Friday, March 19, 2010
SOCIALIZED MEDICINE IN PRACTICE
Below are five reports from just ONE DAY in Britain
Terrifyingly inept foreign doctors are a symptom of a sickness in the NHS - not the cause
By Professor Karol Sikora
When a supposed cure has instead become a new kind of sickness, then surely something is badly wrong. Yet that is what has happened in the modern NHS. The target culture brought in to benefit patients is having fatal consequences. A system that originally aimed to improve performance and efficiency is now threatening patients' lives, distorting clinical priorities and encouraging the use of foreign doctors, who may be too inexperienced or unqualified for the jobs they have been given.
The tragic case of 94-year-old Ena Dickinson is a heart-rending example of what can go wrong in a health service that puts compliance with political requirements above the real needs of patients. Mrs Dickinson, a Lincolnshire grandmother, died in 2008, soon after she underwent a hip replacement operation which was carried out at Grantham Hospital by a German locum surgeon, Dr Werner Kolb. In an appalling series of errors, Dr Kolb cut through the wrong muscle, severed an artery and used the wrong cutting tool, with the result that Mrs Dickinson lost almost half her blood in an operation that should have been routine. One witness, another doctor from the hospital, said he was 'horrified by what I saw', while an expert surgical witness, Professor Angus Wallace, told the inquest on Tuesday that he 'could not believe the level of neglect in the operation'.
The episode raises troubling questions about the NHS's increasing reliance on foreign doctors, both from the European Union and from further overseas, a practice that has been driven partly by the Government's fixation with meeting targets and partly by an inadequate supply in the number of domestic trained doctors.
We do not, of course, live in an insular world and overseas doctors have long been an integral part of the NHS. Indeed, when I first worked in the NHS in the early Seventies, I saw that the service would not have been able to function without the support of doctors from Asia. And, whether we like it or not, Britain is part of the European Union, one of whose guiding principles is the free movement of labour throughout the member states. So, without drastic political changes to the very nature of our society, we would not be able to adopt a siege mentality when it comes to employment in the NHS.
Nevertheless, the disastrously botched operation that Mrs Dickinson suffered highlights a worrying trend, where too often foreign doctors have been imported to provide cover in the NHS, without any proper checks on their background, their ability to speak English, their experience or their competence.
According to reports about Dr Werner Kolb, he had actually performed few hip operations during his career and had spent most of his recent years giving lectures, hardly a record to inspire confidence in the operating theatre. Dr Kolb's negligence may be particularly graphic, because of the way he sawed through the wrong muscle, like some grotesquely inept carpenter.
Some might argue, therefore, that it is particularly dangerous to let foreign doctors carry out surgery without rigorous monitoring. But this would be a fallacy. Every branch of medicine, from general practice to pathology, has the potential to do mortal harm because of its intimate connection with the delicate structure of the human body. In my own field of cancer care, disasters can occur because of a misdiagnosis or the administration of the wrong dosage of drug.
The calamitous risks of incompetence by GP locums were illustrated in early 2008 by Dr Daniel Ubani, who flew in from Germany to Cambridgeshire to provide weekend cover for a local practice, only to end up killing one pensioner, David Gray, by accidentally giving him ten times the maximum dosage of diamorphine. The coroner then said Mr Gray's death had been caused by 'gross negligence', words that carry a chilling echo in the Dickinson case.
One of the key problems is that, under an EU directive of 2004, doctors who qualify in any EU country can move to work in any other EU state without even the most limited examination of their skills, aptitude or language. In contrast, foreign doctors (ie from outside the EU) must pass a skills and English language test - yes, even the Australians and Americans.
EU countries are also not forced to provide information on their doctors' professional histories - for example, whether they have been struck off for committing a criminal offence or killing a patient through negligence.
There are estimated to be around 20,000 EU doctors registered to work in the NHS, a quarter of them from the former Eastern Bloc countries.
Now the vast majority of them are certainly perfectly competent, but, even so, difficulties will inevitably arise over language and culture. Every nation, for instance, has its own medical hierarchies, differing relationships between doctors and nurses, or unique approaches to patient care.
Moreover, foreign doctors without a sound grasp of English will not understand what their patients are telling them, something that is a particular concern in GP services.
It is telling that EU doctors are twice as likely to face disciplinary hearings before the General Medical Council as their British counterparts, in which foreign doctors from outside the EU are three times as likely to be struck off the medical register - statistics that point to the laxity of checks.
We cannot blame foreign doctors for wanting to work in the NHS. Britain has one of the best-rewarded medical professions in the world, with GPs earning on average over £100,000-a-year and leading consultants far more. These are incredible riches for doctors from the old Soviet sphere of influence. In Poland, where my family has some of its roots, a doctor is likely to earn around £500 a month or £6,000-a-year, a sum that can be made with a few weekend or holiday stints in Britain. As a consequence, one in six of Poland's doctors now works abroad.
Nor is the NHS management entirely to blame for the catalogue of controversies that has arisen from the employment of foreign staff. NHS bosses are under tremendous pressure to meet waiting lists targets set by the Government, so they will take any action, bear almost any cost, to achieve this. So rather than postpone operations during periods when staff are on leave, they bring in foreign doctors to keep the conveyor belt moving.
In Ena Dickinson's case, it would not have mattered if her hip replacement operation had been delayed by a week or two, but no doubt the management of Grantham Hospital was appalled at the idea of slipping behind the Government's arbitrary 18-week deadline for such routine surgery. So, in a disastrous misjudgment, Dr Kolb was brought in so the needs of bureaucracy, if not the patient, could be met.
The problem has been compounded by the Government's failure to assess correctly the needs of the NHS for doctors, with the result that foreign doctors have been brought in to cover gaps in supply. It must be admitted that the demands on the NHS have grown enormously in recent years as a consequence of increasing numbers of elderly patients, a growth in the British population and advances in medical care. Twenty years ago, the idea of carrying out a hip replacement operation on a 94-year-old grandmother would have been unthinkable.
Moreover, the EU working time directive drastically reduced the number of hours that any doctor could be on duty, which meant that more staff had to be made available. But the need to increase the supply of doctors only emphasises the need to scrutinise their competence more vigorously. What we need, therefore, is an assessment of their skills by practical and verbal demonstration, accompanied by checks on their background and a basic language test. We're doing it for our own graduates, after all. That is what our NHS patients deserve. We cannot allow any more tragedies like that of Ena Dickinson.
Killer Muslim doctor with repeated disregard for patients is suspended for just FOUR MONTHS by British regulators
A doctor with a 'disregard' for patient safety was suspended for just four months today for sending home a baby girl who died the next day from blood poisoning. Dr Salawati Abdul-Salam failed to spot little Aleesha Evans' deadly condition and sent her home saying she had a viral infection that needed only Calpol and Nurofen. She died the next day.
A year before the baby's death, another of Abdul-Salam's patients died after a wrong diagnosis, while a pensioner suffered a collapsed lung under the trainee's care. GMC panel chairman Professor Denis McDevitt said the doctor's actions demonstrated a 'total lack of attention to detail' and a 'serious degree of carelessness.'
Colin Perriam, 66, had died after Abdul-Salam analysed six-month old blood samples, then wrongly diagnosed a ruptured ulcer as constipation. Mr Perriam was discharged from Cardiff's University Hospital of Wales on December 15, 2004 with a prescription of laxatives.
Widow Pamela Perriam had told the hearing: 'She said that he was suffering from constipation. 'We were given some powders that you mix with water for mild constipation and we were not given any other instructions. 'We were not given anything else except to say that it was mild constipation and mild laxatives should deal with the problem.'
But the next day Mr Parriam could not get out of bed and when his stomach appeared swollen and blotchy the following evening, his wife called an ambulance. By the time it arrived her husband was unconscious. Mr Parriam underwent emergency surgery but never recovered and died the next day on February 5, 2005.
A month earlier, Abdul-Salam gave a 79-year-old woman an unnecessary chest drain after reading the wrong x-ray. She had to apologise after the elderly woman's lung collapsed.
On August 9, 2006, Aleesha Evans was rushed to the Royal Gwent Hospital in Newport, Wales, vomiting with a rash and a temperature of 37 degrees. But the trainee specialist registrar did not even examine the baby and discharged her two hours later after noting her condition was 'unremarkable.' The doctor had seen the patient by this stage and noted she appeared to be better than she had been and that she was playing. But her heart rate was still high and her temperature had risen to 39 degrees, the hearing was told. The baby was discharged at 11pm with a diagnosis of viral illness.
But she was suffering from meningococcal septicaemia - blood poisoning - and died the following day. Abdul-Salam was placed under supervision at the Princess of Wales Hospital in Bridgend after Aleesha's death. She was only allowed to perform three hours of clinical work a day and had to sign every patient off with a supervisor. But within three weeks Abdul-Salam had broken the terms of her training and more than a third of her patients had been discharged without her superior's consent.
One of these patients was a 10-year-old girl with a broken wrist who attended A&E on 22 September 2008. The child required treatment under anaesthetic but Abdul-Salam discharged her to the outpatient fracture clinic.
Prof McDevitt told Abdul-Salam: 'The panel has concluded that you have not yet fully appreciated the magnitude of your deficient performance and misconduct. 'You demonstrated poor judgment when under pressure. Your lack of careful clinical method resulted in the inadequate assessment and management of patients and you failed to appreciate fully the discordance between the patients' clinical condition and the results of investigations. 'The panel considers there remains of risk of you repeating errors and exercising poor judgment, particularly if you were to return to work in a more pressures environment than you are currently exposed to.'
Prof McDevitt said the panel had considered imposing conditions on Abdul-Salam's practice but concluded her actions involving baby Aleesha Evans were too serious: 'Taking all the factors into account, the panel concluded that your registration should be suspended for a period of four months. 'Your misconduct was sufficiently serious to undermine public confidence in the profession. It is also important that you, and the medical profession, are left in no doubt that such behaviour, which clearly had consequences for patient safety, is unacceptable.'
The doctor had been working as a locum at the Kent and Sussex Hospital in Tunbridge Wells, Kent for the last five months, but she will now be unable to keep her job.
British doctors who wouldn't listen allow little girl to die
An eight-year-old girl with an acute fear of dentists who starved to death after her milk teeth were taken out under anaesthetic died because of a “lack of communication” between health agencies, an investigation has concluded.
Sophie Waller refused to open her mouth even to eat after the operation. She had developed her phobia at the age of four when her tongue was scratched during a routine check-up. When she refused treatment after cracking a tooth on a boiled sweet her parents became so concerned they took her to their GP who referred her to the Royal Cornwall Hospital in Truro.
Surgeons decided to remove eight remaining milk teeth under anaesthetic to avoid problems in future. But she was left so traumatised by it she refused to open her mouth to eat or drink.
A report by the Local Safeguarding Children Board has now found there was a “lack of clarity” from the agencies responsible for Sophie’s care after her discharge from hospital. She was sent home despite her condition and her parents did not know who to turn to when her health deteriorated.
By the time of her death in December 2005 Sophie, from St Dennis in Cornwall, was severely malnourished and weighed just 22kg. Her parents had been feeding her a diet of yoghurt and mashed fruit and tried to get help from their GP and the hospital but were instead referred to a child psychologist.
She was found dead in bed by her mother four weeks after her discharge and the cause of death was given as kidney failure as a result of starvation and dehydration. An inquest in February 2009 found there was no blame attached to her parents who had tried to get help for their daughter.
The serious case review found of a lack of communication between all the health agencies involved in her care. The report says: “No clear written plan was made on discharge and there was lack of clarity about responsibility for medical review following discharge.
“The clinical psychologist made telephone contact with the child’s parents in the week after discharge but did not see her again. “There was a lack of clarity over the open door arrangement which was intended to allow the child’s parents to bring her back in the week following discharge. When they phoned for advice on the seventh day, they were referred back to the psychologist for support.”
Her mother Janet Waller, a nursery school teacher who has two other children, said the report highlighted how their pleas should have been heard. She said: “All we’ve wanted all along is for people to listen to us. People ask me how many children I have, I say three, but technically I haven’t any more. I’ve got to live with this for the rest of my life.”
At Sophie’s inquest in February last year the Cornwall coroner, Dr Emma Carlyon, said that the Royal Cornwall Hospital was guilty of a number of failings which led to Sophie’s death. She said: “The severity of her malnutrition and dehydration was not recognised. This prevented her from receiving the medical support that could have prevented her death.”
Dr Ellen Wilkinson, Medical Director of Royal Cornwall Hospital Trust, said: “We would like to apologise to the family of Sophie Waller. Everyone involved in her care was saddened by her tragic death. This was a very unusual case. “There were shortcomings in the communication between the health organisation and Sophie’s parents.”
'Blood-spattered walls and mouldy equipment': How a quarter of British government hospitals fail to meet basic hygiene tests
A quarter of NHS hospital trusts are failing to meet basic hygiene standards, with some treating patients on blood-spattered wards or with dirty equipment, a damning report has found. A third of ambulance trusts have also missed the targets set, according to the Care Quality Commission. The watchdog's report follows the introduction of tough new hygiene standards after a series of scandals at hospitals in Maidstone, Basildon and Stafford.
It also came as a survey of NHS employees found many are too overstretched to do their jobs properly because of staff shortages.
On hygiene, the CQC found 42 out of the 167 NHS trusts inspected were in 'breach' of registration requirements by failing to meet standards, with some hospitals being warned over blood-spattered wards and dirty equipment. In Basildon, where at least 70 patients died as a result of poor hygiene last year, investigators found a commode soiled under the seat and 'procedure trays, used by staff to carry equipment when they take blood samples or give injections, had blood spattered on them'.
At children's hospital Alder Hey, in Liverpool, the inspection revealed dirty toys, hair stuck to medical equipment and 'nappy changing mats stored on the floor next to a toilet'. Water 'ran brown' from taps in patient areas.
A total of 36 trusts did not provide areas to decontaminate instruments, three trusts failed to flush unused water regularly to control legionella outbreaks, and a dozen failed to keep clinical areas clean. The situation was so bad at four ambulance trusts that they were given written warnings about the state of their vehicles and stations.
Nigel Ellis, the CQC's head of inspection, said: 'We have on rare occasions found evidence of a direct risk to patients and have intervened using our enforcement powers to ensure swift improvements were made. 'In over half of trusts we have made some suggestions or requirements for improvements to ensure their practices are the best they can be.'
A spokesman for the Department of Health said: 'There's no doubt that the trusts rose to the challenge --we've seen swift and tangible improvements in their performance, and on follow-up meetings all met the required standards.'
Meanwhile, half of NHS workers claim that staff shortages are stopping them doing their jobs properly. Of the 160,000 workers questioned by the CQC, 46 per cent said they were unable to do a proper job.
One in ten doctors in Britain is foreign and untested
Almost one in ten doctors on the medical register comes from the EU and has not had to take any language or competence tests before working in Britain. The shocking figure exposes the lax controls over European locums taking up hospital posts in the NHS and providing out-of-hours GP cover. Unlike doctors from elsewhere in the world - who are forced to prove language skills and medical knowledge before being registered - such testing is forbidden for doctors qualified in Europe and Switzerland.
Campaigners want a complete overhaul of the system after the death of a grandmother following appalling blunders by a German surgeon flown in by the NHS. Ena Dickinson, 94, lost nearly half the blood in her body during what was meant to be a routine hip operation at Grantham Hospital in Lincolnshire. Werner Kolb, who had been working in the NHS for three weeks, severed an artery and became so flustered he started speaking German in the operating theatre.
An expert witness described it as the worst case of negligence he had come across - yet Dr Kolb, pictured today for the first time, was left free to work in the UK for a further eight months before being suspended by the General Medical Council.
Dr Kolb, who had been mainly lecturing for four years before the tragedy, refused to attend the inquest and denied his conduct had anything to do with Mrs Dickinson's death eight weeks later from pneumonia. Last night a colleague at Bethesda Hospital in Stuttgart insisted: 'I find it hard to reconcile the words said against him in Britain with the precise surgeon I know.'
But Mrs Dickinson's daughter Kathy Ingram, 57, said: 'The system is disgraceful and clearly isn't working. NHS trusts have to assume that locum doctors' qualifications from Europe are reliable without doing their own checks. 'You trust your doctor because he's in authority but if he hasn't been verified and isn't monitored, you never know what standard of treatment you'll get. The law has to be changed so that there is closer monitoring.'
Figures show there are more than 230,000 doctors on the GMC register of which 21,451 - almost 10 per cent - gained their qualifications in other EU countries. The ban on checks comes from a European directive ordering member states to allow workers free movement. This means the GMC is forced to accept qualifications at 'face value', according to its chief executive Niall Dickson.
The GMC has protested about the rights of doctors to work freely across Europe being put ahead of a patient's right to safe treatment. In a presentation to the EU's Green Paper on the European Workforce for Health, it said: 'Legislation must be amended to allow healthcare regulators across Europe to establish that a doctor has the level of language proficiency necessary to practise safely. 'We are also prevented from adopting a general requirement to prove competence and cannot specify the standard of acceptable competence. 'The current situation is profoundly at odds with the pursuit of safe and high quality health care.'
Dr Vivienne Nathanson, head of science and ethics at the British Medical Association, said: 'Whilst it is essential doctors are able to communicate with their patients and the regulatory authorities are able to assess fitness to practise, it is also important we don't make it impossible for those that do have the appropriate skills to work in the UK.'
Posted by JR at 12:47 AM