2003)
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Green ink
- Gordon G Anderson (5 December 2003)
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Re: JAMA citation
- alan j carson (5 December 2003)
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Re: Re: The long drop (aka. a medical career)
- Steven Ford (5 December 2003)
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A-I, Negligence and Revalidation.
- Russell D. Lutchman (5 December 2003)
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In response to Fenton and Carson
- Gurli Bagnall (5 December 2003)
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Re: In response to Fenton and Carson
- Alex Psirides (6 December 2003)
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Two cultures
- Michael O'Donnell (6 December 2003)
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Re: Green ink
- Catherine Clarke (6 December 2003)
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Re: Re: Green ink
- Mark Struthers (7 December 2003)
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Re: A-I, Negligence and Revalidation.
- Catherine Clarke (7 December 2003)
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A sign of our times
- Amitava Banerjee (18 December 2003)
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System failure should not be punished by a custodial sentence
- W. Hamish Wallace (3 January 2004)
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The scene in India
- Jerry Varghese (15 January 2004)
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Kieran A McCaul, Research Fellow School of Population Health, University of Western Australia, Crawley 6009, Western Australia
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While reading Holbrook’s editorial1 I was truck by the names of the doctors who had faced criminal manslaughter charges - Feda Mulhem, Hiral Hazari, Rajeev Srivastava, Amir Mizra, and Huraise Syed. Now I’m sitting here on the other side of the world without any intimate knowledge of the British health care system and I realise that this is five out what appear to be 23 cases since 1990, but if we assume that these events were accidents – random events – then do I conclude that a large proportion of doctors practising in British hospitals are not ethnically Anglo-Saxon. If that is not the case, does it indicate that doctors who are not ethnically Anglo-Saxon are more prone to committing medical errors that result in the death of a patient. Or does it indicate that doctors who are not ethnically Anglo-Saxon and who make medical errors that result in the death of a patient, are more likely to be charged with manslaughter. 1. Holbrook J. The criminalisation of fatal medical mistakes. BMJ 2003;327(7424):1118-1119. Competing interests: None declared |
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David A.C. Maclachlan, Consultant Physician and Rheumatologist Kantonales Spital, Werdstrasse 1, CH-9410 Heiden, Switzerland
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As a British-trained doctor working in Switzerland, I have become increasingly aware of the negative environment in which doctors in the UK have to work through reading about such cases and other health scandals in the medical and lay press. It seems to me that individual doctors are made scapegoats for failures in the system. My impression is that civil cases against doctors are much rarer in continental Europe than in the UK (despite working for over 12 years in Germany and Switzerland, I have never been aware of any colleague being involved in any form fo civil action) and criminal procedings are virtually unheard of. Doctors in the United Kingdom also seem to be increasingly suspended for minor reasons or on the basis of weak evidence. This is also exceedingly rare in Germany or Switzerland. My impression is that this treatment of doctors will only excacerbate the recruitment problem as fewer and fewer young people opt for the medical profession and more and more emigrate or pursue careers outside medicine. This crisis needs to be tackled now. Systems need to be changed to avoid such errors occuring in the future. With regard to the mistaken intrathecal injection of vincristine, surely it must be possible to devise a mechanism making it impossible to connect the syringe containing vincristine to the the LP needle. Due to different nozzles on petrol pumps, it is virtually impossible to fill a car with leaded fuel if the car requires unleaded petrol. Competing interests: None declared |
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Peter J Davis, Consultant Paediatric Intensivist Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ
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Editor The editorial by Holbrook highlights the current highly litigious nature of the UK and its response to medical mistakes, as it follows in the path of the United States. It would seem that the prevailing public mood will no longer accept that "to err is human". As a profession it is therefore imperative that we strengthen our approach to risk management to prevent individual doctors, most often juniors, being hauled into court on a criminal charge for their final part in a greater systematic error, for which they have become the fall guy. I would also hope that I am not alone in my concern as I read the names of the various doctors mentioned in the article, that all of them had ethnic non-Anglicised names. Is this coincidence in terms of the cases highlighted, or are ethnic doctors more likely to face criminal charges? Is this possibly a wider failing of our training of doctors from outside of the UK to the perils of practice in this country, or more worringly still, a further sad reflection on our society, in terms of racial prejudice? Competing interests: None declared |
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Sujay K Shad, LAT SpR Harefield Hospital Harefield, UB9 6JY
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There is an Indian story that is rather long but the message is rather clear. Old times;a GURU and his desciple; are on a tour of the various countries. They come across a country with a big banner pronouncing (this is the) ''Dodgy country with a strange King, and here every item sells for the same price whether it is ordinary grub or dry fuits''. It is difficult to translate the punch line of the title. The desciple gets excited by the prospect of cheap goodies and decides that this is the place to be. The GURU on the other hand dismisses the place as lunatic and following an argument they part ways. GURU goes outside the countries border while the desciple enjoys the luxuries. Come morning and there is a big crowd in the marketplace because the Strange King is going to deliver justice. A crime had been committed, criminal apprehended and case presented to the King who goes through the case in public and delivers his verdict. Death by hanging. As it happens in a lot of stories the noose is loose and the criminal escapes justice.It is now accepted that fate has intervened on behalf of the criminal. However a crime has been committed, so a punishment must be delivered. So they set about finding the neck that fits the noose and they find the desciple just right and that is done. The media, justice systems, press etc. will always look for a great story, headline news and in case of some judges record punishments will be granted so their names appear in press. The public demands and gets justice but frequently fate is on the side of the real crooks and somebody else just fits the noose. Dr. Kelly/ Dr. Mulhem. Whatever happened to the systems approach, of the various airline models that are being touted to us everyday, of not apportioning individual blame so that errors are reported to the NPSB in a blame free culture,to improve patient safety in the context of Clinical Governance. It is a long road ahead. Competing interests: None declared |
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Jay Ilangaratne, Founder Medical-Journals.com
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Why is it only the junior doctor is charged commonly, when the ultimate responsibility,at all times, lies with the patient's named Consultant? In Dr Mulhem's case it was reported that "the senior house officer had been in the department for only five weeks, and neither doctor had been given training in administering cytotoxic drugs"(1). So, was the Consultant in charge of those two doctors completely innocent, and did not play any part leading to this tragedy? Therefore,one wonders what criteria are used by the Crown Prosecution Service('CPS') when determining the legal responsibility for such fatal events in the NHS.Of course, in cases of corporate manslaughter, as as happened in recent rail disasters, charges are brought not only against those who were directly involved, but also against directors/executives/manager of the organisation concerned. So is it the CPS that had developed this trend of exonerating the NHS Consultant in-charge, but instead go for the 'jugular' of the junior doctor, often coming from an ethnic minority? Or does the law formally discharges the burden on the responsible Consultant for the acts/omissions of his/her junior doctors? References (1)Dyer C. Doctor sentenced for manslaughter of leukaemia patient.BMJ 2003;327:697. Competing interests: None declared |
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Caroline L Litman, staff grade general adult psychiatry Clarendon House Mental Health Resource Centre'28 West Street,Dorking,Surrey RH4 1QJ
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I applaud Jon Holbrooks stance on the prosecution of fatal medical mistakes.Unfortunately the trend to prosecute seems set to rise. But perhaps as a British caucasian female I needn't worry about facing prosecution if I make a disastrous mistake in the future.It is alarming that all 5 doctors reported in the article have names presumably from ethnic minorities (Feda Mulhelm,Hiral Hazari,Rajeev Srivastava,Amir Mizra and Huraise Syed) It seems there is a serious bias in the selection of these individuals. I cannot believe that all serious medical mistakes are committed by this small group of doctors alone.My unpalatable conclusion is that race is somehow implicated. It would be interesting to know how many similar cases involving,lets say,John Brown and Jane Smith ,never made it as far as the solicitors office. It is human nature to want to find someone to blame when things go wrong,but usually common sense and mutual respect and understanding allow mistakes(however severe) to be dealt with,without the need for criminal prosecution.Why did these particular cases go so far and what measures be put in place to protect ethnic doctors, who quite clearly are infinately more at risk than the rest of us? Competing interests: None declared |
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Shehnaaz Jivraj, SpR Obstetrics and Gynaecology Jessop Wing, Tree Root Walk, Sheffield, S10 2SF
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Dr McCaul's letter refelected my thoughts as I read the editorial - the criminalisation of fatal medical mistakes and I applaud Dr McCaul for his response from Australia. I could not help notice a common factor in all the names stated in Mr Holbrook's editorial - Feda Mulhem, Hiral Hazrai, Rajeev Srivastava, Amir Mirza and Huraise Syed. These are all foreign sounding names. I am a British trained doctor. I graduated from a UK university in 1995 and have since worked within the NHS in the UK. A large proportion of my training has been through teaching by more experienced foreign doctors working within the NHS who have been perfectly competent. Also noticeable is that, practising defensive medicine is becoming more rife, but increasingly we are encouraged by senior colleagues to do what is best for the patient rather than practise medicine defensively. Defensive in our practise or not, we are all human and hence fallible. If by probablity, a foreign sounding doctor is more likely to be charged with negligence, practising defensive medicine is only going to be encouraged. References: Holbrook J. The criminalisation of fatal medical mistakes. BMJ 2003;327:1118-9 Competing interests: None declared |
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Himanshu Patel, Pharmaceutical Physician Synergy PMC Limited, Pharmaceutical Medical Consultants, Hampshire, SO53 3HH
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Sir, It is more than a sheer coincidence that all of the names cited in Jon Holbrook's Editorial refer to junior doctors in training and are from the ethnic minorities. Whilst, we may not be privy to the details surrounding the individual cases cited, such cases probably only represent the thin edge of what is yet to come. However, the inevitability of this should not come as a great surprise to any of us given the recent debates regarding the "Rise if trust doctors"(1), many of who are recruited from the ethnic minorities,and the virtual lack of training and supervission afforded to these unfortunate doctors (...or more correctly work-horses). Indeed, it is presumptious for any of us to apportion blame solely to a more litigious society without first casting an introspective eye over the tacit acceptance, by senior doctors, of the dangerous working conditions faced by trust doctors. We should all consider where the real seeds of such medical "criminality" lies; I would hazard a guess that one would not have to look too far outside the boardrooms of various PCTs around the United Kingdom. References: (1)BMJ 2003;327:943-944,25 October Competing interests: None declared |
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Umesh Prabhu, Consultant Paediatrician/NCAA adviser The Pennine Acute NHS Trust
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I am very pleased to read this interesting and important article in the BMJ but rather concerned and worried to note that all doctors who have been charged with manslaughter are non Anglo-Saxon sounding names. Is it really "Medical error is being criminalised or is it about decriminalising racism? Published study has shown that there are 800,000 medical errors, 4% resulting in permanent disability and may be 20,000 preventable deaths due to medical errors. Where are all those doctors? Why they have not been charged for manslaughter? Is it Institutionalised racism if not then why doctors with Anglo-Saxon names are not being charged? Or am I right in thinking that it is only non-Anglo-Saxon doctors make serious errors? Patient safety is an important aspect and is too important for us to ignore but not by criminalising serious errors or not be decriminalising racism. We need a strong supportive and learning culture. If a doctor irrespective of his grade, race or gender makes any serious error, it has to be reported honestly and the organisation must learn lessons. Most errors are due to system failure or unintentional human errors and are not a malicious act. These doctors need strong support, help and advice and an opportunity to learn from their mistake. Most doctors are devastated by these errors more so if it results in tragedy to their patients. Why the CEO or the Board is not charged with manslaughter for system failures? Is it because the whole Board is made up of Anglo-Saxon people? NHS as a whole must make sure that doctors are not punished just because they happen to be an ethnic minority. If it is not an institutionalised racism then why only non-Anglo-Saxon doctors are being charged with manslaughter? I sincerely request our Chief Medical Officer, the DOH, NPSA and NCAA to look at these issues and find an urgent solution. Competing interests: Various Senior Clinical Manager in the NHS |
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Giusto Giusti, professor of legal medicine 00133 Rome (Italy), Università di Roma "Tor Vergata"
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Solutions to repair medical errors varied along the history, from the lex talionis in the Code of Hammurabi (1780 b.C.)to the dispositions contained in the Austrian Penal Code of Emperor Joseph 2nd (1804). According to this Penal Code, a doctor who made a mistake was sent back to a medical Faculty to learn what he didn't learn or he forgot, and that was all on the penal ground. Presently, most western Countries treat tha medical error followed by the patient's death as a manslaughter, with some notable exceptions that privilege the damage repair, not excluding however the criminal prosecution. A rising number of penal trials against doctors should be expected , unless a special law for medical errors is approved, but this is very far in the mind of the Members of Parliament. A possible solution is to treat any medical accident as a work accident, and to compensate the victim without prosecuting the doctor. Competing interests: None declared |
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archana desurkar, SPR Paediatrics Borders General Hospital, Melrose, Roxburghshire, TD6 9BS
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Reading the article of Jon Holbrook, it is very easy to see that only names of the doctors from ethnic minorities have made it in the news! These doctors make a sizeable proportion of the doctors working in the NHS in various capacities. Most of the doctros especially, from the Indian subcontinent are quite experienced, competent, have had post graduate training with good deal of clinical experience before coming to the UK. As has been pointed out by one of the responders, they do impart good clinical training to their juniors/colleagues. Thus it seems unlikely that only they will make serious/ criminal errors. Is it not another way of discriminating these doctors apart from what they already face in the NHS? Why are these juniors are being scapegoats when their consultant should be liable to as much blame? Ultimately, it is a chain of adverse events that leads to a a tragedy rather than an isolated mistake. The system failure, latent or active that needs to be tackled to prevent these tragedies. After all, that is what clinical risk management is, to promote a 'blame free culture'! It really is getting into 'blame and claim' culture and there have to be ways developed to address this to improve the relationship between doctors and the public. As a human being, everyone is falliable. On this background, i would like to recommend a book by the name ' Complications' written by ethnically an Indian surgeon trained and working in the US (Atul Gawande), who has been an advisor to President Clinton on Health Policy. Indeed, personally, i think everyone working in the NHS and espacially those in the managerial/supervisroy repsonsibility should definitely read this. Competing interests: None declared |
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Stan Goldstein, Medical Director HCF Sydney, Australia 2000
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Dear Editor, No doubt this will be but one of a loud chorus of commendations for the views expressed by Jon Holbrook in relation to "The criminalisation of fatal medical mistakes". However any concern about repetition should be overpowered by a greater concern about the future of health care, not only in the UK, but worldwide. I can only assume that every doctor is aware from the time they know enough about the profession they have chosen, and certainly from their pre -registration year, that they will make errors, and probably potentially fatal ones. However unless the current trend towards seeking criminal prosecution of such inevitable events can be stemmed, then what intelligent person would elect to place their name in this lottery for criminal prosecution and medicolegal litigation? Society demands much of a doctor, and yet there is little or no consideration that we are flying without safety harness, with fallible instrumentation, under variable weather conditions, with minimal ongoing retraining, frequent near misses, and most certainly without a parachute. There will come a time when we should be concerned at any individual who shows such flagrant disregard for their own well-being that they wish to become a medical practitioner. Clearly there is an extraordinary need to develop a science of creating systems which protect against medical error, of recognising the statistical fallibility of most medical decisions and systematically minimising their chance of occurrence, without enveloping the caring aspects of healthcare in a shroud of bureaucracy. However the science of medicine is based on probability. The studies to which we refer as evidence draw their power from statistical likelihood and not legal guarantee. There has been little discussion in the media of the social consequences of this "Sword of Damocles" environment. Where once a doctor's life was balanced between their preparedness for self-sacrifice, against the immense thanks of those they might help, what is it that has replaced the self-sacrifice on these scales of social justice, for surely "ambulance chasing" opportunism now holds sway in the perceptions doctors have over the paradigm of thanks in the community. If the same commercial drivers as are associated with the medicolegal drivers are reflected in doctors' motivations, then I fear for the long term health of our society. Perhaps it is time to bring out the discussion on the costs of the rights of individuals to seek retribution or fortune from adverse medical events, or even error. It will certainly be hard to create a valid system to cushion doctors, while not entirely eliminating the need to have a remedy for wilful harm or uncaring negligence. Yet perhaps society should be allowed to view the window into the future that many of us are forced to observe, and to discuss whether this "perfect" legal remedy should be more important to them than a reasonable medical remedy of which they might be deprived. Speaking to many undergraduate doctors I am distressed at the number who cannot see the practice of medicine as a long term option. I am concerned: who will take care of my children, and who will teach those that come after? Of one thing I am certain, it will not be the justice system, Stan Goldstein Competing interests: None declared |
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Jonathan Punt, Consultant paediatric neurosurgeon (retired) PO Box 6016 Keyworth Nottingham NG12 5RP
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Mr Holbrook's timely and thoughtful discussion regarding recent trends towards criminal prosecution of those deemed responsible for patient deaths through allegedly negligent acts or omissions [Holbrook J. The criminalisation of fatal medical mistakes. BMJ 2003:327:1118-1119(15 November)], begs the question of who is really responsible for such tragic events, and for their prevention. It is striking that in each of the four recent cases that Mr Holbrook cites none of the doctors held senior positions, and there appears to be no mention of any, or any adequate, involvement by a doctor in a substantive consultant post. Is this not at the heart of the issue? Management should be looking to ensure that styles of practice are not allowed to conceal inadequate standards. Where this does occur with serious sequelae the managers, especially those who have special knowledge through their medical qualifications, should be considered equally culpable. It will remain for Parliament, the Courts, and society to decide whether a search for criminal liability is the appropriate response, and, if so, how far that liability should extend. Competing interests: None declared |
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manan vasenwala md, mrcp (uk), consultant-cardiologist(non-invasive) k.k.heart center, aligarh-202002.india
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whites are often deterred from making complaints against fellow whites out of loyalty and peer pressure. similarly, a non-white would probably condone a mistake made by non-white in uk, but not in india. also he would be afraid to complaint against a white out of fear of not being taken seriously or out of fear of jepardising his treatment from 'gang-ho' effect. as i have worked in other countries, i think this problem is not limited to anglo-saxons but widespread also, say, in the middle east. fortunately, in india we are all free from these considerations. the consumer redressal forum has made every physician a sitting duck! it is free for all. Competing interests: None declared |
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Jayaprakash Gosalakkal, Consultant Paediatric Neurologist 10016
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Even after giving allowance for peer group pressure in the way we complain it is remarkable how some complaints are directed at certain groups.Communication difficulties is one such and from my experience would seem to have an asian monopoly!.It is a particularly cruel jibe at some of us who spent a life time acquiring the language of the bard and also parents who spent a fortune in educating us in "English medium" schools!Rarely have I heard it directed at other non native English speakers.The worse case scenerio was an esteemed chairman who suggested that one of my totaly normal colleagues undergo-Speech therapy! Competing interests: None declared |
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Janet M Pinder, medical litigator/nurse Wake Smith S1 2EF
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I appreciate that my response to this article will be highly unpopular but as I have worked on both sides of the fence I feel that I have a valid opinion. Doctors very rarely mean to harm their patients. Sometimes however, this harm is as a result of gross negligence and not a simple straight forward accident. If we apply the same circumstances to say a Road Traffic Accident where someone was seriously injurred or killed as a result of dangerous driving then there is a high expectation that the punishment would be custodial. Why then should it be any different in a case where a doctor has made a gross error? Is it because doctors feel that they should be treated differently to the rest of society? If anyone, in whatever job/circumstance seriously harmed another by acting in such a grossly negligent way then the same laws and punishments should apply. It is the patient who is important and this is often forgotten. If I was badly injurred in a Road Traffic Accident by someone driving dangerously (and dangerous driving can be a split second error of judgment)then first of all I would expect the person responsible to be punished. I would then expect to recieve compensation for my injuries. I do not see why we expect patients who are injurred by a doctor's gross negligence to be satisfied with anything less than this. Competing interests: None declared |
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Satyanarayan Hegde, Specialist Registrar in Paediatrics Hammersmith Hospital, London W12 0RE
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I was sad to hear the story of Feda Mulheim. It was beyond a mere co- incidence for so many Non-Anglosaxon doctors to be prosecuted. If society wants the criminalisation the fatal and serious medical errors, the society in general will suffer in the long run. It will not help the manpower crisis in medical profession. Talented youngsters will be dissuaded away from the medical careers. Defensive clinical practice is not to the benifit of the patient. Doctor patient relationship will be transformed in to just a vendor-customer relationship (which is already the case to some extent). Before it is too late society - patient organisations, legal professionals, politicians etc. - should wake up and stop this degradation. Competing interests: None declared |
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Paul Balen, partner Freethcartwright solicitors NEM House, 34-44 Bridlesmith Gate, Nottingham NG1 2GQ
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I too am uneasy about the use of criminal sanctions but the dreadful nature of the error (it was worse than portrayed in the article) and its outcome has not been adequately reflected in any other process ie employment or professional sanctions. The doctor in this case of course pleaded guilty. It turned out that he was an unstable personality who by the time of his trial had already been in custody on unrelated violence matters for a year. One questions the thoroughness of any vetting procedures in his immigration/employment/academic progress! No-one appears to have questioned why such an unstable personality was not picked up by the system earlier. No-one in authority has carried personal resposibility for his appointment and actions and all the other failures of system independently verified. The abiding memory is that of the Chief Executive of the hospital caught on national television punching the air with delight when the inquest verdict of accidental death was recorded by the coroner rather than that of unlawful killing. As a result of the criminal process he will no doubt be deported and will not work as a doctor at least in this country again. The CMO has promised to introduce a fail safe device but has not yet done so. After 15 or so similar deaths in this country since the first one I know of in 1975 it's hardly suprising that a guilty plea was entered. Until a more effective system of accountability is introduced it is doubtful that society's requirement for accountability and retribution will be assuaged. Competing interests: I acted for the family of the deceased at the inquest and in the civil claim. |
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Francesco Carelli, EURACT Council ,National Representative - RCGP 43017 - GMC 4256757 - Italian College of G P 20123 Mlan - Italy
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Criminalisation of doctors is "the new way" in our Societies, before it was in the States, now it's coming and growing in Europe. In Italy, everyday, you can see and read on the media about the neologism " malasanità" ( the bad health service ). This is destroying the relationships beteween patients and doctors, mainly you can see where these were strong and essential, like in Primary Care. It will not help to maintain doctors with enthusiasm in the profession. A recent national survey in General Practice showed that two on three GPs are in burn out, not only because of bureaucracy, paperwork, pressing by the Health Authorities on cutting expenses and controlling their work. The worst point concerns the progressive worsening in the relationship with patients, not yet trusting doctors, but conflictual and claiming. This is supported everyday by mass-media pushing people to ask more and more and to criticize and to indicate the Courts, as the place where to find the real health. A defensive medicine is growing, and it's rare, and dangerous for a doctor, to take initiative by him-herself and to undertake a lot of decisions, indications, little operations and therapies, that before were the usual and natural way of life for a good General Parctitioner. Competing interests: None declared |
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Anil Pandit, Resident, ER/OPD Patan Hospital, Lalitpur, Nepal , GPO 252, Kathmandu
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After going through editorial by Holbrook, J and rapid responses, I got an impression that media and the public are against the ethnic minority doctors. I am sure there were other white doctors who were charged against criminal offences. The editorial seems to be biased while citing the examples only ethnic minority doctors. It would have been unbiased if the editorial had shown a table that would reflect all the cases of criminal offenses charged against the doctors with names, charges and judicial outcome. The present judicial system in UK seems to be working very less in legal issues pertaining to the malpractice. This is a high time warranting amendment in present judicial system incorporating justice both for practitioners and patients. Competing interests: None declared |
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Anthony R Cox, Adverse Drug Reaction Pharmacist City Hospital, Dudley Road, Birmingham, B18 7QH.
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Mr Holbrook raises an important point about the willingness of the Crown Prosecution Service (CPS) to use manslaughter charges in cases of medical error.(1) However, this issue is not confined to the medical profession. In 1998, a recently qualified pharmacist and a pre-registration pharmacist where involved in the extemporaneous preparation of peppermint water. An error in the amount of chloroform in the preparation led to the death of a three-year-old baby, Matthew Young. Both individuals were charged with manslaughter following a police investigation.(2) As with the vincristine case in Nottingham, a number of systems errors were also implicated. Expert witnesses raised important points about undergraduate training and the levels of supervision within community pharmacy. As a result, the Crown Prosecution Service (CPS) asked the judge to rule that there had been no criminal intent and to direct not guilty verdicts. Both defendants were found instead guilty of dispensing a defective medicine under the Medicines Act 1968 Section 64. In the UK, the CPS seems to be travelling in the opposite direction to government policy on medical error. In 2000, the publication of “An organisation with a memory” signalled a recognition that the NHS could learn from its errors. There was a political will to change NHS culture so that it encourages the reporting and analysis of errors, yet the CPS continues to criminalize those who have made errors. The mixed messages that healthcare professionals receive are in danger of undermining initiatives to reduce the risk of medical treatment. Error reporting schemes run by the National Patient Safety Agency are one example. One cannot have a culture of openness and learning promoted by one agency, while another is pressing manslaughter charges. As activities like prescribing are extended to other professional groups, such as pharmacists and nurses, the risk of future manslaughter cases in other professional groups may increase. All the professions should be working together to ensure that healthcare professionals can work in an open culture of learning, which is ultimately safer for patients. Society and the CPS need to become engaged in a debate about the negative consequences of criminal sanctions in cases of error. The net effect of the current culture may be that future errors are not prevented. 1. Holbrook J. The criminalisation of fatal medical mistakes. BMJ 2003;327:1118-1119 2. Boots pharmacist and trainee cleared of baby's manslaughter, but fined for dispensing a defective medicine. The Pharmaceutical Journal 2000; 264: 390-392 3. An Organisation with a Memory. Department of Health. 2000. London. Competing interests: None declared |
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Jeffrey C McILwain, Consultant, Clinical Risk Management Whiston Hospital, Prescot, Merseyside L35 5DR
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Sirs Coming late to this debate, I am unable to square the process of the criminalisation of fatal medical mistakes with the much vaunted cultural changes required in clinical incident reporting viz "fair and just blame". To propose that clinicians should put their names to incidents within the "just blame" environment only to potentially find that the same clinician may be subject to a criminal prosecution as a potential consequence, is a paradox of intention. The extension from fatal to serious incident prosecution that this trend may support sends Clinical Risk Management back to the dark ages and hampers any work that the National Patient Safety Agency promotes. Having returned from speaking at two conferences on risk in London and Edinburgh I am appalled that the hard work to support and encourage clinicians to report incidents, demonstrated and supported at these national conferences, could be nullified by the fear of criminal prosecution. A prosecution brought upon the individual, not, the systemic failures that created an environment that allowed such failure(s) to occur. One wonders if one follows the logic of such a negligence approach will the Secretary of State for Health be subject to a Corporate Manslaughter charge? Following the principle of tort, the duty of care, breach in duty of care and consequent causation which leads to harm within the NHS may have a root source in the system failures that the NHS, and so by default the Government, is responsible for, as the legal owner of the NHS. Perhaps it is time that society that allows the creation of law and acts as the jury should consider the position of corporate accountability as much as individual accountability in perceived cases of medical harm or error. Competing interests: None declared |
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Jay Ilangaratne, Founder Medical-Journals.com
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In addition to a venomous attack on a doctor,it is said "as a result of the criminal process he will no doubt be deported and will not work as a doctor at least in this country again", in a response under the title "A solicitor responds" dated 17 November 2003. As the author of the said response claims to be a solicitor,and for moment if we were to take his aforesaid assertion seriously,then it is fairly clear that an 'overseas' doctor' will also be deported to his/her country of origin upon being convicted of a criminal offence. Though I do not personally take comments of solicitors too seriously,those who are inexperienced and vulnerable might be unduly alarmed by the said disclosure. Given there is a large number of ethnic-minority doctors who are members of the BMA,and each one is prone to medical error at some stage during their career, I think a clarification on the issue of 'deportation' is due, and it should come from the BMA. Perhaps,given the gravity of the said remark, the Department of Health and Home Office might feel it is necessary to comment.Also, one might turn to the Law Society to check the accuracy of the assertion made by this solicitor. I also wonder whether this public outpouring of vengeance against a convicted doctor is part of this solicitor's retainer, and/or an extension of his professional responsibility to his client. Competing interests: None declared |
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Penny Mellor, Advocate Home WV9 5HX
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Paul Balen is a practising solicitor. Any person who obtained residence in the UK as part of their employment is liable to a deportation order upon conviction for a criminal offence, there are no asylum issues and foreign employee's residence depends upon continued employment, therefore Mr Balen was correct to assume that the offending doctor will be deported. Mr Balen also had the advantage of being personally involved in the case and therefore has the advantage of having access to more facts than us mere commentators on media reports. He also expressed concern about the criminalisation of medical errors, whilst highlighting the inadequacies how incidents like this are currently handled, something which has been of great to concern for many parents fighting for inquests when their children die in hospital. As to comments about touting for business, well the same could be said for doctors that write up child abuse cases continually and as a result get paid extortionate fees when called as "expert" witnesses in high profile child abuse cases! Competing interests: I would like to see any doctor who is culpable of deliberate harm to child patients criminally prosecuted. |
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Richard G Fiddian-Green, None None
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In the US judgement in malpractice cases used to be based upon the "standard of care" within the community in which the doctor in question practiced. Had that been the criterion upon which the Shipman deaths were judged he should not have been convicted. From my analysis of the published data, which differed from that performed by the professor of general practice, Shipman's outcomes were not significantly different from those of other GPs in the community. This raised the possibility that it was not Shipman but the standard of practice within the community that was at fault.[He had no good or consistent motive and from my discussion with one of his patient's in Hyde had appeared to have been the model of the concerned and attentive GP]. The standard of care in the US today is judged by the highest standards in the country. In a subsequent study of 1009 GPs 33 including Shipman had a mortality more than two standard deviations above the standardised mortality (1). This raises the possibiilty that all 33 should have been investigated. On the other hand three or even four standard deviations may, I believe, be more acceptable statistical cut-off in determining whether the performance of any one GP can be considered an "outlier" relative to those of his/her peers. I am not aware of any data in the US the have shown that litigation per se has had a significant impact upon outcome. [The same applies to the deterrent effect of the death penalty in the US]. This does not mean that there might not good grounds for preventing some practioners found guilty of negligence or criminal behaviour from returning to practice. On the contrary litigation has encouraged defensive medicine and in so doing might even have had an adverse effect upon outcome. The fear of litigation has certainly increased the number of unneccessary investigations and conributed to the rising costs of care. Dr Mulhem's mistake was inexcusable but was it him or the hospital in which he worked that was responsible? I submit it was the latter. In this respect it was of interest to note in Dr Foster's reports in The Times last week that all consultants working in the same institutions reported the same standardised outcome data. The implication is that they take responsibility for the actionsof their trainees and had agreed to share the blame for poor performance and the credit for good performance. That is admirable and constructive. Outcome data are essential if we are to improve our results. Litigation and criminal prosecutions have no part to play in achieving this objective. That does not mean that patients should not have the right to damages from negligent actions. Neither does it mean negligence should not be grounds for criminal proceedings. They are, however, entirely different issues. The belief that litigation and criminal proceedings will improve outcome must be condemned. 1. Paul Aylin, Nicky Best, Alex Bottle, Clare Marshall Following Shipman: a pilot system for monitoring mortality rates in primary care Lancet 2003;362(9382):485 Competing interests: None declared |
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Kamal Kumar Mahawar, SHO, Surgery Arrowe Park Hospital, Upton, Wirral
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I have just come out of the Resus. We fought hard for 3 hours but couldnt save the patient. As I was leaving the place, Maria, my reg remarked," You are very efficient. Have you done ATLS?" I just smiled and left. Maria clearly thought it is the ATLS which made me efficient. But then everybody around me had done theirs too. What probably made me better was not ATLS but the fact that I had probably been through more than a hundred such resus before I came over to UK. Most of them carried out with minimal of the resources with far fewer people with not so bad results. Let us face it. Doctors from the subcontinent work in the posts in NHS which are not commensurate with their experience. They are normally more experienced that their British counterparts and have to prove themselves harder. But does that make them immune from making mistakes? Clearly no. What then if I make a mistake? Is the society or law going to be as understanding in case of a Kamal as it would be for a John? I think, most people here would, but sadly some wouldn't. The general public realizes the contribution we make to the NHS. "Many have frankly admitted this to me." One patient even said that you lot are not only better but kinder too. Which, I think, is probably true because we culturally dont treat medicine as just another job and can easily empathize with the patient. As we know from our experiences, most people in Britain are far more tolerant than many other societies. That is probably going to be reason enough for us to continue to deliver our best. I am sure the remaining few would also change their mind in due course. Competing interests: None declared |
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Gurli Bagnall, Independent Patients' Rights Campaigner Marlborough Sounds, 7273, New Zealand
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Whatever happened to “First, do no harm”? Articles and editorials such as “The criminalisation of fatal medical mistakes” generally revolve around damage control; without a hint of shame, the authors rarely if ever, consider the suffering and hardships imposed by iatrogenic death or disease and/or disability of those who lived to tell the tale. One would agree with Holbrook that Mulhem did not seek to harm his patient if it were not for the horrendous medical error statistics. “The costs associated with adverse outcomes were taken from statistical and research reports. …drug related problems accounted for 116 million extra visits to the doctor per year; 76 million extra additional prescriptions, 17 million emergency department visits, 8 million admissions to hospital, 3 million admissions to long term care facilities, and 199,000 additional deaths. The total cost was estimated to be $76.6bn ….No setting is free from hazards and no speciality is immune, and patients are at risk no matter what their age, sex, or health status.” [1] Medical error “constitutes the third leading cause of death in the United States” [2] What other industry can generate so much of its own business? How much longer is the public supposed to put up with this wholesale medical mugging? Medical error is the beginning of what often turns out to be a life- long nightmare for many of those who survived it. Typically, once the damage has been done, a curtain of silence descends and backs are turned upon those who, through no fault of their own, can no longer earn a living to support themselves and their families. Is it right that from thereon they should have to cope every day of their lives without competent medical help and without the financial resources to enable them to purchase their special medical needs? Is it right that they are sentenced to a life of poverty on a state benefit when fair compensation would at least remove financial worries from the shambles that is left of their lives? Is it right that parents of a once healthy child, find themselves facing a life sentence of caring for that child who was left brain damaged after surgery, or as a result of prescribed drugs or vaccines? How much longer is the public expected to accept, forgive and forget the adverse consequences of blatantly dishonest psychiatric diagnoses made because the physician who will not admit he cannot explain the physical symptoms? “…making an incorrect diagnosis or choosing the wrong medication, were more likely to have been preventable and more likely to result in permanent disability than technical errors.” [1] Is it right for a physician to place his greed for wealth over the lives and health of their patients? Have conflicts of interest become so common that they are now regarded as “respectable”? Professor Simon Wessely, psychiatrist, believes this to be so. He proudly tells us of his own conflicts of interest and urges us to grow up and accept that this is now a fact of life. [3] Holbrook’s editorial is a simplification of a very serious subject; the above are just a few points that contribute to the gross medical “error” statistics. Grizzling about the rising numbers of law suits is not going to alter anything. Claims for compensation will continue to rise until such time as the medical profession takes a refresher course in ethics and puts its own house in order. References: 1. “Epidemiology of medical error” Weingart, Wilson, Gibberd, Harrison. BMJ 18 March 2000; 774-776 2. “Is US Health Really the Best in the World?” Barbara Starfield. JAMA Vol. 284 No.4; 26 July, 2000 3. Letter “It’s time we all grew up”. BMJ 9 August, 2003; 327:341 Competing interests: None declared |
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Joseph . C . Obi, Chief Consultant WellnessClinics.co.uk
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Times are indeed getting exceedingly hard , these days...and it is not proving very easy for many British Lawyers to consistently make ends meet. Legal Aid is not all that lucrative any more...and as such , the BMJ has now (understandably) become a 'Premium Cruising Ground' for Ethical 'Freebie' Advertising. I therefore humbly plead with my irate colleagues (out there) not to look down on these 'Vibrant Legal Luminaries' as 'Scrounging Opportunistic Vermin'... but to warmly embrace them as the blemishless and blameless casualties of the worst Legal System in Europe. Competing interests: Dr Joseph Chikelue Obi MBBS MD MPH DSc FRIPH FACAM is also the Chairman of the General Wellness Assembly (GWA); an International Professional Body for Independent Wellness Consultants. 16 of his close relatives are Barristers. |
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Nigel Dudley, Consultant in Elderly Medicine St James's University Hospital LEEDS LS9 7TF
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The Code for Crown Prosecutors (www.cps.gov.uk) indicates that there is a two stage test that needs to be passed before proceeding with a prosecution. Some respondents to Jon Holbrook's article may perhaps believe that these stages are, (1) Is the person a junior doctor? and (2)Is the person non-white? The reality is that the first stage is the evidential test that "Crown Prosecutors must be satisfied that there is enough evidence to provide a realistic prospect of conviction". If this stage cannot be passed then the prosecution is not able to proceed any further. The second stage is the public interest test. The Code outlines common public interest factors in favour of or against prosecution; perhaps surprisingly to some, race is not among the in favour subsections whereas "the defendant was in a position of authority or trust" is. This explains why people such as junior doctors, consultant surgeons, and rail company managers are prosecuted in cases of avoidable death through alleged acts of gross negligence. Competing interests: None declared |
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Dr BR Pal, Locum Consultant UK
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In Hatcher v. Black [(1954) Times, 2nd July] Lord Denning explained the law on the subject of negligence against doctors and hospitals in the following words: "in a hospital when a person who is ill goes in for treatment, there is always some risk, no ‘matter what care is used. Every surgical operation involves risks. It would be wrong , and indeed bad law, to say that simply because of misadventure or mishap occurred, the hospital and the doctors are thereby liable. It would be disastrous to the community if it were so. It would mean that a doctor examining a patient or a surgeon operating at a table instead of getting on with his work, would be forever looking over shoulder to see if someone was coming up with a dagger. His professional reputation is as dear to him as his body, perhaps more so, and an action for negligence can wound his reputation as severely as a dagger can his body, you must not, therefore, find him negligent simply because something happens to go wrong; if, for instance, one of the risks inherent in an operation actually takes place or some complication ensues which lessens or takes away the benefits that were hoped for, or if in a matter of opinion he makes an error of judgement. You should only find, him guilty of negligence when he falls short of the standard of a reasonably skillful medical man, in short, when he is deserving of censure for negligence in a medical man is deserving of censure" The legal definitions are NEGLIGENCE: of a doctor is defined as breach of responsibility or duty owed to his patient and which results in actual damage to his patient. RASHNESS: An act of omission or commission when a reasonable person ought to do or abstain respectively and result in damage amounts to rashness. MALPRACTICE: Any breach of morals, ethics or duty in performing professional work amounts to malpractice. Malpractice is genus and negligence and rashness is species of it. MISJUDGMENT: Error of judgment at a given moment could mislead a person to result in damage to a person. Misjudgment does not amount to malpractice or negligence or rashness. There is very thin line dividing misjudgment and malpractice. This is the inherent risk involved in taking plea of misjudgment by doctors. MISADVENTURE AND EMERGENCY SITUATION: In unusual situation and emergency in good faith a person may resort to misadventure to save life of a person who otherwise is going to be dead due to disease or accident. This amounts to experimentation in extreme situation. Again there is thin line dividing misadventure malpractice so one has to be careful in taking plea of misadventure. The onus of proving that doctor is negligent is on the person who alleges negligence. It is almost impossible to prove negligence of doctor if he has taken following precautions: 1. Doctor has obtained informed consent. 2. If doctor has proper registration from the medical council. 3. If doctor has kept a proper record. 4. If the doctor has explained to the relatives and patient all acts about disease investigation,procedures, treatment, surgery and outcome. 5. If doctor has not done anything secretely or in closed places (where patients relative's do not have access) It is thus difficult to prove negligence of doctor in most cases. Competing interests: None declared |
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Declan P Fox, Freelance physician N Ireland, Scotland, Canada
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Janet Pinder reminds us that the patient is important, amid our cries of "racism" and our perceived pleas for special treatment for doctors who screw up. I would expect a nurse to know that doctors do not screw up in isolation; system failures are commonly to blame and very obviously so in this case. And why do doctors take on far more than they should? Why do doctors routinely race through the day constantly trying to fit gallons of work into pint pots of time? Why do relatively inexperienced doctors attempt treatments and procedures which are way beyond their skills and knowledge? Because they, too, see the patient as all important. Because they, too, put patient care way ahead of everything else in their lives. Because they are willing to compromise their own safety and careers in their efforts to make patients better. But such dedication is rapidly vanishing off the face of the earth, thanks in part to court cases like that described and to the attitudes of people like Janet Pinder. Perfection, we will find, costs a lot more than most are willing to pay. Declan Fox MB MRCGP
Competing interests: None declared |
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Anthony R Cox, ADR Pharmacist City Hospital, Dudley Road, Birmingham, B18 7QH.
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Gurli Bagnall misses the point. The problem is not prosecutions are unfair on doctors or other health professionals, but that punitive sanctions create a culture that learns nothing from errors. Society has to decide if it wants the short-term satisfaction of "justice" in these cases or if it wants the greater benefits of an open culture of learning. The first will push errors underground, while the other may lead to a reduction in iatrogenic disease.
It is worth revisiting a paper by James Reason1: Blaming individuals is emotionally more satisfying than targeting institutions. People are viewed as free agents capable of choosing between safe and unsafe modes of behaviour. If something goes wrong, it seems obvious that an individual (or group of individuals) must have been responsible. Seeking as far as possible to uncouple a person's unsafe acts from any institutional responsibility is clearly in the interests of managers. It is also legally more convenient, at least in Britain. Nevertheless, the person approach has serious shortcomings and is ill suited to the medical domain. Indeed, continued adherence to this approach is likely to thwart the development of safer healthcare institutions. A system based on enforcing best practice through fear, rather than improving systems within which professionals work, will continue to endanger future patients. They deserve better. 1. Reason J. Human error: models and management. BMJ 2000;320:768-770 Competing interests: None declared |
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Jenny L Robertson, Journalist SW15 5DP
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The current NHS environment is also increasingly negative for patients. We need to start learning some lessons about healthcare systems from our European neighbours who simply would not tolerate our NHS with all the waiting lists and battles to get seen at A+E. Competing interests: None declared |
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CA Johnson, Parent LA9
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Anthony R Cox's concern is valid up to a point, but only given the assumption that mistakes occur in a genuinely contrite culture. How often do families wait years for even an explanation for a mistake? Apologies are yet thinner on the ground, grudgingly offered only after cases have been pursued through the courts. Indeed, quick explanations and apologies would often be enough to avert the litigation which follows medical mistakes - frequently it is the only thing the families really want; but medical authorities hold back from this basic human decency to protect their PR and their pockets. And what of the repeat offenders? A culture which does not properly deal with such individuals is burying its head in the sand. When a leading paediatrician urges the GMC to dismiss multiple complaints on the grounds that they are multiple, one has to wonder whether the medical establishment is too arrogant to conceive of repeat offenders in its ranks at all. If in the course of my work my recklessness resulted in the death or injury of an undergraduate, I would expect a prosecution. So would the victim's family. The investigation would expose my failings and provide guidance as to how such harm could be prevented again; and no doubt my term in jail would remind me not to be reckless in future. If, however, I were neither prosecuted nor dealt with by my profession, I might conclude that I had nothing to learn and could get away with it again. Only my conscience and hoped-for humility woould guard against another family's suffering, and that lottery, frankly, isn't enough. Competing interests: None declared |
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Gurli Bagnall, Independent Patients' Rights Campaigner Marlborough Sounds, 7273, New Zealand
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Anthony R. Cox believes I have missed the point. He is wrong. Over the years I have had contact with many who survived medical injury but suffered permanent disease and/or disability as a result of it. Initially, most thought that once the treatments had been identified as the causes of their conditions, they would be treated with compassion and given whatever help was needed. But that is rarely the case. What they got instead, was denials, blame and medical behaviour that left a lot to be desired. They were routinely told that their symptoms were the result of depression or some other psychiatric condition, or they were menopausal, or they were malingering or were generally inadequate as human beings etc. In short, they were subjected to a blatant character attack. Needless to say, the suffering is compounded by such gross behaviour. Mr. Cox stated that “punitive sanctions create a culture that learns nothing from errors…..Society has to decide if it wants the short-term satisfaction of ‘justice’ in these cases or if it wants the greater benefits of an open culture of learning. “The first will push errors underground, while the other may lead to a reduction in iatrogenic disease.” Given the statistics, I find this statement remarkably naïve. There have literally been millions of opportunities to learn from mistakes yet nothing has changed - except on the negative front. Where conflicts of interest are concerned, lessons are simply not on the agenda anyway. Having rejected the chances to initiate reform, what else can society do but turn to punitive measures? Mr. Cox argues from the point of view that ethics are observed. They are not. Too many victims of medical error (and “error”) are painfully familiar with that unattractive culture of arrogance, self interest, deceit and the perception of superiority. It concerns me that the patient’s situation is generally ignored. Indeed, the seeking of compensation is often portrayed as greed and revenge. I would like to make it absolutely clear, that for the patient, survival takes priority over such “luxuries”. Keeping roofs over heads and food on tables becomes a nightmare particularly when doctors are intent upon protecting their reputations and comfortable livelihoods at the expense of those they injured. Where the latter is concerned, justice most assuredly becomes an issue but it is hardly a matter that can be described as “short-term satisfaction”. The term itself judges the victim in a demeaning manner. In most countries, calls for more health funding is generally an annual event. Here in New Zealand, people die while languishing on waiting lists for surgery, yet no one seems to consider the costs associated with preventable medical error. In the United States it is nearly $77 bil per annum, while Australia with a relatively small population, estimates the cost to be about $400 mil. Imagine the health systems we could all have, but for this waste. Mr. Cox is right in one respect. Patients DO deserve better. Competing interests: None declared |
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Simon P Kelly, Consultant Ophthalmic Surgeon Bolton Hospitals NHS Trust, BL4 OJR, on behalf of NPSA Clinical Specialty Advisers - see list below
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Sir The NPSA was established following the publication of ‘An Organisation with a Memory’ (1) a response to the case which subsequently led to Dr Mulhem’s sentence. The main thrust of that document is that we all learn from mistakes in order to prevent them ever happening again. To achieve this we need to follow the example of the aviation industry where safety is paramount, and create an open and fair culture in which staff can admit mistakes. (2) It is hoped that the Home Office, the Crown Prosecution Service, the bench and police might support the Chief Medical Officer’s welcome initiative of advancing patient safety culture and learning from unintended medical errors. The editorial on criminal charges to punish doctors who make mistakes (3) coincided with the National Patient Safety Agency’s (NPSA) launch of the ‘Seven Steps to Patient Safety’. (4) This offers a way forward for health organisations to improve patient safety by looking to the root causes. For too long, the NHS response to mistakes has been to find an individual to blame rather than concentrating on the faults in the system which led to the mistake. The best way of reducing errors is to target the underlying systems failures, rather than take action on individuals. Blaming individuals is based on two myths: the perfection myth (if staff try try harder, they will not make errors) and the punishment myth (if we punish people who make errors, other staff will make fewer errors). In reality, similar errors happen recurrently (1) (4) because individuals forget and unfortunately new staff do not have the opportunity to learn from these previous occurrences. Instead, systems must change to ‘contain the memory’ and must be error proof. An ‘open and fair ‘culture does not imply a 'no fault’ or ‘no responsibility’ ethos. Doctors who act recklessly and irresponsibly should be punished if they “show such disregard for the life and safety of others as to amount to a crime against the state and conduct deserving of punishment” (3) However, staff should not be prosecuted for “the sort of mistake that a reasonably competent doctor could make due to an error of judgement” (3) particularly if the underlying errors are systematic as outlined in the Toft Report which dealt with the fatal medication error referred to in the editorial. The Chief Medical Officer’s aspiration of embedding the culture of patient safety is a step in the right direction. Culture change, however, will take time. The emphasis should be on learning from adverse events and developing solutions for their prevention. 1. Dept of Health. (2000) An organisation with a memory. London: The Stationary Office. www.doh.gov.uk/orgmemreport 2. Dept of Health. (2002) Learning from Bristol. London: The Stationary Office. Available at www.doh.gov.uk/bristolinquiryresponse 3. Holbrook J. The criminalisation of fatal medical mistakes. BMJ 2003; 327: 1118-1119 4. The National Patient Safety Agency (2003) Seven Steps to Patient Safety – A Guide for NHS Staff. The National Patient Safety Agency. London. www.npsa.nhs.uk or the NHS response line 08701 555455 Clinical Specialty Advisers of the NPSA – Mr Simon P Kelly (Ophthalmology), Professor Terence Stevenson (Paediatrics and Child Health), Dr John Dyet (Radiology), Revd. Dr Victor Barley (Clinical Oncology), Dr J H B Scarpello (Medicine), Mr D W Morgan (Surgery), Dr Brian Ayers (Radiology), Professor James Walker (Obstetrics), Dr Ian Woods (Anaesthetists), Professor Peter Furness (Pathology). Competing interests: Clinical Specialty Advisers of the NPSA |
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Christopher I. Price, Clinical senior lecturer in medicine Northumbria Healthcare NHS Trust, NE29 8NH
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It is easy to relate other important topics to Holbrooks' article (1), but they cloud the issue. We need to put aside concerns about ethnicity and the perpetuated historical view that the medical profession prefers to “cover-up” mistakes. Lets also not mix up "criminal" cases with "compensation" claims. That leaves only two discussions. Firstly, did this legal outcome adequately reflect the intent of the individual guilty doctor to cause harm? Clinicians should not be immune from criminal prosecution at work, but as they perform complex tasks every day without the intent of harming a patient, it seems that a criminal charge of manslaughter does not truthfully reflect the context of a single deadly error. If we extrapolate the outcome of this case then could any doctor be found guilty of manslaughter for misreading a test result that delays a life-saving treatment or fails to spot an unexpectedly fatal complication of appropriately prescribed treatment? Or is it only the person on the end of a cytotoxic syringe who goes to court? Anybody comparing the outcome of medical mistakes to reckless driving has no appreciation of the intent of the medical profession to helps its patients, the stressful conditions under which many clinicians still work, and the inadequate supervision given to many juniors (which often reflects service pressures on the seniors rather than attitude). The legal system has apparently failed to recognise these factors in the verdict, although I suspect that the judge was sympathetic to them in the sentencing. Secondly, how can two state-run organisations (the NHS and CPS) now find short and long-term solutions to medical error? Whilst the NHS encourages us to become an organisation with a memory, the CPS threatens us that we may become individuals with criminal records. This mixed message will be an obstacle for incident reporting that could save lives. Also, if only equally large sums of money used in this legal exercise could be spent on identifying and training even a handful of under- performing clinicians, then further harm could be prevented. Progress here is a responsibility to be shared by civil servants, politicians, and the legal system. However the case reflects a "Cluedo" mentality rather than a multifactorial representation of aetiology and effect. Next time (and I'm sure there will be one) I would encourage the CPS to also charge the NHS with corporate manslaughter to see if the outcome is more useful for future patients. 1. Holbrook J. The criminalisation of fatal medical mistakes. BMJ 2003;327:1118-1119 Competing interests: None declared |
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Peter Morrell, Hon Research Associate, History of Medicine, Staffordshire University, UK
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Sir, For the sake of clarity, for all readers, not just those he styles as "Scrounging Opportunistic Vermin," it would be most helpful if Dr Obi were to explain in more detail his claim that the British legal system is "the worst Legal System in Europe." Competing interests: None declared |
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Jai Shankar, Retinal Fellow Moorfields Duke Elder Eye Centre, St.George's Hospital, London SW17 0QT
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EDITOR, It was interesting and sad to read the plight of doctors involved in fatal incidents caused by errors of judgement.1 We live in an increasingly litigatious society where provision of medical care is treated in the same category as any other public service. What was rather striking in the article was that all the doctors cited had “non-English” sounding names. Perhaps medical gross negligence manslaughter is something genetic or racial. Or is there some other explanation not quite so overt? 1. The criminalisation of fatal mistakes. Holbrook J. BMJ 2003;327:118-9. Competing interests: None declared |
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Ediriweera B.R., Desapriya, Research Associate Department of Pediatrics, Centre for community Child health Research, BC, V6H 3V4
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The view expressed by Accident Line and the BMJ adopts and reinforces a social intolerance towards "accidents" as being events that have an innocent origin (1). Action to reduce clinical risk should not include punitive actions against the people who make the mistakes, but rather action on the systems in which the mistake occurred. In the complex environment of acute health, it is very common and surprisingly simple for medical errors to occur. The health care system is significantly behind other high-risk industries in its attention to ensure basic safety. The key behind reducing clinical errors is to make it difficult to do the wrong thing, and easy to do the right thing (2). A profound change in the culture surrounding medical error that is shifting the emphasis from silence to safety is the goal of a new program at Canada, Vancouver’s St. Paul’s Hospital the only Canadian centre participating in a collaborative project of the Boston-Based Institute for Healthcare Improvement (3). This “culture of safety” is essential to allay public health community fears and reprisals not only in UK but also in other countries as well. In the UK, meanwhile, a mandatory no-name, no-blame national system for reporting “failures, mistakes and near misses” has been implemented under the National Patient Safety Agency by the end of 2002. It is time now that we should take some initiatives to see early effects of this program on the quality of overall Medicare system and evaluate effects of this program on future medical errors in UK. (1). Holbrook, J., The criminalization of fatal medical mistakes. BMJ 2003; 327:1118-1119. (2). Mission, J., A review of clinical risk management. Qual. Clin. Pract. 2001; 4:131-134. (3). Kent, H., Talking about errors instead of hiding them goal of Vancouver hospital. CMAJ 2002; 4; 166-167. Competing interests: None declared |
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Dr. S. K. Roy Chaudhary, Principal & Dean, Srikrishna Medical College, Muzaffarpur, Bihar, India
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As an young medical student where ever I went I was respected. In cinema halls medical students did not buy tickets. They just entered and sat. Ticket was brought to them by the gate keeper. 40 years have passed and now I find no body has any respect for doctors in general. All of us must do some introspection and try to redeem our past image or at least make our professional life reasonably tolerable. Competing interests: None declared |
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Russell D. Lutchman, Consultant Forensic Psychiatrist Reg. Addr: c/o Broadmoor Hospital, Crowthorne, Berks, RG45 7EG
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There is no criminalisation of medical mistakes. Doctors were never exempt from criminal liability if their actions in the course of medical practice led to criminal acts. The medical profession was probably given some breathing space well into the early 1900’s. Doctors around that time got away with things that would be considered criminal using present-day lenses. Countless patients were seriously and irreversibly damaged in the furtherance of medical knowledge and ‘expertise’. It was settled in R v Bateman (1925) 19 Cr App R 8 that causing death by gross negligence could attract criminal liability. The law on negligence took a very important turn in Donoghue v Stephenson (1932 ) when Lord Atkins set the general principle of ‘duty of care’ as central to the tort [civil wrong] of negligence. Before that, there was no generalised duty of care in negligence and duty had only applied in a non-uniform way in negligence cases. The requirements of duty of care were further refined and laid down by Lord Bridge in Caparo Industries v Dickman [1990] 1 All ER 568 to include foreseeability of damage, proximity of relationship and whether it is fair, just and reasonable to impose a duty. In the case of Osman v The United Kingdom (1998) (87/1997/871/1083) it was held that “a blanket immunity to instigate civil proceedings on the police was a breach of Art.6(1) [right to a fair trial] of the European Convention on Human Rights and amounted to an unjustifiable restriction on the applicant's right to have the merit of the claim determined.” In effect the police are no longer shielded from negligence lawsuits. The House of Lords in Arthur J.S. Hall & Co v Simons [2000] wiped away a two-hundred-year old immunity protecting barristers and solicitor-advocates from negligence lawsuits. The above small handful of cases is sufficient to plot the trajectory of developments in negligence law. Immunities have been stripped away across the board. Any notional protections for doctors were washed aside by a changing tide, driven largely by public policy considerations. Holbrook (1), as a barrister, is aware that Mulhem’s lack of intention to harm his consenting patient is the key defining feature of involuntary manslaughter; of which ‘manslaughter by gross negligence’ is one kind. It is entirely true, though perhaps shocking for us medics, that Mulhem’s "crime" was his mistake. It is not simply Mulhem’s mistake but the nature and quality of it. All that is the law and all doctors had better learn it well. Too many doctors, largely ignorant of the law and resentful of lawyers, hold culturally accepted beliefs, that innocent mistakes arising from good intentions to heal are pardonable. Not so in law. Many doctors and their non-medical managers still have misguided ideas about medical negligence, that:
The medical profession was given a clear and stern warning by Lord Woolf (2) that the legal profession will be less deferential to the medical profession. Doctors will need to fully incorporate legal accountability in their medical practice, else the courts will spell it out for them what is required - and statute will direct them how to do it. Lawyer-bashing will take us nowhere fast. If we continue to sulk and refuse to modify our attitudes and practice, we will pay one way or the other; in legal settlements, rocketing defence union and GMC fees, damage to our group professional image, and for some doctors severe restrictions on their liberty if they end up in prison.
1. Holbrook J. The criminalisation of fatal medical mistakes. BMJ 2003;327:1118-1119 2. Clare Dyer. Courts too deferential to doctors, says judge. BMJ 2001;322:129 Competing interests: None declared |
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Andrew D Beggs, House Officer Guys & St. Thomas' Hospital NHS Trust
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It seems that every event that happens in society these days has to be settled via legal action. Most of the "crimes" that involved doctors were mistakes. They should never have happened but they were not commited by a doctor intending to commit deliberate harm to their patient. Patients would be better served by putting proper systems in place to prevent medical accidents from happening in the first place, instead of wasting money on legal action. Simple steps that could take place to reduce mistakes are already coming to place, but slowly, such as the European Working Time Directive, also a clear chain of responsibility. However, with regards to the comments from Russell D Lutchman, should doctors press for legal action every time a patient verbally or physically assaults them? Should every case of medical negligence that is disproved be met with a vigorous counter-suing by our Medical Defence Bodies for slander/libel? Should instance of a junior doctor working over their contracted hours merit an immediate cessation of work and a lawsuit against the hospital for being put under such pressures? The answer, obviously, is no. If this were to happen, as Dr Lutchman would want if we to fully apply the standards of the legal profession to ours, the NHS would collapse in on itself. No work would be done, no patients would be treated and the system would fail our patients. Surely the best solution for everyone is to be sensible about legal action. What has the legal action against Dr Mulhelm solved? A devastated family whose pain has been undoubtedbly exacerbated by their sons tragic death being dragged through the media, a doctor with a criminal conviction who will be deported from Britain, and after all this the only people who truly benefit are the Legal Profession. Competing interests: None declared |
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Jay Ilangaratne, Founder Medical-Journals.com
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Though medical error per se is not a criminal act, upon such error being prosecuted on the ground of manslaughter (a criminal charge),it is difficult to disagree with Holbrook’s notion of “criminalisation" of fatal medical mistakes. The crux of the message in Holbrook’s editorial, is the high preponderance of ethnic-minority doctors who have been charged with manslaughter following medical error. However, there is no clue in the editorial whether the sample of doctors identified were the only ones who have been charged with manslaughter, or chosen selectively by Holbrook, for some other reason. Hence, I am sure, a clarification from Holbrook would be appreciated by many, and that may also allay any doubts as to race-related prosecutions of doctors. The BMJ too owes a duty in this regard,rather than simply raising the 'temperature' in relation to a sensitive matter. Of course, fears expressed by others in respect of possible racial discrimination are entirely justified given the CPS’s track record. An independent inquiry by an academic lawyer, Sylvia Denman, set up by the CPS to stave off a CRE investigation, found institutional racism at work throughout the service in her 2001 report (1). Mr Calvert-Smith QC, Director CPS, said at the time: "Albeit without intending to, our behaviour can, does and has discriminated. I unreservedly accept the finding that as an organisation the CPS has been, within the Lawrence report definition, institutionally racist"(2). I do not understand, why the writer felt necessary to cite Arthur J.S. Hall & Co v Simons [2000] as that only confirms the end of immunity from suit in respect of lawyers.The medical profession had not enjoyed such unjust immunity for so long, compared to the lawyers.Even if doctors received deferential treatment in the past from lawyers,then it is most unlikely that ethnic-minority doctors were the major beneficiaries of such favouritism.When one comes from an ethnic-minority, 'pulling up the socks' seems just not enough to receive fair treatment. References Competing interests: None declared |
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Alex Psirides, Registrar, Intensive Care Medicine Wellington, New Zealand
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Dr. Lutchman, If 'doing my best' isn't acceptable to society, then what is? If the law expects more then the law is wrong. Dr.Beggs, Thank you for presenting a balanced counterpoint. I agree that the continued escalation of disagreements resulting in legal recourse benefit only one group of people. It is difficult to see how any blame culture can be curbed when money is to be made from it and it would seem, in ever increasing amounts. I am fortunate to work in a country where a central government agency provides free healthcare & compensation and attaches no blame, albeit at the cost of higher taxation. This is something I gladly pay via direct taxation rather than indirectly through escalating GMC & defence union fees. This is one of the many reasons I left the NHS to work in New Zealand. And why doctors here shake their heads in amazement as our trans-Tasmin colleagues are unable to work because their defence union goes bankrupt, leaving them unprotected. Ultimately, in all cases, patients suffer. The question seems to be whether we allow the medical profession to suffer with them. Competing interests: None declared |
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Andrew Al-Adwani, Consultant Psychiatrist Department of Mental Helath, Scunthorpe General Hospital, Cliff Gardens, Scunthorpe, DN15 7BH
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Sir: Mr. Balen labels Dr. Mulhelm "an unstable personality". Apart from there being no such diagnosis, his evidence is suspect. We are not told whether Dr. Mulhelm was convicted of any offences related to violent conduct, and in what way his alleged offence related to the case in hand. Furthermore, if fourteen cases of the same nature had occured, what was done by the NHS to prevent further mishaps and what of corporate responsibility. Why, in addition, was this the only case to result in imprisonment and what were the supposed features of this case that Mr Balen says were "worse than portrayed in the article". Evidence is the cornerstone of both medical and legal practice and one could be forgiven for thinking that a solicitor would appreciate this. My experience though is that most solicitors are motivated by money and winning, with the latter providing the former, not truth. Competing interests: None declared |
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Gurli Bagnall, Independent Patients' Rights Campaigner
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The following statement made by Dr. West is a little difficult to understand: “Patients would be better served by putting proper systems in place to prevent medical accidents from happening in the first place, instead of wasting money on legal action.” Does this mean that patients should use their own resources to initiate the “proper systems” and if so, how should they proceed? Given the profession’s reluctance to put its own house in order, many in the lay community have already been trying unsuccessfully to do get those “proper systems” in place for a number of years. Their efforts have been met with medical resistance and much resentment. Dr. West displayed a typical attitude where patients are damned if they do and damned if they doesn’t. When they eventually rise together and demand that the profession faces the maiming and the killing it was responsible for, will Dr. West then say, “Don’t blame us! Why did you put up with it? Why did you not protest earlier?” Dr. West reacted to Russell D Lutchman’s comments defensively. Personally I found the latter’s knowledge and sound advice refreshing. Competing interests: None declared |
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Hari D Maharajh, Consultant psychiatrist Neuroscience clinic , 3 Endeavour Road , Chaguanas, Trinidad W.I.
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Dr. Russell Lutchman's response is extraordinary. Like a good law student he omitted R v Adomako(1994)3WLR288;1WLR15. Would his inclusion in his submission colour his thinking on institutional racism? Adomako, the appellant was convicted of manslaughter in terms of gross negligence as the basis for liability rather than recklessness. Gross negligence eclipsed or reinstated, doctors the fallen Gods are now at the mercy of the Lords. The law is an ass and is based on elements of circularity. Dr. Lutchman should do an indepth analysis of Adomako. Why did the learned Lord by pass R v Lawrence(1982) AC510 and used R v Bateman(1925)19 Cr APP R 8. Come on Dr. Lutchman can't you see Justice is blind for ethnic minorities? I shall not be a case of a migrant Stockholm syndrome. Pull up my socks-I think not. Competing interests: None declared |
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Steven Ford, GP Haydon & Allen Valleys Medical Practice
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Sir This has been a particularly dispiriting correspondence. How can a career in medicine now be viewed other than as a long drop on a rope of unknown length. All doctors, without exception, make mistakes. Some mistakes are fatal. Perfection is unattainable. No system, however elaborately wrought, can deliver flawless performance but the systems within which medicine and many other facets of life currently operate do incur massive costs and hobble performance. Perhaps someone knows how many Judges and barristers (and their international equivalents)are currently serving time for misdirecting juries or knowingly permitting false information to be presented to a jury. Their errors are not infrequently catastrophic and even fatal for the accused and not much less frequent than errors in medicine I suspect. No special pleading or pontificating about privileged status will wash here - it's perfection or death - the rules apply, or should apply, equally, if justice is a meaningful concept at all. It is difficult to name many activities that have not been associated with injury and death. Even being inactive is notably harmful. The chief danger is that at some point the system will simply fail completely because the tasks become so complex that they can no longer be performed. Risk, injury and death are inherent in life itself. Doing the best you know how may not be a legal defence but it is the wretched reality that most of us inhabit. I can hear the tumbrel now... Steven Ford Competing interests: I confess. I too am a doctor. |
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Gurli Bagnall, Independent Patients' Rights Campaigner Marlborough Sounds 7372, New Zealand
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Maharath’s response to Lutchman is a classic example of the medical attitude that drives victims of the medical profession to the courts. Please do not make this a racial issue! White, brown, green or purple, a patient does not consult a doctor expecting to be injured or killed but the chances are they will end up as part of the statistics - as far as they are known. (Medical “treatment” is the third biggest killer after heart disease and cancer; it causes a third of disease/disability and has created a problem of addiction far greater than addiction to illegal substances.) [1] THIS is where justice is blind. When damaged patients have to battle attitudes such as displayed by Maharath, obtaining the assistance they need is often impossible. Self-interest, arrogance and misrepresentation of the facts do NOT encourage patients to forgive and forget. Come on now, Dr. Maharath, where is the shame for your profession’s shameful record? Reference: 1. “Stop the grizzling” Gurli Bagnall http://bmj.bmjjournals.com/cgi/eletters/327/7424/1118#42066 Competing interests: None declared |
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Vadivelu Vasanthakumar, Specialist Physician Dubbo, NSW 2830
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Despite the BMJ banning the word 'accident' from its pages 2 years ago (J Holbrook, BMJ 15 November), the words 'Cerebrovascular accident' and the abbreviation 'CVA' continue to be used very frequently by doctors. May I suggest that these words be banned from use in medical practice and be replaced by the simple word 'stroke' which in fact describes the condition very well. I have seen relatives becoming concerned when they see the word 'accident', and it looks even worse when they see it on a death certificate. Competing interests: None declared |
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Alex Psirides, Registrar, Intensive Care Medicine Wellington, New Zealand
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Bagnall’s remarkable claim that doctors kill more patients than everything other than heart disease or cancer and are responsible for a plague of drug addiction exceeding those taken voluntarily left me with one question. If you are are diagnosed with anything other than heart disease or cancer, then presumably you would be better off not seeking any medical advice at all? Perhaps the people who fund our hospitals & medical schools could be informed of this as it would appear that we are all wasting our time, as I apparently have for the last ten years by choosing a non-oncological or cardiological speciality. Still, it's good to know that at least we are doing something right by only coming in third. Unfortunately I was not able to validate this claim as the reference quoted refers to another rapid response in this sorry thread posted by the same author which doesn't contain any more information. Perhaps Bagnall could provide us with a more accurate source. Competing interests: I tend to use sarcasm as a communication aid. |
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Hari D. Maharajh, consultant neuropsychiatrist Neuroscience Clinic, Chaguanas, Trinidad W.I..
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Gurli Bagnall’s advocacy for patient’s rights is indeed admirable and informative. I did not know that ‘medical treatment’ ranked so high in the world burden of diseases. I shall be grateful for more information. The shame "for my profession shameful record" lies in the fact that physicians have become too humane. We must adopt the attitudes of lawyers and work within the confines of a narrow predetermined structure with passing reference to the task at hand. The question must be asked. What would have been the outcome of these patients if there were no intervention? What would have been their natural outcome? In the majority if not all cases, the physicians intervention is only a confounding variable in the demise of these patients. Should not the question be asked "but for" the intervention of the physician would the patient have survived? The issue of causation in medical intervention needs to be revisited by a joint select committee of both doctors and lawyers and not only the Law Lords. The doctors shame lies in the fact that over the years they have deviated from the Hippocratic oath and have not adhered to preserving a quality of life but only life. The criminalization of medical mistakes can only have one outcome, that is, to prevent those who had some chance of survival however small, from having it. Doctors learn fast, in most societies they belong to the top ten percent of the best academic brains. This is unique for any profession and doctors will make the necessary adjustments to the burden of others. On the issue of racism, perhaps doctors are again victims of diagnostic formulation. A local politician has reminded us that if it walks like a duck, quacks like a duck and looks like a duck--it must be a duck! Let's stop pretending that it is not happening. Racial profiling is one of the greatest shame against humankind. And Gurli the last four letters in my surname is 'rajh'-not 'rat'. I have noted the Freudian slip - raj is derived from the Indian language ‘raj’ which means king – rat is a nasty rodent. Competing interests: None declared |
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Giuseppe Vetrugno, Resident Universita' Cattolica Sacro Cuore, Policlinico, Achille M. Luongo, Massimo Volpe, Fabrizio Celani, Fabio De Giorgio, Fidelia Cascini, Leonardo Scorcelletti, and Ernesto D'Aloja
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The case of Dr. Mulhelm is amazing for the penalty inflicted: 18 months of imprisonment (1). This case was not the only one and it is not a record. In 1990, an Italian surgeon was sentenced to 7 years imprisonment in Italy. In Ancient Rome the physicians were punished in the same way as the most vulgar criminals, with the lash, with the grindstone or with hard labour in the mines, unless the occasion was not animated by breaking their legs or even crucifying them. However, the medical art was not particularly appreciated. The poet Martial was even sarcastic; according to him the physician Diaulus who had recently become an undertaker, had not really modified to any great extent the matter receiving his attentions: "Nuper erat medicus, nunc est vispillo Diaulus: Quod vispillo facit, fecerat et medicus" (translated in: "Once a physician, Diaulus is now undertaker: What he does as undertaker, he already did as physician", by Martial, Epigrammata X, 47) Even so, with a certain difficulty some did propose the problem of medical error. The Roman General Marius condemned to the stake the physicians did not recover his fracture of an astragalus. The intervention of an esteemed colleague saved the poor wretches because he managed to demonstrate that the situation was inevitable. Over the centuries, the possibility of medical error is no longer admitted, and may even become a motive for resorting to the criminal courts. Nowadays, the main reason of the attitude to persecute the medical mistakes lies in the pathological degeneration of criminal law (2) and in the role played by experts in courtrooms (3) and in the comments made in specialised journals. The victim has entered into trials in an oppressive manner. His rights are sustained not only by the Public Prosecutor and by his own legal representatives, but also by associations, opinion groups, and various movements that, by assuming the burden of the needs of the person damaged by modern medicine, amplify in the optic of mass media the request for justice presented by the victim. In this way the trial is destabilised because the accused, who should be considered innocent until proved guilty, is considered “probably guilty”; thus, the safeguarding clause “in dubio pro reo” frequently becomes “in dubio contra medicum”. In the same time, in courtrooms, expert medical witnesses seem authorised more to speak than to prove. The instruments for providing satisfaction to the victim of medical errors should be completely different from criminal penalty: either by civil law or by administrative sanctions. The introduction of a non-fault legislation could satisfy requests for indemnity on the part of victims (4). However, no fault legislation would not be sufficient to provide the answer for greater safety in health procedures that public opinion loudly demands. It would therefore be necessary that, in parallel to indemnity mechanisms based on the non-fault legislation, health establishments should be able to monitor errors in order to study them and, when possible, prevent them. The professional orders (for physicians, nurses and technicians) in the presence of gross errors on the part of a professional person, would be able to intervene for promoting the suspension of him/her who made gross error, forcing him/her to follow educational courses. NHS would be able to declassify the hospital where gross error often happen. Expert witness about medical responsibility should demonstrate, over and above any reasonable doubt (5), that the damage suffered by the patient would not have occurred without the gross medical error (i.e. error conditio sine qua non of damage) avoid reasoning based on simple hindsight. Bibliography 1. Holbrook J The criminalisation of fatal medical mistakes, BMJ; 327:1118-1119, 2003; 2. Garapon A, Salas D La République Pénalisée, Ed. Hachette, 1997; 3. Milroy C M Medical experts and the criminal courts, BMJ; 326: 294 – 295, 2003; 4. Gaine WJ No fault compensation systems, BMJ; 326: 997-998, 2003; 5. Daubert vs. Merril Dow Pharmaceutical Inc., 509 U.S., 113 S.Ct. 2786, 1993. Competing interests: We are human beings |
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Mark Struthers, GP Her Majesty's Prison, Bedford, UK
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I too have found this correspondence particularly dispiriting. However Steven Ford’s absurd contribution to that correspondence has done nothing to raise those spirits – but then I don’t think he was trying very hard. We can’t always do our best of course; not every day. Human beings make mistakes; to err is human. Judges, barristers, (and their international equivalents) as well as doctors, will make errors. Even the Americans, an exceptional form of humanity, are not perfect - and their doctors even less so. For all these judges and barristers (and their international equivalents) currently serving time, pleasuring Her Majesty for “knowingly permitting false information to be presented to the jury”, the error was presumably in getting caught. I stand in shock and awe at the ‘massive costs’ of an ‘elaborately wrought system’ that the hapless Dr Mulhem managed to hobble in his performance. If his son had been at the end of Dr Mulhem’s spinal needle, would Steven Ford have been so philosophical about the lottery of ‘injury and death’ ‘inherent in life’ and British hospitals. What concept of justice would have meaning then I wonder? The reckless Dr Mulhem pleaded guilty to the charge of manslaughter by gross negligence. He didn’t have to; he could have tried his luck with a jury misdirected by a judge. Was this an admission that in reality he had not really done his best? On the other hand, was this yet another conspiracy by devious and dishonest lawyers to knobble a foreign doctor? While I can rarely be accused of being an optimistic person, I too can hear that tumbrel now – but I can’t believe it’s really coming for me – as long as I continue to practise with some due care and attention. If he does the same, perhaps Dr Ford could afford a little less pessimism about the depth of the long drop. Competing interests: I too am a doctor; I too make mistakes. I oppose medical involvement in the death penalty (and their international equivalents). I also confess to serving part-time as a GP at ‘Her Majesty’s Pleasure’. |
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Gurli Bagnall, Independent Patients' Rights Campaigner Marlborough Sounds 7372, New Zealand
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I refer to Alex Psirides request that I provide “a more accurate source” for my “remarkable claim that doctors kill more patients than everything other than heart disease or cancer…” The references have already been made in my letter “Stop the grizzling”, but I am happy to repeat them in more detail. Psirides has demonstrated how important it is to drive home the message that the current volume of medical error is unacceptable and must be addressed. QUOTES TAKEN FROM JAMA Volume 284 No. 4, July 26, 2000. “Is US health really the best in the world?” Barbara Starfield MD, MPH. In the US “ 12, 000 deaths/year from unnecessary surgery 7,000 deaths/year from medication errors in hospitals 20,000 deaths/year from medication errors in hospitals 80,000 deaths/year from nosocomial infections in hospitals 106,000 deaths/year from non error, adverse effects of medications “These total to 225,000 deaths per year from iatrogenic causes. Three caveats should be noted. First, most of the data are derived from studies in hospitalized patients. Second, these estimates are for deaths only and do not include adverse effects that are associated with disability or discomfort. Third, the estimates of death due to error are lower than those in the IOM [Institute of Medicine]. If the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000. In any case 225,000 deaths per year constitutes the third leading cause of death in the United States, after deaths from heart disease and cancer. Even if these figures are overestimated , there is a wide margin between these numbers of deaths and the next leading cause of death (cerebrovascular disease).” QUOTES TAKEN FROM THE BRITISH MEDICAL JOURNAL Volume 320, 18 March 2000. “Epidemiology of medical error” Weingart, Wilson, Gibberd, Harrison. Based on hospital figures: “In Australia medical error results in as many as 18,000 unnecessary deaths , and more than 50,000 patients become disabled each year.” “The costs associated with adverse outcomes [in the US] were taken from statistical and research reports . The authors calculated that drug related problems accounted for 116 million extra visits to the doctor per year, 76 million prescriptions, 17 million emergency department visits, 8 million admissions to hospitals, 3 million admissions to long term care facilities, and 199,000 additional deaths. The total cost was estimated to be $76.6bn, rivalling the aggregate cost of caring for patients with diabetes.” “Universal underreporting, in turn, undermines the ability to measure error accurately…..the more closely we examine patient care, the more error we find. No setting is free from hazards and no specialty is immune, and patients are at risk no matter what their age, sex, or health status.” Perhaps Psirides would care to tell us where the line should be drawn. How much longer does he think the public should put up with this killing and maiming while silently obeying the demand to comply with medical instructions. He may not like these facts, but those affected by them, like them even less. Competing interests: None declared |
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Catherine Clarke, Carer Sheffield, S17
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Psychiatrists play at being GODS. They are a law unto them selves. They are above the law. In the mental health system they are the law. The inhumane medication they forcibly treat - all is within the law. Carers and patients are the most vulnerable people in the whole of the NHS becuase of the legal sectioning power. Who Suffers? My neurolepically damaged son who is being slowly crucified and legally. My daughter, my son, myself and my husband. Who Cares? Out of fourteen psychiatrists in the last four years, only one psychiatrist truely cared. Another psychiatrist stated he would take full clinical responsibility in the event of my son's death from neuroleptic medication. I despise the arrogance, ignorance, deceipt and the inhumanity which is endemic in psychiatrists. Until the day I die: I will never forgive. I will never forget. For what psychiatrists have done to my son. All within the law. Good on you, Russell, for letting the cat among the pigeons. Competing interests: None declared |
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Theo H Fenton, Consultant Paediatrician Mayday Hospital, Croydon CR7 7YE
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Gurli Bagnall seems to have misread Barbara Starfield's article [Is US Health Really the Best in the World? JAMA 284(4);483-485.2000]. In that article, Dr Starfield claimed that iatrogenic causes constitute the third leading death in the United Sates -- about 225,000 deaths per year. This figure included 80,000 deaths from nosocomial infections, and 106,000 'non -error' (her term) deaths related to adverse effects of drugs. She estimated about 27,000 deaths from actual errors. I'm not defending any of Starfields figures, and have no idea how robust they are, but she certainly didn't say that medical error is responsible for a third of deaths. Competing interests: None declared |
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Damian Conway, Registrar Royal Prince Alfred Hospital, Sydney, Australia
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Dear Mr Holbrook I applaud, sir, your recent editorial in the BMJ. I recall my pre-reg house-officer year 10 years ago when I was "at large" on acute surgical wards in the first week of my job having been given a day of so-called orientation at the start. At no time did I receive formal instruction on the drawing up & administration of intravenous drugs & yet I was expected to perform such tasks each & every day. It is fortuitous that I managed not to make an error while doing this, though a house officer from a neighbouring hospital & her patient were less fortunate. She, again not having been properly orientated or trained, injected a fatal dose of an intravenous drug intrathecally. She too faced criminal proceedings, but was acquited at trial. It is often "the system" that has failed if an otherwise intelligent & sensible junior doctor makes an error that has catastrophic & deadly consequences. It is only human to err if not given adequate & comprehensive orientation & instruction before commencing work in a specialised unit. It is especially so if the human being concerned has been on-call or working all night during an arduous busy shift, but such considerations would appear to be well beyond the legal profession & the tabloid press. I recall reading in a British newspaper of how a "killer anaesthetist" had caused the death of a patient during surgery - the journalist expressed his outrage & indignation at how such a monster was still allowed to practice. Right beside that story was one detailing the unfortunate deterioration in the medical condition of none other than Myra Hyndley - the journalist anxious to put across that everything was being done to remedy her plight. The marked contrast in tone between the views expressed about a doctor who had attempted (but failed) to assist the recovery of a patient & those expressed about the poor health of a convicted (albeit famous) mass child murderer was as shocking as it was obvious. The British press is as pre-occupied with the cult of celebrity as it is with naming & shaming "killer doctors". The profession continues to pay a heavy price in the wake of the case of Dr Harold Shipman - since then it has been "open season" on doctors & I believe that this is used time & again as a stick with which to beat us all. The pain, anguish & anger of those bereaved through medical error is totally warranted & understandable, but to pursue a policy of punitive legal action against every doctor who has made a mistake is not going to prevent such events from happening in the future. The adversarial legal system in the UK does the cause of finding out the truth about what went wrong no favours. It is more concerned with pointing the finger & apportioning blame & the lawyers more concerned with receiving their fees in return for a pound of medical flesh. If doctors have been found to be grossly negligent through personal neglect of their professional duty then they should be held accountable. However, if their error was as a result of inadequate training or instruction, then it is the system that should be held accountable & the doctors concerned & all those following them should be provided with the appropriate knowledge & training before being expected to perform specialised tasks. Competing interests: None declared |
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Gordon G Anderson, gp NE Links
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Please can dillusional ramblings be kept off what is meant to be a forum for reasoned debate. Competing interests: None declared |
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alan j carson, consultant neuropsychiatrist edinburgh
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The cited article in JAMA refers to nonerror adverse events and is being misquoted. Presumably such an 'error' is acceptable in a campaigner but not a doctor. The misquoting of journal articles to suit personal hobby horses seems to be a standard tactic in the electronic age. Competing interests: a doctor |
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Steven Ford, GP Haydon & Allen Valleys Medical Practice
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Dear Dr Struthers My apologies for being absurd. You would not have employed such terms had you not been sincerely moved to do so but I am afraid I could not really discern the key point of dissension between us. Perhaps we are talking past each other. Most parent's first reaction to the death of a child, where a perpetrator appears to have been found, would be murderous. Insofar as I have any knowledge of the Mulhem case, I am no apologist for him, nor I ever sought to be so. Had my son been the fatally injured patient of Mulhem I hope I would eventually have brought myself to view and attempt to comprehend the facts, as far as they could be ascertained, before reaching a settled attribution of blame. Other correspondents have queried the lack of action against the consultant involved and the suggested want of vetting in the appointment of Mulhem - these are areas that seem to remain unresolved. Probably the only common factor amongst the inmates of the world's jails is that they got caught. I do not think that you and I are alone in this tumbrel Sir. Though presently hidden by the fog of our mutual incomprehension, I believe I can hear almost all of our careful peers close by and many others besides. It is the capricious, equally error prone but strangely-impervious-to- criticism-and-inconvenient-reality nature of the law that I protest, which may yet be all of society's undoing. Major and fatal legal errors are known. I repeat my question - do the lawyers and judges responsible suffer sanctions comparable to those they visit upon others? Is it possible that a system could be devised that brought equity and justice, rather than the desiccated application of law and precedent alone? Adversarial justice is a medieval relic that has no place in a civilised society. Steve Ford Competing interests: As before |
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Russell D. Lutchman, Consultant Forensic Psychiatrist Reg. Address: c/o Broadmoor Hospital, Crowthorne, BERKS RG45 7EG
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Lord Bingham of Cornhill in his delivery at the Newsam Memorial Lecture, "The Mandatory Life Sentence for Murder" on 13 March 1998 opened by stating:
On the principle of fashioning penalties to the seriousness of offences Lord Bingham went further to say:
Whilst his comments were in the context of murder, the general principles applicable to crime and punishment cannot be in question. Are a significant proportion of doctors anarchists, fascists or revolutionaries? Have not the courts applied the principles described, justly and fairly to doctors who commit crimes (- albeit not murder -) arising from medical mistakes? If not, why not and how not? Is the unintentional negligent killing of consenting patients in under-staffed, under-resourced facilities, not a matter for serious public concern? I’m afraid many of the respondents in this forum, by demonstrating a shocking lack of knowledge or awareness of legal principles in medical negligence, will be the laughing-stock of those in the legal profession. It is evidently the case that many respondents know not that they know not, and have demonstrated arrogance along with ignorance (in recognition of Catherine Clarke's contribution). Perhaps the equation that needs to be examined in medical negligence is: Arrogance + Ignorance => Negligence I suggest that all medical educators focus on minimising the A-I factors and ensure that medical students graduate oozing with the relevant legal principles. Furthermore, all doctors attending revalidation assessments should be required to demonstrate that they can properly apply legal principles to their medical practise - else they don't pass 'Go' - and they don't go to jail either! Best of all, patients don't die at their hands! Competing interests: None declared |
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Gurli Bagnall, Independent Patients' Rights Campaigner Marlborough Sounds 7372, New Zealand
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Correction: I refer to my rapid response “In response to Alex Psirides” (4 December, 2003) and in particular, the quotation from JAMA. There is a typing error in the third line. It should read: “20,000 deaths/year from other errors in hospitals.” I would like to comment on two rapid responses published since then. The first was written by Theo H Fenton who stated that I seem (quote) “to have misread Barbara Starfield’s article…. In that article, Dr Starfield claimed that iatrogenic causes constitute the third leading death (sic) in the United Sates -- about 225,000 deaths per year. This figure included 80,000 deaths from nosocomial infections, and 106,000 'non -error' (her term) deaths related to adverse effects of drugs. She estimated about 27,000 deaths from actual errors……. she certainly didn't say that medical error is responsible for a third of deaths..” I have three comments to make: (1) It is hardly credible denying the iatrogenic cause of nosocomial infections. (2) I see no way to interpret the “106,000 deaths/year from nonerror, adverse effects of medication” other than physicians who continue to prescribe drugs even when their adverse effects in patients have been recognized. (3) No one as far as I am aware, has ever claimed that medical error is responsible for a third of deaths. What Starfield said was that iatrogenic injury was the third leading cause of death after heart disease and cancer. There is a vast difference. The second rapid response upon which I would like to comment, was written by Alan Carson who stated that the article referred to “nonerror adverse events and is being misquoted”. I suggest Dr. Carson actually reads the article before making further comments. Nothing was misquoted. Even we humble campaigners do our best to be accurate. It is interesting to note that no attack was made upon the material taken from the BMJ (1) which was used as a reference (number eleven) by Starfield in JAMA. (2) It is understandable that the gentlemen concerned do not wish to face the unpalatable truth, but if the only way to defend a case is by misrepresenting the facts, then there IS no case to defend. References: 1.Weingart SN et al. Epidemiology of Medical Error. BMJ Volume 320. 774-777. 18 March, 2000. http://www.bmj.com/cgi/content/short/320/7237/774 2.Starfield B. Is US health really the best in the world? JAMA vol. 284 No. 4. July 26, 2000. http://jama.ama-assn.org/issues/v284n4/ffull/jco00061.html Competing interests: None declared |
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Alex Psirides, Registrar, Intensive Care Medicine Wellington, New Zealand
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Ms.Bagnall, thank you for providing the original reference. I have read the paper. I have three comments on your comments: "..(1) It is hardly credible denying the iatrogenic cause of nosocomial infections..." I would, inevitably, beg to differ. Iatrogenic: 'Induced in a patient by a physician's activity, manner, or therapy' Nosocomial: 'Of or pertaining to a hospital' You appear to be implying that doctors are the source of all hospital infections. Doctors are not the only people in hospitals, in fact we represent a minority. Patients are regularly exposed to pathogens carried by others - visitors, air conditioning systems, canteen food, even, dare I suggest it, each other. On the whole, the patients tend to be sicker than the doctors. I am not aware of any evidence that cites physicians as the sole cause of nosocomial infections. Perhaps you could enlighten us. "..(2) I see no way to interpret the “106,000 deaths/year from nonerror, adverse effects of medication” other than physicians who continue to prescribe drugs even when their adverse effects in patients have been recognized..." Well how about this then. Every patient is an individual. Side effects of drugs are unpredictable as they represent an individual response to a common stimulus (the drug). A side effect profile is compiled from effects noted on large populations during testing. Not everyone suffers from the same side effects. When I prescribe a drug I presume that the beneficial effects outweight the detrimental. Any drug that does not fulfil this will not get out of small scale clinical trials. If a drug gives patient A a rash, this does not mean I wouldn't prescribe it for patient B. This doesn't make me negligent. I cannot predict if someone will have an anaphylactic reaction to a drug unless their previous history indicates otherwise. I am also not aware of any drugs that are completely side effect free. This does not mean that they are not beneficial for the purpose for which they are intended. Perhaps, again, you could enlighten us. "...(3) No one as far as I am aware, has ever claimed that medical error is responsible for a third of deaths. What Starfield said was that iatrogenic injury was the third leading cause of death after heart disease and cancer. There is a vast difference...." At last we agree! I presume this original statement that you criticise was as erroneous as your typo. My original question remains - if your interpretation of the Starfield article stands (which I don't agree with) then, if you were diagnosed with anything other than cancer or heart disease, I presume you would not wish to consult a doctor further? Would you rather die of meningitis than risk anaphylaxis from Penicillin? Competing interests: None declared |
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Michael O'Donnell, FRCGP. Former GP turned journeyman writer Loxhill GU8 4BD
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Maybe because of the company he keeps, Dr Lutchman seems unaware that there are circumstances in which the highest honour to which a doctor can aspire is to be a “laughing-stock of those in the legal profession” Competing interests: Experience of human problems seen in general practice rather than in Broadmoor |
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Catherine Clarke, Carer Sheffield S17
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Gordon, I feel disrespected by your dismissive atttiude. Competing interests: None declared |
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Mark Struthers, GP HMP Bedford, UK
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Dear Mrs Clarke Why do you feel that Dr Anderson’s dyslexic twitter applied to you? It seems to me that in this forum for ‘reasoned debate’ it has been exclusively doctors who have been guilty of deluded rambling. It is Dr Anderson’s banal contribution to this debate, which should have taken the short drop into a vat of the editor’s red ink. Readers will have been curious as to Dr Anderson’s provenance. In fact, he works from a fortress surgery on the Grimsby Road, Cleethorpes, in the county of North East Lincolnshire. This was once part of the old county of Humberside, itself carved out of the ancient counties of Yorkshire and Lincolnshire. Dr Anderson may well play golf. We all needed to know those things. Competing interests: I worked for many years as a GP in Grimsby. Some of them were happy. I didn't play golf |
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Catherine Clarke, Carer Sheffield S17
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Arrogance and Ignorance paramounts to Negligence? In my experience, surrounding NHS professionals, there are other attitudes associated with behaviour that paramounts to negligence. Deception, dishonesty, insincerity, defensivness, cohersion, power and disrespect. Needs and feeling are projected onto others, people lack accountability for their own behaviour, which results in proportioning blame elsewhere. All these attitudes are experienced by people with weak personal boundaries resulting in difficulties with interpersonal relationships. This includes relationships in debates which land up in slanging matches and one up- manship. Legal negligence? or Self negligence? When people begin to take care of themselves by developing their own SELF-KNOWLEDGE and SELF-AWARENESS, they will cease being negligent of their own self and develop stronger personal boundaries. Yes, people make mistakes. We are all human beings. Individual personal development makes accountabilty for our mistakes easier together with the punishment which the Law meters out. Which ever side of this debate you are on, I ask that you give a thought to all those 60% of people who are ineffectively medicated with neuroleptics. Many of these people are incarcerated in institutions. Basically they are in prison for life. Competing interests: None declared |
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Amitava Banerjee, Senior House Officer, Accident and Emergency Hull Royal Infirmary, Kingston-upon-Hull, East Yorkshire. HU3 2JZ
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Dear Editor, I read Holbrook's article with great interest and also the variety of responses. I would like to add a few points. Firstly, there is obviously a difference between deliberate acts of malice and non-intentional(ie. accidental) mistakes, even though the outcome is fatal in both cases. This difference means that they should be treated completely differently. As a junior doctor myself, making mistakes in a correctly supervised setting is the lifeblood of my clinical learning. If I was doing everything right already, then I would not need further training. Every measure must be taken to avoid fatal medical errors, but the very few people who make them should not be made into scapegoats by the media, society and their professional colleagues. Naming,shaming and sentencing an individual does not prevent the same mistake happening again. Errors do not happen in isolation and tend to be symptomatic of a chain of errors or a fault in the system. We live in a world of collective responsibility, and yet I have not heard the consultant's name mentioned in the case of intrathecal vincristine injection. Although we have to be accountable for our mistakes, we are still human. If on the one hand society wants doctors to be less paternalistic and more human, it cannot also expect us to be more God-like and perfect. Secondly, the fact that there were less legal cases in the past does not mean that there were less fatal medical mistakes. It may well be that patients were less likely to complain or that doctors had a much more paternalistic and powerful role.The increase in the number of complaints and legal cases is a sign of society's changing expectation. Of course, medicine has to change as society changes. However, the ideals of medicine have not changed much since the very first Hippocratic Oath, ie. beneficience and non-maleficience. The patient should always come first, and some would say that increased successful litigation shows this. I think that because of Accident-Line and a greater number of convictions (such as those discussed by Holbrook), every medical student and doctor is brought up too much on the doctrine of "If you had to stand up in a court of law, could you defend yourself?" This is fair enough but the motivation for practising good medicine is far more than avoiding the courts. This is not dissimilar to the obsession, in my own A&E department, with 4-hour waiting times.It is assumed that this one criteria will improve patient care, and concentration on this seems to detract from care of the patient. We live in an age where public and political hysteria periodically change our medical practices instead of the gradual changes in systems that are necessary. We should not lose sight of why we entered medicine as a career in the first place. Yours sincerely, Amitava Banerjee 1. The criminalisation of fatal medical mistakes. J Holbrook BMJ 2003; 327: 1118-1119 Competing interests: None declared |
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W. Hamish Wallace, Consultant Paediatric Oncologist Royal Hospital for Sick Children, Edinburgh EH9 1LF
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Sir, As a pracising paediatric oncologist the inadvertant administration of vincristine intra-thecally is my worst nightmare, it is universally fatal. As stated in Jon Holbrooks editorial (BMJ 2003;327:1118-9) there are 23 reports worlwide and 14 in 15 years in the United Kingdom. The custodial sentence for Dr Feda Mulhem will not stop a further mistake, but the implementation of the recommendations in the Toft report (www.doh.gov.uk/qmcinquiry) almost certainly will. The Toft report stated that the adverse incident that led to Mr. Jowett's death was not caused by one or even several human errors but by a far more complex amalgam of human, organisational, technical and social interactions. These recommendations have been adopted nationwide in children's cancer units. In our hospital we have developed a process of open reporting of critical incidents that has led to the identification of potential system errors and their correction. A "near miss" if reported and investigated becomes a "free lesson". We must not allow a blame culture to develop within the health service that unfairly persecutes individuals for system failures. In 2000 the DOH published a report of an expert group on learning from adverse events in the NHS, chaired by the Chief Medical Officer (An organisation with a memory). The conclusion was that the NHS needs to develop: unified mechanisms for reporting and analysis when things go wrong; a more open culture, in which errors or service failures can be reported and discussed; mechanisms for ensuring that, where lessons are identified, the necessary changes are put into practice; a much wider appreciation of the value of the system approach in preventing, analysing and learning from errors. These recommmendations must be implemented and adopted within the NHS. The criminalisation of fatal medical mistakes will not stop the inadvertant intra-thecal administration of vincristine, the acceptance of the concept of system failure, the investigation of near misses and the adoption of a no blame culture within the health service is more likely to stop further tragic medical mistakes occurring in the future. Holbrook J. The criminalisation of fatal medical mistakes. BMJ (2003) 327:1118-9. Toft B. External inquiry into the adverse incident that occurred at Queen's medical centre, Mottingham, 4th January 2001.www.doh.gov.uk/qmcinquiry. An organisation with a memory (2000). www.doh.gov.uk/orgmemreport. Competing interests: None declared |
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Jerry Varghese, Consultant Psychiatrist MGM Muthoot Medical centre, Kozhencherry, Kerala. 689641
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Medical Negligence or misadventure was and still remains a serious concern all over the world. I read with bemusement about the racial difference in the number of cases suggested and fully agree with some of those opinions. I would like to suggest a possible solution based on my impression of the scenario in India. Up until a few years back medical negligence case was very popular and usually involved a lot of publicity including handcuffing of doctors being paraded on streets being garlanded with slippers ect. Most clames were for monetary compensations. Recently there was a judgment that what ever monetary clame was awarded would be given as a fixed deposit of a long period before the money could actually be made available to the litigants. This assured that the money went to the litigants and not to the lawyers who were in fact instigating the people to file the cases with their payments being a commission of the rewarded clame. Having to shell out the advocates fees on their own or the payment reaching the advocates after inordinate delay the lawyers slowly lost interest and the number of cases being filed has now come down significantly. Measures such as these may help reduce the possibility of instigation from third parties who want to make a fast buck in the name of feigned morality. Competing interests: None declared |
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