Cancer unit faces ministerial inquiryBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7119.1327b (Published 22 November 1997) Cite this as: BMJ 1997;315:1327
The Department of Health is to conduct a “full and detailed investigation” into the clinical and management practices of a leading gynaecological surgeon after allegations of serious professional misconduct were reported in the House of Commons.
In a debate on NHS whistleblowing on 5 November Jim Cousins, Labour MP for Newcastle Central, complained that Mr John Monaghan had performed radical vulvectomy without previous biopsy on a patient; approved unacceptable standards for cervical smear testing and other pathology services; and was allowed to maintain his own clinical files away from his hospital's central registry and under his sole control.
Mr Monaghan has declined to comment, but on his behalf the Medical Defence Union has said that he “denies that there is any truth in the allegations against him in parliament.” The Medical Defence Union also claimed that the allegations are “not new” and had been “considered and dismissed” by the General Medical Council and the then regional health authority. Some complaints about Mr Monaghan were upheld by investigators from the authority, and he was required to change his clinical practices.
Test of new policy
The Monaghan case has become the first major test of the new policy on NHS whistleblowers. A week earlier Gateshead Hospitals NHS Trust had planned to dismiss one of Mr Monaghan's surgical colleagues, Mr Debi Sinha, who first drew the problems to its attention.
The morning before the debate the trust abandoned plans to sack him, telling him instead that “there is a strong case for your dismissal.” But the trust was “not satisfied that to do so would necessarily be in the best interests of the NHS.”
Mr Sinha and Mr Monaghan are both consultants in gynaecological oncology. The House of Commons was told how Mr Sinha had tried officially to raise his concerns about the clinical practices of his colleague for 10 years. The two surgeons have next door offices but—after permission from the health authority in 1989–Mr Monaghan limits access to information about the patients he treats.
As a result of a dispute between the two consultants, early in 1990 the Northern Regional Health Authority commissioned Professor James Scott and Professor John MacVicar to conduct an independent review.
The report highlighted the unusual practices of Mr Monaghan and his team in reporting their own pathological results. It was “essential” to have a “truly independent” pathology service, the investigators warned. The previous practice was quickly ended.
Three years later Mr Monaghan's name was at the heart of a second health authority inquiry after a local GP was found to have been collecting cervical smears using his finger (and a spatula) but not a speculum.
The recall of 738 patients was delayed for more than a year because Mr Monaghan offered verbal and written support for such practices as being of “high quality” and suitable for women from “lower socioeconomic groups.”
A third health authority inquiry was called in 1994 after Mr Sinha cited evidence of 34 clinical events of serious concern. These included the cases of “Mrs A” and “Mrs B,” both of whom underwent radical vulvectomy and lymph node removal. The investigator, Mr Michael Brudenell, reported that Mr Monaghan “clearly chose to ignore accepted practice” in operating without prior biopsy.
Such procedures would also be condemned by the standards Mr Monaghan himself sets as editor of Bonney's Gynaecological Surgery and other texts, in which he describes prior biopsy as “vital.” He writes: “No matter how expert and experienced the operator, a biopsy of a vulvar lesion is mandatory prior to radical surgery.”
Mr Brudenell nevertheless advised against disciplinary action against Mr Monaghan on grounds that included the risk of “adverse publicity” for the regional health authority. Mr Sinha reported Mr Brudenell's finding and his evidence to the GMC.
Although Mr Sinha complained of more than 30 instances of alleged serious professional misconduct, the GMC decided to look only at the cases of A and B. They were unable to pursue the case of Mrs A as a matter of alleged professional misconduct since she would first have to be told what had gone wrong. The trust refused to do this. Mrs B had already died.
Matters then foundered until 1996, when Mr Sinha was instructed to provide cover for his colleague. He agreed but warned trust managers that it was his professional duty to advise patients if their notes showed that they had received damaging treatment which they did not know was unnecessary.
With advice from the BMA and colleagues, Mr Sinha maintained his position. He was threatened with dismissal. Mr Sinha's constituency MP then took the affair to parliament. In the debate Mr Cousins condemned Mr Monaghan's withholding patients' files from colleagues as “extraordinary” and “full of risks to good, sound patient care.”
The health minister, Alan Milburn, did not endorse claims by Mr Monaghan, the health authority, and the trust that problems in Gateshead had already been dealt with. Highlighting the right of concerned NHS staff to speak out, he replied that it was “absolutely clear that there can be no justification for an employer penalising staff who speak out about genuine concerns.”
His words may have struck home in the northern region. Three years ago Professor Liam Donaldson, then regional general manager of the Northern and Yorkshire Regional Health Authority and now chief executive of the Northern and Yorkshire region, provided the BMJ with a compelling account of the difficulties of problem doctors, warning that “patients and the quality of their care will suffer as they have done in the past because of a reluctance to face up to difficult issues” (BMJ 1994;308:1277-82). The guiding principle for managers was “never seek a quiet life by avoiding dealing with problems which may be to the serious detriment of patients and the effective functioning of a clinical department.”