British woman dies waiting for brain scans

A high-flying television producer died from a suspected epileptic fit while waiting for vital brain scans on the NHS. Laura Price, 30, who worked on shows such as Big Brother and Strictly Come Dancing, was found dead in her home just hours after she had been discharged from casualty.

The evening before she died, Miss Price, from Notting Hill, west London, had begged a junior A&E doctor for anti-seizure drugs but had been told they could only be prescribed by a neurologist.

Two days earlier she had visited a specialist at Charing Cross hospital and was told she would have to wait six weeks for a brain scan. She had felt "concerned and afraid" at having to wait that length of time for a test before being treated for a recurrence of childhood epilepsy, Westminster coroner's court heard.

She had not had a seizure for more than 10 years, but after a series of "strange episodes", including a numb face and flashing lights in her vision, she had visited her GP and was referred to the specialist.

On the night before she died Miss Price entered her flatmate Sarah Jackson's room in a confused state. Miss Jackson told the court: "I was very concerned and called an ambulance." Once at Charing Cross hospital Miss Price begged a doctor for drugs. Dr Christina Coppel, who treated her, told the inquest it would have been against hospital guidelines to prescribe them without a neurologist.

At lunchtime the next day Miss Price was found lying on the floor and an ambulance pronounced her dead at the scene. A post mortem examination concluded it was a sudden unexpected death in epilepsy. Dr Paul Knapman, the coroner, returned a verdict of natural causes. Yesterday, her parents said they were considering legal action against Hammersmith Hospitals NHS Trust.

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Dangerous public hospital negligence in Australia

Safety experts say too little is being done to stop patients being harmed or even killed by avoidable errors in Australian public hospitals

PATRICIA Skinner has experienced the sharp end of medical mistakes. She spent 18 months with a pair of 15cm scissors in her abdomen. Why? Because doctors forgot to take them out at the end of an operation. [What happened to the before-and-after count that should have been routine procedure?] "It was agony ... my husband would drive over a bump in the road, and I would scream,'' recalls Skinner. "My husband would say, `What's the matter with you?', and I thought I had cancer. I said to my doctor, `I feel like I've been knocked to the ground and someone's been kicking me with steel-capped boots'.'' In a way, of course, something had. But unfortunately for Skinner, now 79, for some time medical staff refused to believe anything was wrong. She had had major surgery, they told her; what did she expect?

The truth was only discovered after Skinner herself eventually insisted on an X-ray, which was performed at Sydney's St George Hospital [A notorious hospital] in October 2002, 18 months after surgery at the same hospital to remove bowel polyps. "They did the X-ray twice, because I don't think they could believe what they were seeing,'' Skinner says. She went straight back to the hospital, and had surgery to remove the scissors the very next day. But after so long inside her, the scissors - which in the meantime had moved from her abdomen to near her coccyx, the tailbone at the base of the spine - had become partially overgrown by her own tissues. To get them out, doctors had to cut out a chunk of Skinner's bowel as well.

What she wanted then was an explanation of how it could have happened, but Skinner and husband Don had little joy here either. "They said at the time that scissors were `too big to lose', which was absolute nonsense,'' Skinner tells Weekend Health. "Was somebody off sick, or was somebody working for hours and got tired? I said there must have been a reason, but I wasn't allowed to talk to anybody. If you can understand what happened, you think, `OK, I can accept that'. But when you don't know, there's nothing to accept.''

The X-ray images and her story were reported around the world, and eventually Skinner, now 72, accepted compensation from the hospital, the size of which is confidential. The hospital also changed its counting procedures to make sure equipment is properly accounted for after operations.

Sadly, as Australia's first national report on serious mistakes shows, Skinner's experience is far from unique, either in terms of the mistake or the culture of secrecy and denial that surrounded it. The report, published this week by the Australian Institute of Health and Welfare and the Australian Commission on Safety and Quality in Health Care, recorded 130 instances of "sentinel events'' reported by 759 public hospitals in 2004-05. These events fell into one of eight categories of serious events that were agreed by Australian Governments in 2004.

As The Australian reported this week, nearly half (41 per cent) of the 130 events were in the category of wrong site or wrong patient - where an operation or test was performed on the wrong part of the patient's body, or on the wrong patient altogether. Retained instruments - the category that Skinner would have fallen into - took second place, accounting for 27 cases.

The factors that contributed to these and other incidents were varied: staff ending their shift giving inadequate briefings to other staff starting a shift, or staff acting when they didn't know the full facts. For example, in one incident a patient was transfused wiTh blood intended for another patient with an incompatible blood type - a potentially fatal mistake - because the co-ordinating nurse only knew of one transfusion request, and when a courier delivered some blood she assumed - wrongly - that it was meant for that patient. Other reasons included staff not following rules or guidelines, or not recording information on charts or other documents properly.

The report's authors say the reasons for doctors and nurses not reporting mistakes in the past include "fear of litigation and adverse publicity'', and admit that while low, the numbers of sentinel events in this week's report are likely to rise in future editions as doctors and nurses start to feel more comfortable about owning up after something has gone wrong. Even so, outgoing commission chief executive Diana Horvath rejected suggestions the numbers were merely the tip of the iceberg, claiming they were instead "a substantial part of it''.

But independent safety experts disagree, and it's not as if you have to look far to find other examples of medical mistakes every bit as horrifying as that which happened to Pat Skinner. In a bulletin sent to its members earlier this year, doctors' insurance company MDA National revealed an unnamed 24-year-old patient suffered nightmares after a "throat pack'' - a wad of absorbent gauze or dressing to soak up blood and other fluids during surgery - was left in place after prolonged oral surgery. "The patient coughed up the throat pack some hours later on the (recovery) ward,'' the bulletin said. "He was very distressed ... although the pharynx was sucked out under direct vision at the end of the procedure, the bloodstained pack was not seen until the patient coughed it up several hours post-operatively. "Sporadic reports of this complication continue to occur, sometimes with disastrous consequences for the patient.''

MDA National said measures that might help avoid repeat occurrences included labelling patients' foreheads if throat packs were used, and recording the pack on the list of items that have to be accounted for at the end of the procedure.

In another case in the same bulletin, a 35-year-old patient went to an emergency department complaining of severe renal colic. He asked for a painkiller called hydromorphone, also known as Dilaudid, which he had previously found to be the most effective medication. Instead the doctor ordered hydromorphine - a drug eight times more powerful - because she did not realise the difference. The bulletin said this patient did not suffer any negative long-term effects from the overdose, although it added that some other previous mix-ups involving hydromorphone "have resulted in patient deaths''.

This week's report said the reporting culture was improving, and numbers of reported events will be higher in future reports. But other safety experts think Horvath's suggestion that this week's figures already represent a significant proportion of the problem is little short of ridiculous. Steve Bolsin, associate professor of patient safety at Victoria's Geelong Hospital, says the "notion that 130 adverse events is the majority of the iceberg is completely erroneous. Previous work has shown that between 5 and 10 per cent of admissions have adverse events associated with them, and things may be worse in general practice. So there's a huge need to begin to improve in these areas.''

Bolsin points to the findings of the groundbreaking Quality in Australian Health Care Study (QAHCS), published in the Medical Journal of Australia 12 years ago (1995;163:458-71), which claimed that up to 16 per cent of hospitalised patients would suffer an adverse event, and that 50 per cent of these would be preventable. Of these preventable events, 10 per cent would lead to permanent disability or death.

Some doctors have been bitterly critical of the QAHCS findings, saying it was biased and found a much higher rate of adverse events than a similar US study. Had the same analysis applied in Australia as in the US, they say, the rate of adverse events reported in QAHCS would have been up to 25 per cent less. With 4.3 million hospitalisations in public hospitals in 2004-05, the QAHCS suggests Australia's toll of serious adverse events should be closer to 35,000 than 130. But even a 25 per cent pullback from that figure still paints a worrying picture.

A follow-up editorial in the MJA two years ago (2005;182:260-1) asked if there was any evidence that health care had become any safer in the decade since the 1995 report, and promptly answered the question itself: "Unfortunately, the answer is no''.

Adverse events are also associated with significant costs. Another study in the MJA last year (2006;184:551-5), conducted in 45 major Victorian hospitals, found each adverse event contributed an extra $6826 in costs, and the total cost for all the events in the participating hospitals in 2003-04 was $460 million - over 15 per cent of direct hospital costs.

Bolsin says there are "an incredible number of adverse events going on that are not being reported'' through the existing channels. However, a pioneering scheme already piloted at his own hospital in Geelong could hold the answer. For the pilot, 14 anaesthetic registrars used personal digital assistants (PDAs) fitted with special software to report adverse events to a central database, identifying them in one of four categories - events causing death, serious outcomes such as extended hospital stay or permanent harm, transient or minor harm, and "near miss'' adverse events that had no bad effect on the patient. Researchers combed through the notes of cases where no incidents had been reported, to check how many incidents had been missed.

The findings, reported last year in the International Journal for Quality in Health Care (2006;18(6):452-7), found an adverse incident was reported for 156, or 3.5 per cent of the 4441 anaesthetic procedures reported, nearly half (46.2 per cent) of which were near misses. Only one incident was identified in the case notes as having been missed, giving a reporting rate via PDAs of 99.5 per cent - far higher than has been achieved anywhere else in the world. Bolsin says PDAs can also be used to download appropriate clinical practice guidelines and other relevant information to help guide doctors, use of which he says has been proven to improve treatment outcomes.

So far, however, there has been limited enthusiasm from health bureaucrats for implementing a PDA-based system for adverse event reporting. "If we are really serious about safety in health care, we have to start using these technologies, and we have to start using them effectively and constructively,'' Bolsin says.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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