NHS KILLS MOTHERS TOO

They're not fussy: Mothers, kids, who cares? Everybody still gets their salary and nobody is ever penalized significantly

Ten women died during childbirth or shortly afterwards in a hospital that suffered from a lack of clinical leadership, a poor working culture and an overloaded maternity unit. The deaths, at Northwick Park Hospital in northwest London, occurred between April 2002 and April 2005, and involved women giving birth or within 42 days of birth. The Healthcare Commission publishes a detailed account today of each of the deaths.

In April 2005 the commission recommended "special measures" to restore good standards at the hospital, which included calling in an outside team to safeguard women. In today's report it says that these measures are working. But the report lays out in painful detail what can happen in a maternity unit that has inadequate systems. In nine out of the ten cases, the report says, there are grounds for criticism. It summarises these as:

* Insufficient input from a consultant or a senior midwife (in five cases), with difficult decisions often left to junior staff.

* Failure to recognise and respond quickly when a woman's condition changed unexpectedly.

* Inadequate resources to deal with high-risk cases: there were too few consultant obstetricians and midwives; not enough dedicated theatre staff; a reliance on agency and locum staff without adequate support; and a lack of a dedicated high-dependency unit.

* A culture that led to poor working practices.

* Failure to learn lessons on the unit, leading to mistakes being repeated.

* Failure by the North West London Hospitals NHS Trust board to appreciate the seriousness of the situation. It was aware of the number of deaths, and should have acted sooner.

Two aspects of the service are singled out for praise. The report says the anaesthetists and the haematology department, which provided blood for the patients, responded well under difficult circumstances.

Of the women who died, six were Asian, two African, one Afro-Caribbean and one European. The hospital serves half a million people in Brent and Harrow, two boroughs with large black and minority ethnic populations.

The causes of death varied. Strokes following pre-eclampsia (very high blood pressure) were the cause in three cases, with bleeding after giving birth in four other cases. One women died of viral encephalitis, one of a cardiac arrest.

The hospital investigated the deaths from a predominantly legal point of view, as if seeking to defend itself, the report says. Common factors were not found, but the commission says that they did exist and should have been identified.

Marcia Fry, the commission's head of operational development, said: "We hope this report gives some answers to the families involved. "We expect trusts across the country to read this report. Most women give birth safely. But there are risks and the NHS must ensure it does all it can to reduce them. There can be no excuse for failing to learn the lessons from tragedies of this kind." Since April 2005 three additional consultants and 20 more midwives have been recruited. The inspectorate also believes there is a better team working among consultants, obstetric staff and midwives.

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Another incompetent foreign doctor in an Australian State government hospital

Up to six people might have died because a pathologist in northern New South Wales misdiagnosed their tests, the state government said today. NSW Health Minister John Hatzistergos and the chief executive of Hunter New England Health, Terry Clout, today announced the results of a review of 7350 anatomical pathology tests taken by Dr Farid Zaer. The review was conducted in March this year after concerns that Dr Zaer, who worked at Tamworth Hospital from 1999 to 2001, may have failed to correctly analyse tests for diseases, including cancer.

Mr Clout said that of the 7432 tests re-examined, 38 cases had significant variations which would have a serious impact on patient care. Of these, he said, five or six people had since died. "It may or it may not have been the case (that the misdiagnosis caused death) and because we don't have a parallel universe we will never know," Mr Clout said.

Mr Hatzistergos said he would willingingly refer the matter to further authorities if the families of the deceased wanted him to. "Obviously this is a dreadful thing to have happened," Mr Hatzistergos said. "I am very concerned by the results that have been revealed."

Three independent pathology laboratories conducted the review and advised the government that 97 per cent of Dr Zaer's tests were accurate. Of 217 people who were found to have had variations, Mr Clout said all but four had been contacted. "Those doctors have confirmed that in 179 of those cases there was no impact on the care provided to the patients," he said. "But that does regrettably leave some 38 patients where the significant variation in the test has meant that there was a less than desirable treatment provided." As a result of the misdiagnosis, the patients had either been over-treated or under-treated, including a small number who underwent unnecessary surgery. "We have undertaken a few operations that were not necessary, I have been quite clear about that," Mr Clout said. "Regrettably there have been cases where there appears to have been an error in the original diagnosis, (that) if known at the time, might have meant the patient received different care." But he refused to say if patients had lost arms, legs or breasts as part of the procedures, saying he did not want to identify people in a small rural community who "have already gone through anxiety in relation to this issue".

Dr Zaer, who was trained in India, has been banned from practising as a pathologist in NSW. Mr Hatzistergos said Dr Zaer was no longer working in that field, but was believed to be working in Queensland, possibly as a general practitioner.

Mr Clout said there was no way of knowing if the five or six people who had died in the past seven years had done so because they had been "significantly misdiagnosed". "We can't draw conclusions from that," he said. "Just because two things happen in the same window of time does not mean that one is a causal link to the other." But Mr Hatzistergos said he would refer the matter to the coroner for further investigation. "I am happy to refer anything to any further authority if required to," he said. Asked if he anticipated action by distressed family members, he replied: "We neither expect nor rule it out, it's obviously a matter for the families to make a decision in relation to that."

Concerns about the quality of Dr Zaer's work first surfaced in 2004 while he was working at the Illawarra Health Service. Despite this, thousands of patients were not tested until this year. Mr Hatzistergos said he was disappointed it had taken so long to get the results. "The only thing I do regret is that it has taken as long as it has," he said.

Source

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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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