NHS deaths and “blame culture”

A picture of Nico Reed, a young white boy with ginger hair, sitting in a swing designed for a disabled user, with straps and a full seat, holding on to the support ropes with both hands. He is smiling. The swing is in a back garden with white plastic garden chairs on a patio behind, and a rear door to a house behind them.Last week a report was published by the Health and Social Care Advisory Service (HASCAS), commissioned by the NHS Oxfordshire Clinical Commissioning Group, about the death of Nico Reed (right), a young man who died at a residential home run by Southern Health, the same NHS trust whose negligence led to the the deaths of Connor Sparrowhawk and others in its learning disability and mental health units (report in PDF format here). An inquest into Nico’s death found that he had not been observed as often as he should have been, but the family have said that after he was forced to move for financial reasons from the school where he had lived since he was six, the physiotherapy he depended on ceased and the staff ceased trying to communicate with him, which both his family and the school staff had done mainly through a communication book, which they lost. This comes on the heels of revelations about the deaths of hundreds of mostly elderly patients at a hospital in Gosport after they were prescribed doses of diamorphine (heroin) that they did not need through syringe drivers; it has been alleged that the patients given this treatment were the noisy or disruptive ones, not those in most pain. In reaction to this, health secretary Jeremy Hunt called to an end to the “blame culture” within the NHS, which he claimed prevented whistle-blowers from coming forward, as this could have prevented further deaths during this period in Gosport. (More: Alison Cameron.)

As someone who has followed the stories of a number of disabled young people who have died as a result of negligence by both NHS and private health care providers, I do not believe that this comment by Jeremy Hunt is really intended to strengthen the position of whistle-blowers. That needs specific legislation to prevent such people being dismissed or otherwise penalised when they raise concerns, either with their management or with anyone else. As the BBC article linked above says, nurses tried to raise concerns with the management 30 years ago but were ‘silenced’; people have seen their careers ruined for raising concerns about corruption and other issues with people within their own organisation, which is not “whistle-blowing” in the real sense, anymore than informing authority such as the police about wrong-doing is whistle-blowing. I believe it has more to do with reducing the capability of patients and their families to hold healthcare providers and their staff accountable for wrongful deaths or injuries, and is strongly linked to complaints, usually from right-wing tabloids, about “compensation culture”.

Most of the cases I have been following do not hinge on a single negligent action by a single doctor or nurse (the case of Oliver McGowan being a notable exception). They are the result of decisions made by a whole series of people from healthcare bureaucrats and managers to medical staff. Inquests generally look at the immediate circumstances, such that the inquest into Stephanie Bincliffe’s death did not ask why she was in an institution where the staff clearly did not know how to treat her and so left her for seven years in a windowless room where her only comfort was gorging on junk food until she died of obesity-related sleep apnoea, or why nothing had been done to rehabilitate her into the community in all that time, and the inquest into Nico Reed’s death concentrated on the interval of his observations rather than the wider picture: why he was in that institution, why he was denied physiotherapy when it was of clear benefit, and so on. So, identifying human error contributing to a disabled person’s death is difficult as the inquest only looks at the immediate circumstances; as the original coroner in the case of Colette McCulloch (who has now stepped down as a result of complaints by Colette’s family) said, he is there to rule on how she died, not why.

The idea of attacking “blame culture” in the NHS rather smacks of the “no-blame approach” some schools favour when dealing with bullies: they want to get everyone round a table (or in a circle on the floor) and talk about the problem, why the bully wants to hurt someone, what the victim might have been doing that might have contributed to the problem, and so on. It rather assumes that every bullying situation is a “six of one, half-a-dozen of the other” situation and that the victim might actually be frightened to sit in a room and talk about their feelings with a bully, who might well be the dominant person in the class or year group and might then pretend to agree and then betray everything they have been told to their friends in the playground. In the real world, blame is a fact of life. If I shunt another vehicle at 10mph and damage someone’s back bumper, there is blame: either I or my insurer pays for the repair and/or replacement. If I make a mistake and cause a serious accident, I may lose my licence or go to jail. The same is not true of mistakes in medicine; if a doctor thoughtlessly prescribes the wrong medicine, or one they had been advised had caused adverse reactions and which the patient and their family had asked not be prescribed, the chances of their being held accountable are slim even if the patient dies. They are generally given the benefit of the doubt and the bereaved family’s view is regarded as emotional and biased, inferior to the doctor’s authoritative, expert opinion.

Also this past week, it was reported that an Australian gynaecologist, Emil Shawky Gayed, was facing an investigation after mutilating a number of women and performed unnecessary operations on numerous women over a decades-long career, with consequences that could have been fatal for the women or harmful to the babies they were carrying. One of the patients, Vicki Cheadle, was told by another surgeon that Gayed’s treatment of her had been botched and that she would have died if she had waited any longer for treatment, but refused to support her with a statement about Gayed’s errors:

“He threatened me, and told me he would make sure no doctor in [town] would treat my sons or myself if I took legal action against Gayed,” she said. “That he would get on the stand and lie, because I was lucky any doctor operated on me and that I should respect Gayed’s training and experience.”

I saw a tweet by a feminist blogger who claimed that this represented how much Australia values women. It’s more a reflection of the lengths the medical profession will go to back each other up even when they are in the wrong, even with lethal consequences for ordinary mortals. The doctor referred to in this quote clearly had more to gain by retaining Gayed’s friendship and professional support than by protecting other women he might operate on. In the case of the elderly people killed at Gosport, the doctor was a woman and the patients were of both sexes; she was defended by hospital management and even this past week, a former nurse who worked under her defended her, claiming she was a “good woman” who just wanted to make patients comfortable, even though this was the justification given at the time for giving the overdoses.

Of course, whistle-blowers have to be protected and to be able to expose wrongdoing without fear (and the fear might stem from the fact that their own record might not be squeaky clean) and not every family of a person who dies as a result of wrongful actions while in hospital wants a single person to carry the can. They do want what happened to their relative never to happen to anyone else, but sometimes this means the people responsible being out of the profession, or in jail. It’s exceedingly distressing to watch one’s disabled relative — son, daughter, brother, whoever — be treated with callous disregard to their well-being, happiness, family life and liberty over a series of decisions, for them to suffer obvious abuse or neglect and then die, and absolutely nobody held accountable to the point of even taking a pay cut. When those of us in less skilled occupations mess up and people die, there are consequences for us; in healthcare and its management, there is simply too much impunity. If a patient is not photogenic and they or their family are not well-connected, doctors (especially consultants) know that acting according to their prejudices or with indifference to their life and well-being is something they can get away with. Before we even talk about “ending blame”, we must end this.

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