Murder in the NHSBMJ 1994; 308 doi: http://dx.doi.org/10.1136/bmj.308.6924.287 (Published 29 January 1994) Cite this as: BMJ 1994;308:287
- W J Appleyard
Individuals and organisations cannot plan for the truly extraordinary. When a once in a millennium event occurs there is a high chance that people will react badly and make mistakes. The deliberate killing and injuring of children in a British hospital by nurse Beverley Allitt was just such an event,1 and many mistakes have been made in the aftermath.
But for the diligence of the two consultant paediatricians, Drs Nelson Porter and Charith Nanayakkara, at Grantham and Kesteven Hospital Beverley Allitt would probably not have been convicted of murder. Now, however, nine months after she was convicted of killing four children and injuring nine more in the children's ward of Grantham and Kesteven Hospital,1 the two consultants are without their jobs. They also fear criticism from the Clothier inquiry, set up by the secretary of state for health into the circumstances of the murders and due to report next week. The consultants have not had a chance to defend themselves in public. Because of the decision to hold the Clothier inquiry in private, health service employees and the public cannot be sure that all the lessons that might have been learnt will be learnt. And, worst of all, services for children in Grantham have been diminished.
In an environment such as a children's ward, where staff are dedicated to providing the best possible care, the threshold for recognising covert acts of excess and inappropriate administration of therapeutic substances is high. It is not therefore surprising that several deaths had occurred before that threshold was reached. Nevertheless, when each individual unexplained death occurred the consultants quite properly sought help from their regional tertiary paediatric centre in Nottingham. In one case Dr Nanayakkara sought the opinion of a paediatric pathologist, but this request was persistently denied. It was the consultants themselves who eventually started to see a pattern to this nightmare of unexplained deaths and illnesses on their ward and who prompted the police inquiry. During their investigations the police asked the head of the children's department at Queen's Medical Centre, Nottingham, Professor David Hull, to review all 14 suspicious events. In only one of these cases did he think in retrospect there was definite evidence to raise a suspicion of foul play.2 And the British Paediatric Association stated in its evidence to the Clothier inquiry that many paediatricians would [probably] have had similar difficulty in recognising the criminal acts which occurred in Grantham. The association also said that from the information available the Grantham paediatricians' standard of clinical practice was comparable with that of paediatricians elsewhere.
It came as a great shock therefore that both paediatricians were made redundant when the contract for providing paediatric services to Grantham was transferred by the regional health authority from the local hospital to Queen's Medical Centre in Nottingham. The decision was made hastily and without the opportunity for local hospitals to compete. It also completely ignored the recommendations of the region's own independent inquiry; this was set up after Beverley Allitt's arrest to look into paediatric clinical and staffing practices at Grantham. This inquiry team, which included a paediatrician and a nurse, commended many aspects of the paediatricians' work while recommending ways of making both doctors and nurses less professionally isolated. It concluded that the paediatric department has the ability to provide a local and easily accessible friendly service for the child population served. It also recommended the appointment of an additional consultant paediatrician with an interest in community child health, together with new intermediate grade and junior doctors.
Instead, once the contract was transferred to Nottingham four new consultants were appointed by Queen's Medical Centre, three based in Nottingham and one in the community. Each visits Grantham one day a week. The time available to Grantham was therefore reduced to the equivalent of one full time consultant. Both Dr Porter and Dr Nanayakkar were invited to apply for these posts but neither was appointed. Despite a challenge by the BMA in the high court, under European Union legislation on the transfer of services, the redundancies were upheld.3 The consultants are now appealing to the secretary of state against their dismissal under the paragraph 190 procedure.
At the trial of Beverley Allitt the judge said that he hoped the paediatricians would have the opportunity of putting their case in public. This was not to be. Despite the clamour for a public inquiry into what had happened in Grantham, the Clothier committee sat in private. Though charged with making a judgment on a paediatric unit, the committee does not include a paediatrician. Natural justice and custom and practice dictate that doctors should be accountable to a committee which includes their peers and that they should have the opportunity of challenging any potentially damaging evidence against them.
Irrespective of what the Clothier committee recommends, there are lessons here for doctors and other professionals caught up in extraordinary events. The health authorities revealed their own inadequacies under pressure by abandoning the expected consultation procedure on the reconfiguration of services. The reconfiguration has had the effect of diverting attention away from poor management and inadequate levels of medical and nursing staffing at Grantham. Queen's Medical Centre should have had a sense of shared responsibility for the cases for which their professional help was sought. That support has not been evident since the murders came to light. Moreover, it used the opportunity to introduce a model of service - based in a tertiary centre with outreach services to a district hospital 28 miles away - that flies in the face of current recommendations for a combined community and hospital child health service and was introduced with little debate or consultation. The position is further complicated because the internal market provides an extra incentive for Queen's Medical Centre to take on the contract: the end result of the reconfiguration is more work for the tertiary centre.
There is an urgent need to revise the contract for paediatric services at Grantham. The recommendations of the regional inquiry for a combined child health service conform to the model recommended by the Royal College of Physicians and the British Paediatric Association and should be implemented. The consultants' diligence and involvement in the day to day care of their patients should be recognised. No charge has been levelled against them, and no justice will be served until they are allowed once again to provide the local population with readily accessible high quality paediatric care in a combined child health service.