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On drinking from a poisoned chalice

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2347 (Published 31 October 2008) Cite this as: BMJ 2008;337:a2347
  1. Rod Griffiths, president, Faculty of Public Health
  1. rod{at}stonebow.demon.co.uk

    For a period in the late 1990s there were repeated headlines about research on children in North Staffordshire NHS Trust using continuous negative extrathoracic pressure (CNEP). They alleged that excessive deaths had occurred. As regional director of public health I had already commented to the media that premature babies of that age had a significant mortality and that the children in the trial had fared no worse that expected. Public health passed the story to the research and development directorate.

    The story did not go away and local MPs took it up. A meeting with the relevant minister and one of the MPs took place. The director of research and development should have gone, but he was in America. The minister wanted someone from the regional office to be present. I went.

    By the time of the meeting formal complaints had already been made both to the General Medical Council and to the trust. To my surprise the minister asked a new, though not unreasonable, question: could there be a problem with the governance system, at that trust or in general? I was the regional director of public health, and I came out of the meeting having agreed to do a low key review to look at the system. Lesson one: poisoned chalices are easy to pick up.

    After the review was announced new patient groups appeared, complaining about what was then known as Munchausen’s syndrome by proxy, nothing to do with our terms of reference, but they were persistent in lobbying the minister’s office. It would have been excessively complex to have commissioned yet another inquiry, so this was added to the task that we were asked to do. Lesson two: when drinking from poisoned chalices, try to avoid top-ups.

    We hired a team that interviewed everyone who wanted to give evidence and appointed a panel with relevant expertise. We reviewed all the statements and decided which individuals or groups we needed to interview in person. We set up dates to take oral evidence and spent several days doing that. A number of potential witnesses were prepared to give evidence only on condition that their statements would not be made public. Of course when we reported, it made it easy for others to say, “Where did they get that idea from?” Some of the evidence that was given in confidence was important and without it we would have had a less complete picture, but it did make the review easier to criticise. Lesson three: if you have to drink from a poisoned chalice, better to do it in full public view if you can.

    We were told many diverse stories about some issues, both in relation to research and in relation to child abuse. They could not all be true but documentation did not exist to verify one consistent story. We had to conclude that the essential question raised by the minister had some validity—there did seem to be something the matter with the system. Accordingly we recommended that research governance needed a better system; that child protection needed clearer guidance about possible fabricated illness; that consent needed clearer guidance; and that there should be a way of reporting supposed adverse events from all treatments, not just drugs. We also concluded that parents really needed to know if CNEP in neonates did damage or not. Short of a new randomised control trial it seemed that funding a longer term follow-up might give the answer. Marlow et al have now completed the review that we commissioned (Lancet 2006;367:1080, doi:10.1016/S0140-6736(06)68475-4); it shows that CNEP was associated with no more damage than control treatments. Several months after we reported and ministers accepted all our recommendations, we were roundly attacked in the BMJ (BMJ 2000;321:715-6, doi:10.1136/bmj.321.7263.715). I can’t think of anything I have found more uncomfortable than that weekend. Worse still was having to speak on the Monday at a conference on a different subject, wondering just how many in the audience had read that week’s BMJ. Lesson four: when drinking from poisoned chalices, don’t expect the effects to wear off quickly.

    It is easy with hindsight to think of ways in which we could have been given different terms of reference, spent more money, done things differently. Commenting on the detail at this distance seems pointless but I do agree with those who say that a body is needed that can either investigate complaints about research or advise on the subject. Had such a body existed at that time, however, I still think it would have come to similar conclusions. We do need governance systems that protect patients and provide safe circumstances for research to prosper. Both are essential, but neither was guaranteed by the systems in place before we reported. No doubt the current system could be improved, but we do need a system or there will be more inquiries.

    Finally, does drinking from the poisoned chalice do any good—is it good for the soul, the personal development and all that? Do you develop a thicker skin, making you tougher and more able to take poison in the future? I think not. I feel more vulnerable and easier to hurt as a result of the experience, though that may be a good thing. People who are in senior positions need thin skins, not thick ones. So lesson five for poisoned chalices is simple: when handed one, drink up and smile—it goes with the job.

    Notes

    Cite this as: BMJ 2008;337:a2347

    Footnotes

    • Editor’s note: This article was originally posted at bmj.com on 1 April 2006 as a webextra article to an unrelated personal view. Since this article did not show up in searches, was not enabled for rapid responses, and did not include a formal citeline, we are republishing it to make the article more accessible and to allow it to be referenced.

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