Case of “dysfunctional” Dutch doctor exposes “culture of silence surrounding mistakes”

BMJ 2009; 339 doi: (Published 11 September 2009) Cite this as: BMJ 2009;339:b3720
  1. Tony Sheldon
  1. 1Utrecht

    A report into how a Dutch teaching hospital allowed a “dysfunctional” consultant neurologist to continue working unchecked for more than a decade has raised serious questions about the supervision of hospital consultants in the Netherlands.

    The report, And Where was the Patient . . . ? followed an external investigation into neurologist Ernst Jansen Steur, who worked at the Medisch Spectrum Twente in Enschede between 1992 and 2003.

    Investigators led by Wolter Lemstra, former chairman of the Dutch Hospitals Association, concluded that Dr Jansen harmed patients through misdiagnoses and incorrect prescribing.

    Although alerted to errors by other hospital staff in 1998, the hospital’s management board failed to act. The report concludes, “The extent of the damage would have been significantly less if those directly concerned had met their responsibility for the quality of care.”

    By 2003 Dr Jansen was forced to take extended sick leave and then early retirement after stealing drugs and falsifying a prescription for his own use. He left with a severance package, and the case was not referred to a medical disciplinary board.

    In January this year Dr Jansen was found to be working in a private clinic in Germany. Amid accusations of a cover-up, the present hospital management board ordered an independent investigation.

    The Lemstra Committee found that Jansen had worked in isolation, had kept hardly any patient notes, made diagnoses that could not be substantiated, often prescribed drugs that were not recommended, and altered the results of neuropsychological tests to ensure that certain drugs could be prescribed.

    In particular, patients were incorrectly diagnosed with Alzheimer’s disease and Parkinson’s disease.

    Dr Jansen remained unaccountable, distancing himself from protocols made by the neurology specialty, with which he had serious conflicts. In 1998 the hospital’s board of management failed to act when a colleague neurologist made a written complaint. It laid the responsibility for solving the conflict with the specialty itself, which became resigned to the situation. The Health Care Inspectorate, the government body charged with maintaining patient safety, was aware of the conflict but took no action. The Lemstra Committee concluded that no one had asked whether the situation had endangered patient care.

    Once Dr Jansen had left, states the report, the efforts of the hospital board were directed to keeping the affair “in house” to avoid damaging the reputation of Dr Jansen and the hospital. One former patient was paid damages on the condition that he remained silent and withdrew a medical disciplinary complaint.

    The committee emphasised that the system of checking the quality of care was no different from that used in many Dutch hospitals. The affair could have occurred elsewhere and, despite improvements since the 1990s, still could. Its recommendations include making explicit the divisions of responsibility between doctors and hospital management for the quality of care; introducing stricter intercollegiate testing, including reviewing patient notes; and introducing medical managers for every specialty.

    The Dutch Medical Association supports the conclusions. Johan Legemaate, head of legal affairs at the association, who is advising the government on the “lessons from Enschede,” emphasised that together with clear agreements on responsibilities, hospital consultants should be subject to annual evaluation. “The culture of silence surrounding mistakes and colleagues’ mistakes must end,” he said.

    So far 140 former patients have lodged complaints. A decision is pending on whether to launch a criminal prosecution.


    Cite this as: BMJ 2009;339:b3720

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