Safety First?

The 2018 World Patient Safety, Science and Technology Summit at the ‘stunning’ 8 Northumberland Avenue in London ‘was organized with the support of the Secretary of State for Health and Social Care, the Rt. Hon. Jeremy Hunt MP’. Prices were $1000 for hospitals, healthcare organizations and committed partners that have made a formal pledge of allegiance to the Patient Safety Movement Foundation (PSMF). For ‘first time’ attendees who were ready to commit it was also $1000. For medical technology, medical product and pharmaceutical companies that have not formally affiliated with the PSMF, the price rose to $5000. The highlight of the conference is the PSMF Humanitarian Award which each year goes to the ‘patient safety leader who has made significant progress in eliminating preventable patient deaths so that we can reach our shared goal of zero by 2020.’ Step forward Jeremy Hunt, without whose support the conference would not have been possible.

Given the large number of preventable patient deaths and widespread avoidable suffering in the NHS due to insufficient capacity, unsafe staffing levels and widespread cancellations of routine care, this would seem a bold choice. True, MD would far rather have a health secretary who is interested in patient safety than one that isn’t, and Hunt has certainly listened selectively to the stories of some people whose relatives have been seriously harmed by healthcare, whilst ignoring the tales of others, particularly NHS whistle-blowers, whose stories are politically inconvenient. His latest campaigns are to try to reduce medication related fatalities (a good thing) and to encourage staff to call consultants by their first name to try to make it easier for anyone to speak up if they spot and error. Hunt cited, as he often does, the preventable death of Elaine Bromiley as an example of a nurse knowing what to do (an emergency tracheotomy after a failed anaesthetic intubation) but not being able to override the consultants. Whether calling them by their first names would have made a difference is debatable.

Elaine Bromiley died in 2005, and MD wrote about it long before Hunt became health secretary (Eye May 2008). She was operated on privately by a very experienced team – her consultant anaesthetist had sixteen years of experience, the ENT surgeon had 30 years under his belt and three of the four nurses in the theatre were also very experienced. There was no short staffing or competing interests of emergency cover and the theatre was fully equipped. It was a ‘dream scenario’ for patient safety, rarely found in the NHS. And yet they made a catastrophic error when the intubation turned out to be unexpectedly difficult. No-one was found guilty of gross negligence manslaughter or struck off.

Contrast this to the preventable death of Jack Adcock in 2011, in NHS circumstances so unsafe that no amount of consultant first-name calling would have made a jot of difference (Eye recent). Indeed, Dr Hadiza Gawa-Barba had no consultant cover on site when she made errors in Jack’s care in an otherwise unblemished career. She missed a diagnosis of sepsis, as thousands have before and since, and yet was singled out for gross negligence manslaughter and aggressively pursued and struck off by the GMC. In 2005, Professor Graeme Catto admitted to missing a diagnosis of septicaemia in a man in his twenties admitted as an emergency, who subsequently died. Catto was not found guilty of manslaughter or struck off, but he had been president of the GMC for 4 years when he made his public admission.

The GMC has variously been described as racist and vindictive in pursuing a BME junior doctor when so many senior white men who make similar human errors face no sanctions. Hunt has at least spoken up about the folly of permanently erasing an otherwise competent doctor who openly admitted to her errors and should never have been put in such an unsafe situation, but he has overseen the 100,000 vacancies and widespread bed shortages in the NHS workforce that make it such an unsafe place to work and be sick in. As he was collecting his award, Dr Chris Day tweeted ‘Had a man with bowel obstruction with lactate of 4 (seriously ill). Patient had to have fluids in corridor and his wife had to act as a drip stand as one could not be found. Whilst all the patient safety champions are off at conferences congratulating themselves, NHS staff deal with reality.’ Dr Day is a true patient safety champion who blew the whistle on unsafe staffing levels in intensive care in Woolwich, was removed from his training program and discovered that 55,000 junior doctors have no whistleblowing protection. (Eye). The NHS has spent £100,000 trying to block his case getting to court and Jeremy Hunt, global humanitarian patient safety leader, refuses to meet him. Perhaps Dr Day should organise a global patient safety conference and give Mr Hunt another gong.