§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Charles R. Morris.]
§ 12.14 a.m.
§ Mr. Christopher Price (Birmingham, Perry Barr)The interest in the subject that I am raising tonight, that of precautions against errors in surgical operations in hospital, has stemmed from a recent case in Birmingham. But I do not intend to talk about that case at all tonight, since an inquiry has been set up and it is up to the inquiry to make all the investigations into it. I understand that my hon. Friend the Parliamentary Secretary will be able to tell us a little more about the inquiry tonight. I intend to talk about the future, not about the past. I shall make some suggestions as to how it might be possible to reduce the rate of errors in surgical operations.
It is right that Parliament should debate this subject. The public seldom discusses it, because when cases occur they quickly become sub judice. Cases often do not come out into the open. The Birmingham case, which was particularly severe, came out into the open. There should be much more public discussion about the general problem of precautions against these errors.
I hope that my hon. Friend will clear up some of the doubt we have about the true figures for wrong operations. On Monday, in answer to a Question tabled by me, my hon. Friend said that the figures of wrong operations notified to the Ministry were 3 in 1962, 10 in 1963, 6 in 1964, and 7 in 1965. It would be wrong if the public got the impression that those were the total figures for wrong 1908 operations. It is difficult to discover how many wrong operations take place, but the figures of the Medical Defence Union, apart from the figures for errors such as leaving swabs or instruments inside patients, are considerably in excess of those given by my hon. Friend. The Medical Defence Union's figures are 24 in 1961, 16 in 1962, 11 in 1963, 27 in 1964, 23 in 1965, 19 in 1966, and 13 so far this year. Even these figures, which average out at just under 20 per year, are probably not the complete picture, because the Medical Defence Union represents only about 70 per cent. of all doctors. No doubt the other defence unions have figures which would supplement these.
A considerable number of claims are not recorded. Some are not proceeded with. There must be a number of errors which never come to the notice of the patient: the matter is covered up in one way or another. The true figures must be in excess of the average of 20 claims per year notified to the Medical Defence Union. In the light of these figures, the Ministry should take this problem very seriously, particularly as this year's figures show a steep increase.
The real difficulty is that we lack statistics. We have these different sets of figures, but, even so, not even the Medical Defence Union, which is most assiduous in trying to compile information and educate the medical profession in this matter, does not undertake any systematic analysis of the figures.
Is it not the task of the Ministry now not only to collect some authoritative statistics but to analyse them in terms of cause, area, type of hospital, and under any other head it thinks right, so that we may, perhaps, be able to throw up evidence which can help in avoiding some of these accidents, all of which are avoidable if we go about it the right way?
I suspect that the basic reason why the Ministry has not been very assiduous in collecting statistics—the job has largely been left to the M.D.U.—is that it has always regarded this as, so to speak, a clinical area of medicine which should be left to the profession and not one in which it is proper for the Ministry itself to intervene. I contest that view. This is a matter of such public concern now that it is time for the Ministry to move in the matter, compile some facts, analyse 1909 them, and use all the authority at its command to ensure that proper conventions are adhered to.
Turning from statistics to the measures which are taken to prevent accidents in hospital, we find, here again, that it is the professional organisations—or some of them—which have been taking action. In 1962, and again in 1966, the Medical Defence Union, together with two of the nurses' organisations, issued memoranda both about wrong operations—the wrong side, the wrong limb, the wrong type of operation and so on—and about precautions to prevent objects such as swabs and instruments being left in the patient's body. These were excellent and detailed memoranda laying down exact procedures to be followed from the moment the patient entered hospital until after the operation.
One can sense in the 1963 Report of the Medical Defence Union a certain amount of veiled criticism that it was, as it were, forced into producing these memoranda, after waiting for some years for the Royal College of Surgeons to take action. I do not deny that the Royal College had been discussing the matter and has had it under consideration all the time, but I feel that it was really for the Royal College rather than the Medical Defence Union to issue memoranda about precautions against wrong operations. However, be that as it may, two first-class memoranda have been produced.
As soon as I began investigating this matter, it occurred to me that the Ministry should have had a part in issuing these memoranda. At least, it should have been a joint effort between the Ministry and the professional organisations. I understand that the Ministry has given the memoranda its blessing and has on more than one occasion sent advice to hospital boards to the effect that they should be adhered to in their detail, but the fact that it was not the Ministry which produced them has probably lessened their impact.
The Ministry must play a far more important part in the future in producing memoranda and laying down exact procedures to prevent errors. These memoranda have been issued and commended by the Ministry. What we do not yet know is the exact extent to which individual hospitals adhere to them. I fully understand that the Minister can- 1910 not simply issue an edict to every hospital saying, "You will adopt this particular procedure in this clinical operation". It is very much up to the profession to decide how it proceeds. But the whole weight of the Ministry's advisory capacity must now be thrown behind an attempt to make these procedures standard throughout every hospital in the country, because we are a very long way, I suspect, from getting any sort of standardisation. How many hospitals have adopted the procedure in the memoranda, and how many have not? What are the sort of proportions and numbers? We should be told so that we know the kind of task ahead to get standardisation.
The matter is a little more serious because when the matter was debated in another place on 7th June the Under-Secretary of State for Commonwealth Affairs, my noble Friend, Lord Beswick, who took responsibility for answering questions, said that standardisation was not necessarily desirable. Is it the policy of the Ministry of Health that all these procedures are not necessarily desirable? I accept that it is not possible to adopt exactly the same procedure in every hospital, because the lay-out of hospitals differs. But surely it cannot be true that the Ministry's policy is that standardisation is not desirable? We want the absolute maximum of standardisation between hospitals. With doctors increasingly moving from one hospital to another throughout Britain, and shortly far more throughout Europe, we must have some sort of fairly standard procedure, so that both doctors and nurses can almost perform operations in their sleep.
I spent 18 not wholly happy months in the Army as a lance-bombardier in the Royal Artillery. There I was taught the procedure of starting up and closing down radar sets in such a way that after a few months I could almost have done it in my sleep. That is the sort of impression we want to get on our doctors and nurses. I do not want them doing operations in their sleep, but I want them to get into a standard procedure so that if they miss out a step they feel that something is wrong.
I do not want to go through the memoranda and the various things that they have laid down. Some of the most 1911 important and, I think, un-standard things at the moment are the marking with indelible ink of the limb or side to be operated on. I am told that this is not nearly as universal as many of us have been led to believe. Unfortunately, there is a tradition in the medical profession when writing prescriptions which fall into the hands of patients deliberately to write them illegibly so that patients do not understand the sort of medicine with which they are being medicated. This illegible writing often spills over into doctors' notes in hospitals, and the Ministry ought to have a drive on this subject.
Most important of all, we need throughout the country, and we do not yet have, a standardised way in which to refer to fingers. Some people still apparently refer to the first and second finger and so on and many hospitals do not know from which end to count—from the thumb or little finger end. The memorandum lays down exactly what names should be used—the thumb, the index finger and so on right down to the little finger. Each finger has a name and that is the sort of practice which ought to be standardised throughout Britain.
I hope that the Ministry will have a drive on this matter and will not feel that it has to wait for this inquiry and perhaps for the results of further legal proceedings before doing anything. In its own advice to the public about how to make complaints to hospitals, the Ministry says that legal proceedings should not in any way hold up putting things right, having an inquiry and changing the system, and I hope that the Ministry will adopt that attitude towards the total picture.
The three most important pleas which I make tonight are, first, that we should get full statistics from the Ministry in future about these errors in surgical operations so that we know exactly what the full picture is; secondly, that these statistics should be analysed so that we can try to find out some of the causes and try to take precautions against them; thirdly, that the Ministry should make a drive to make the application of memoranda issued by the Medical Defence Union universal in all hospitals in Great Britain.
In raising this subject I do not want in any way to be alarmist. Doctors and nurses throughout the country do a 1912 magnificent job, but when we discuss this problem of avoidable errors in surgical operations it is something of a euphemism to call them errors and it is something of a euphemism to call them accidents or incidents. Every mistake of this kind is a potential tragedy, and that is why the Minister's task is particularly urgent.
§ 12.32 a.m.
§ The Parliamentary Secretary to the Ministry of Health (Mr. Julian Snow)I am grateful to my hon. Friend the Member for Birmingham, Perry Barr (Mr. Christopher Price) for raising the subject of precautions against errors in surgical operations, because it enables me briefly to set out what steps have already been taken in this matter by the Minister, and also to alleviate the understandable concern which reports of these unfortunate errors may give rise to in the minds of members of the public. My hon. Friend has referred to the recent example of such an error, the tragic incident at Birmingham. I am grateful to him for his restraint about this case. As he knows, the Birmingham Regional Hospital Board is to hold an independent inquiry into it and I am sure that the House will appreciate that in view of that I cannot at this stage make any comments on the case. The Board has been fortunate enough to obtain the services of Mr. John Field Evans, a barrister, as chairman, and Professor Robert Milnes Walker, a former professor of surgery and Mrs. M. Comber-Higgs, Matron of Crumpsall Hospital, Manchester.
While every such error is to be regretted, because of the harm suffered by the patient, and because it is, strictly speaking, preventable, it is right that we should compare the number of these errors with the total number of operations performed in our hospitals to see the matter in perspective. In parenthesis I might say that I agree with my hon. Friend that these incidents, or accidents, are matters which can hardly be defended.
The Ministry does not collect statistics of surgical errors as such, but hospital authorities make annual returns of the claims which they receive for compensation in respect of personal injuries sustained in hospital by patients, staff and others. Claims reported in those returns in respect of wrong operations—that is, operation on the wrong patient or part—were three for 1961–62, ten for 1962–63, 1913 six for 1963–64, seven for 1964–65 and eight for 1965–66. These figures relate to England and Wales.
As my hon. Friend mentioned, another type of error in surgical operations is the leaving of foreign bodies, such as swabs, in patients. According to the returns, claims in respect of this type of error for the same years were 14, 12, 15, 25 and 22 respectively.
I should mention that these figures differ somewhat from figures which have been given by the Medical Defence Union. That body has said that, in the three years 1963–65, it has dealt with 61 cases of wrong operations and 110 cases of failure to remove swabs or other foreign bodies. The Medical Defence Union figures, of course, include not only cases arising in National Health Service hospitals, but cases arising in private practice and abroad. To some extent, this may explain the discrepancy between the two sets of figures.
It may be that in some cases the information provided by hospital authorities to the Ministry is not sufficiently detailed to enable cases of surgical errors always to be identified. We are now considering whether the returns should be amended to produce rather more detailed information about these types of surgical errors. These factors explain why there is a difference between the Medical Defence Union figures and ours. Obviously one cannot say that one set is correct and the other incorrect, since they are not compiled on the same basis.
It is fair to say that not all the errors reported in the returns to the Ministry are equally tragic in their consequences. For instance, a patient who has had the wrong tooth extracted in hospital may well have suffered unnecessary pain and deprivation, but his misfortune is of a different nature from that of the recent very distressing case at Birmingham.
Against these figures must be set the fact that the number of operations carried out in National Health Service hospitals in this country is now about two million a year. Compared with that, the number of errors is so small as to be infinitesimal. Therefore, while we all deeply regret that these errors should have occurred at all, the figures prove the high standard of care for which our hospitals 1914 are justly famous. I hope that they will put the matter in perspective and serve to reassure the public.
It is the duty of hospital authorities to see that patients are properly cared for, and one aspect of that duty is to ensure that there are recognised procedures laid down in their hospitals to guard against the risk of error in surgical operations.
I am now addressing myself to the point on which my hon. Friend has spent some time. All National Health Service hospitals where these operations are carried out have such procedures. It is clearly the professional and ethical duty of every doctor and nurse to take precautions against mistakes, and, of course, it is accepted as such. Moreover, failure to carry out this duty of care may lead to actions for negligence against the hospital authority or the individuals concerned, or both. I do not propose to go any further into this aspect, since legal liability will depend on the facts of each case, but the Minister has taken the view that the drawing up of these procedures is essentially a professional matter, for the medical and nursing professions, and he has not himself issued any detailed guidance or sought to lay down standard procedures. I may tell my hon. Friend that I was attracted to the suggestion that there should be "standing orders" at our hospitals, but, for reasons which I have explained, it does not appear to be a practical proposition.
The then Minister of Health, therefore, welcomed the production towards the end of 1961 of a joint memorandum on Safeguards Against Wrong Operations by the Medical Defence Union and the Royal College of Nursing. It listed potential causes of error, such as failure to label patients or to see that the right case notes accompany them, changes in theatre lists after the commencement of operating sessions, insufficient information in the notes as to the side or part of the patient to be operated on, and failure to check these and other points. The memorandum also made detailed recommendations to safeguard against errors. The Minister at the time drew the attention of all hospital authorities to this memorandum and asked them to arrange for the procedures in their hospitals to be reviewed immediately so that a clearly defined and invariable routine should be drawn up by the medical and nursing staff which 1915 was understood and followed by all concerned. He also stressed that if a mistake should occur, the full circumstances should always be investigated by the hospital authority, and precautions taken to avoid recurrence. Hospital authorities later confirmed that they had carried out this review.
The then Minister took similar action when in 1963 the same professional bodies produced a joint memorandum on safeguards against failure to remove swabs and other foreign bodies from patients. Like its predecessor, this also listed potential causes of error and made detailed recommendations to safeguard against them. Again hospital authorities were asked to ensure that procedures were reviewed in the light of the recommendations contained in the memorandum.
In 1966 the same bodies produced revised versions of both memoranda and sent copies to hospital boards. Meanwhile, the Royal College of Surgeons had set up a Committee on Surgical Accidents, and officers of the Ministry kept in close touch with this, attending its meetings and providing information. The Committee eventually came to the conclusion that the most effective contribution that the Royal College could make to the problem was through its normal educational activities. Although the 1966 revisions of the joint memoranda did not contain any changes of substance from the original version, the Ministry have recently drawn them to the attention of hospital authorities and again asked them, where this had not already been done, to review procedures in the light of the recommendations of the memoranda, and to ensure that all the staff concerned were made aware of the procedures to be followed.
I have given this brief account of the steps taken by the Ministry over the past few years to indicate the continuing concern of the Minister that all possible measures should be taken in hospitals to reduce and obviate the risk of surgical errors happening. I do not propose to pursue a number of points which have been raised by my hon. Friend, which require full consideration by experts, but perhaps I might deal briefly with one suggestion which has been made, namely, the question of a uniform standard pro- 1916 cedure, centrally devised and laid down, to be applicable in every hospital and for every type of operation.
At first sight this may seem attractive. Doctors and other hospital staffs move freely from one hospital to another. Indeed, doctors not infrequently have two or more concurrent hospital appointments, and it would undoubtedly be simpler if everything were done in exactly the same way in all hospitals. There are, however, various practical and other considerations, which, I am afraid, make the attainment of such an ideal impossible.
The hospitals regularly undertaking surgical operations vary from some quite small cottage hospitals with perhaps one operating theatre, with no separate anaesthetising room, to the teaching hospitals, or the district general hospitals, with hundreds of beds and several operating theatres and anaesthetising rooms in use at the same time. In some hospitals there are recovery bays adjacent to the operating theatre in which patients recovering from the anaesthetic can remain under the close supervision of the anaesthetist or the surgeon. In other hospitals, less well equipped, other arrangements must be made.
The nature of the operations being performed will also influence the particular procedure adopted. Moreover, as I have already explained, hospital authorities and surgeons have a duty to the patients to provide the best possible care, and it would not be consistent with this responsibility if they were to be subject to the direction of the Minister in such essentially professional questions. In principle, what has been done hitherto seems to be right. A highly professional body prepares general guidance as to the dangers to be guarded against, and the methods available to ensure safety, the Minister ensures that all hospital authorities are aware of this guidance, and the hospital authorities devise procedures suited to their particular circumstances. Perhaps it is worth saying here that however good the procedures laid down may be, there must always be the risk of human error.
It may also be suggested that the Ministry should analyse the cases of surgical error that occur in case there are lessons of general import to be learned As I have already indicated, the Medical Defence Union and the Royal College of 1917 Nursing have in their memoranda identified a number of potential causes of error and recommended safeguards against them, and they revised their memoranda only last year. This is nevertheless a point which my hon. Friend made, and we shall be looking into it.
Lastly, I think that there is a lot of importance to be attached to the question—
§ The Question having been proposed after Ten o'clock on Wednesday evening and the debate having proceeded for half an hour, Mr. SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at sixteen minutes to One o'clock.