§ Motion made, and Question proposed, That this House do now adjourn.— [Mr. Harper.]
§ 10.50 p.m.
§ Mr. Christopher Price (Birmingham, Perry Barr)
I want to raise the question of the death of a 3½ month old boy, the son of a constituent of mine. I raise it not because I feel that this sort of case should necessarily be publicised in this way in the House, but because I think that the circumstances which surrounded both this child's death and the subsequent events raise important principles about the administration of the hospital 886 service to which I feel the Ministry should pay very close attention.
Perhaps I could first outline very briefly what happened. Mr. and Mrs. Linden have eight children. On 13th April, when the youngest was 3½ months' old, they took him to the doctor and the doctor put him on penicillin, but that general practitioner did not indicate that he was seriously ill. He got worse and two days later the doctor sent him to hospital, where he died later that evening.
On 22nd April, there was an inquest. Mr. Linden was not legally represented at all. I shall come to this point later. One reason why he was not legally represented was that he had no reason to believe that he needed to be legally represented. The coroner's verdict was death by misadventure, and the cause of death was given as acute potassium poisoning while suffering from bronchopneumonia.
At the inquest, Mr. Linden was overwrought and, as a result, at the inquest, there was no contact between those people representing the hospital and Mr. Linden and his family. One of the points I want to make is that from the point at which this child died onwards there was far too little contact between the hospital authorities and the family.
There had to be the child's funeral. Mr. Linden, who, as I say, had eight children, was unemployed at the time, and had to sell all his tools, his one remaining asset, to pay for the funeral. His wife became ill. I am glad to say that she is getting better now, but his wife had a very long period of great illness. The result of this death, in my opinion, caused far more distress subsequently than it need have done, and this is the point I would like to raise this evening.
I want basically to make to the Parliamentary Secretary two points, but before I do so I should like to emphasise what I said at the beginning, that I do not do this is any sense of hostility to the medical profession. I would like at this stage to pay tribute to the work of the doctors and nurses at this Dudley Road Hospital. I have seen for myself some of the very good work they have done, and I am not blaming anyone individually. If I am blaming anything I am blaming the system, and I think that it is here, in 887 Parliament, that we can do a great deal to tidy up the system and to make it work a great deal better.
My first point is that the events following this child's death indicated a serious lack of social awareness in the hospital service. This is a point to which attention has been drawn recently by the Royal Commission on Medical Education. The situation is such that, after a death of this kind, especially when it happens to a family of this kind, there ought to be some kind of support forthcoming from the hospital service for the family. But, of course, particularly when a death has occurred, there is the legal position to be considered. Naturally, both the doctors and the nurses do not feel that they can come out and explain all the facts when they have perhaps the threat of legal action hanging over them.
I accept this. But I contend that it is the Minister's job to make sure that in every hospital there is somebody available—whether the doctors or the nurses or somebody else—first, to explain what has happened; secondly, in a case like this, to explain to an individual affected by it what his rights are in advance of any inquest or inquiry which takes place; and, thirdly, to inform and help him with all the social support which the community, not just the hospital, can provide.
I contend that the right people in the hospital to do this are the medical social workers—the people who used to be called almoners. I hope that the Minister will do far more in future to strengthen the force of medical social workers. I understand that there are less than 20 medical social workers in the whole of the Birmingham region. If I am wrong about that, I will be pleased to be corrected by the Minister.
One of the losses which resulted after the Second World War, when the administration of the hospitals was separated from the cities which previously ran them, was an integration between the social workers of the city and of the hospitals. This has not yet been made up. I understand that the Seebohm Report is to be issued the week after next. That will talk about the personal social workers of the local authorities. I hope that the medical social workers will be integrated into that whole net- 888 work of personal social workers so that we can have an integrated network of social workers covering the whole community.
§ Mr. Speaker
Order. The hon. Member will come to the subject which he wishes to raise on the Adjournment.
§ Mr. Price
I am trying to put some of the points which I feel arise from this death, but I will come more quickly to the point.
The second point on the events subsequent to the death is that, where a death like this occurs, clearly the individuals concerned want to be legally represented. When the Minister wrote to me about this case he said that at the inquest Mr. Linden was not legally represented and he could have been. But in this case he had no reason to believe that he needed to be legally represented.
I should like to know what the Parliamentary Secretary has to say about the procedure of hospitals. When a hospital knows that a mistake has occurred, is it the duty of the hospital to inform the relatives that a mistake has occurred and that it will be necessary to have legal representation at the inquest and the inquiry which follow? I think that it is hard of the Minister to imply that it is the negligence of an individual not to be legally represented when it is only the hospital that could have told him of the need for it.
The third lack after the death was, in my view, the fact that Mr. Linden and his family felt that no information or help came forward from the hospital. When I raised this matter with my right hon. Friend the Minister subsequently, he said that it was not the job of medical social workers in a hospital to take the initiative in helping, and that it was not their job in this case. I was told that they would have given help had they been approached by the family.
That is a most unrealistic attitude, because many families, and particularly fairly humble families of this kind, could not possibly know of the existence of people like medical social workers at the hospital. I urge upon the Minister that it was very much their duty, in particular, to identify cases like this and to take the initiative when, as in this case, a child dies.
889 The Minister put it to me in the discussions which I had with him that hospitals cannot support every family in which a death occurs, because hospitals are places where people are dying all the time. That is, in a sense, their stock-in-trade.
§ The Parliamentary Secretary to the Ministry of Health (Mr. Julian Snow)
I hope that, on reflection, my hon. Friend will refine that remark, because hospitals have a very great curative job to do.
§ Mr. Price
Yes. I would not wish to misinterpret any attitude on the part of the Minister. I withdraw that. It was, however, put to me that the incidence of death in hospitals is such that it would be very difficult to erect a social work service to support every family in which it occurs.
When a child in a family dies in circumstances of this sort, particularly when an accident has occurred, it is a traumatic shock quite out of all proportion and of an utterly different order than when an elderly person dies, when death might be expected. It is the duty of the hospital to erect a social work service to look after families in which that occurs. I will be very interested to hear what my hon. Friend has to say about that, too.
I have talked about the support which, I feel, the family needed after the death, but did not get from the hospital. I suspect that it might have been the same in any other hospital. I do not blame this hospital particularly. The second aspect which I would like to raise is the accident itself. According to the coroner's report, the accident occurred because the child, who was ill at the time—although the parents certainly did not feel that he was as ill as was made out at the inquest, although I do not want to argue about that—was injected with a solution of nearly 10 per cent. potassium chloride instead of 0.9 per cent. sodium chloride. In some way, that accident occurred.
In every hospital when nurses are trained there is a drill which every nurse is taught which should make protection against accidents like this foolproof. What makes me slightly unhappy about the case is that at the inquest, where evidence was given by the student nurse 890 who collected the drug and the sister and the doctor who administered it, the implication seems to have been that it was the fault of the student nurse that the accident happened.
I should like the Minister to tell me what the Ministry is doing to make sure that the 8-point drill which every nurse should go through between the time she selects a drug from the drug cupboard and administers it to a patient is followed. There is a great deal of grapevine talk about hospitals. Some is idle chatter, but a lot is true. I am told that hospitals adopt one of two attitudes to this matter. Some follow the drill about drugs in a military way, while others adopt a far less serious attitude
A year ago I raised a question on the Adjournment about surgical accidents in hospitals. The Ministers made some very encouraging remarks about the sort of drill that should be followed there. I look forward to receiving from my hon. Friend some engaging remarks about what the Ministry is doing to make sure that this sort of accident will not happen again. I hope that the Minister will send out a circular to all hospitals emphasising once again that it is their duty to follow the drill exactly on every occasion a drug, however apparently harmless, is administered.
The argument that is often used is that this sort of situation arises due to a shortage of staff, or to the quality of staff. In my opinion, those factors make no difference to the case. The situation arises from the practices and habits of the hospitals, and I feel that it is the duty of the Minister not to be satisfied until he feels that every hospital is up to the same high exact standard in this matter.
I make no apology for raising this issue publicly, even though there is a school of thought which says that this sort of issue is best buried and forgotten. It is only by public discussion and publicity of matters such as this that the standards of our hospitals are raised. I believe that we have good hospitals, but the fact that this accident happened shows that in one or two respects they can be improved. They can be improved in the procedures they adopt for administering drugs, and they can be improved in respect of the facilities they offer for the social support of families. I 891 look forward with great interest to the help which my hon. Friend can give in those two respects.
§ 11.9 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Mr. Julian Snow)
My right hon. Friend the Minister of Health and I were deeply shocked at this fatality and the sad conditions surrounding it. I think that my hon. Friend the Member for Birmingham, Perry Barr (Mr. Christopher Price) is right to raise this matter and to try to clarify certain matters surrounding both the question of how the fatality occurred and the social services which are called into train in these cases.
The circumstances of the baby's death are, broadly speaking, those which my hon. Friend mentioned. The baby was brought in and admitted to Dudley Road Hospital at 7 o'clock on 15th April, Easter Monday, suffering from severe bronchial pneumonia. During the course of the treatment the child was injected with a 10 per cent. potassium chloride solution, instead of a solution of 0.9 per cent. sodium chloride, and in spite of immediate resuscitation measures the child died at 10.40 p.m. Those were the facts which were established at a coroner's inquest held on 18th April, when a verdict of death my misadventure was recorded.
My right hon. Friend has already pointed out to my hon. Friend that there has been this full investigation by the coroner into the facts of the child's death, and, of course, the doctor concerned and the nurses involved gave evidence. Mr. Linden was also present and I understand that he had the opportunity, which he took, to question the witnesses.
The regional hospital board take the view, which my right hon. Friend shares, that there would be no advantage in holding a further inquiry to investigate the facts. The doctor, the sister and the student nurse have already given their own frank account which part each played. If I may say so to my hon. Friends he, being the sensitive man that he is, will understand that for the members of the medical and nursing staff concerned this was a dreadful thing to have happened. The after-effects were 892 very noticeable in the staff concerned when the case was investigated.
I think that no further investigations into the facts are needed, but the Hospital Board rightly felt that, in addition to the coroner's inquest, there was need for an internal inquiry to see whether any further steps could be taken to minimise the risk of any similar accident occuring in the future. They therefore appointed an ad hoc committee of three people—the chairman of the hospital medical staff committee, the regional nursing officer, and the group pharmacist—to examine the hospital procedures with a view to achieving the greatest possible measure of safety for the future.
An apology is owing to my hon. Friend, because there was an implicit understanding that he would be notified about this internal inquiry and in the event he did not receive advice about it due to a failure of communications and to the fact that the hospital authorities involved were most anxious about this matter and wanted to carry out an inquiry while the facts were still clear in the minds of the people concerned.
The Report is being studied by the hospital management committee and the board, and my right hon. Friend awaits their comments on it. It is not, therefore, possible for me to say more at the present juncture than that the committee examined and reported on all the procedures connected with the storage, labelling, checking and administration of drugs at Dudley Road Hospital and the standing orders to medical and nursing staff.
It is the duty of all hospital authorities to see that drugs are safely administered, and for this it is necessary to operate recognised procedures. I should like to outline what these procedures are. A memorandum was issued in 1958 by the then Minister drawing the attention of all hospital authorities to the report of the Aitken Committee on the Control of Dangerous Drugs in hospitals and asked them to take steps to put the Committee's recommendations into effect. The Report of the Aitken Committee dealt comprehensively with all matters relating to the administration of drugs in hospital wards and departments. Appendix II of the Report suggested procedures for checking all drugs—not only dangerous drugs as 893 defined in the Dangerous Drugs Act— administered by the nursing staff.
I should like to read what this procedure is, showing the step-by-step check which was included in that recommendation:1. Read the prescription carefully.2. Ascertain that the prescribed dose has not already been administered.3. Select the drug required and check the label with the prescription.4. Prepare the drug in the presence of a witness who should check with the prescription(a) the drug, () the calculation if any, (c) the measured dose, and (d) the name of the patient.5. Take the measured dose and the prescription to the bedside, check the identity of the patient and administer the drug in the presence of the witness.6. Enter the details of the administration in the appropriate record book …".In commending the Report to hospital authorities, the Minister said that in his view checking in the manner recommended by the Committee should be a strict rule with regard to dangerous drugs and Schedule 1 poisons and where calculation or intricate preparation was required and that it was desirable on every occasion, though its rigid application to the administration of all medicines might not everywhere be practicable.
In the same circular the Minister took the opportunity of reminding hospital authorities of advice given in 1953 with regard to measures necessary to reduce the danger of the wrong solution being injected into hospital patients. In that circular, the Minister said:Evidence has shown that the commonest cause of a wrong injection is failure to read and check the label on the ampoule or container. Responsibility for this must always lie with the user. The person actually giving the injection should always check the label immediately beforehand.The procedures which I have read are included in every nurse's training. Every doctor also learns that it is his responsibility to check any drug which he administers personally. The duty of hospital authorities is to ensure so far as is possible that the recognised procedures are carried out and that everything possible is done to minimise the risk of human fallibility and of momentary forgetfulness or carelessness in times of stress.
The internal Committee of Enquiry which I have mentioned will have been 894 considering whether there are any further steps that could be taken. I hope that I have dealt with the point concerning hospitals and nursing staffs.
I would like to turn now to the other point raised by my hon. Friend. Eammon Linden was admitted at 7 p.m. and his mother, accompanied by one of her daughters, was present at the hospital. When the child collapsed, the police were asked to contact Mr. Linden, asking him to get in touch with the hospital. This they did just before the child died. At the inquest, Mr. Linden said that the police contacted him at 10.30 p.m. It is customary for either a doctor or a nurse—a senior nurse—to break the news of a patient's death to the relatives, personally. When the child Eammon died, the consultant paediatrician himself broke the news to Mrs. Linden, who was still at the hospital. Afterwards, the night sister gave Mrs. Linden and her daughter a cup of tea, and looked after them until they left the hospital. I understand that they were taken home in the care of a neighbour, although the hospital would have arranged for them to be taken home.
So far as I know, Mr. Linden did not attend the hospital on the night of his child's death. The hospital authorities intended to express their sympathy in a more formal manner at the inquest, but there was an incident—a disturbance— at the inquest and there was no opportunity to express the hospital's sympathy. I cannot exactly blame Mr. Linden for this. He was over-wrought, and one has to understand the mental processes of a person subjected to this sort of investigation following quickly on the death of a child.
When the deputy secretary of the hospital management committee saw Mr. Linden some two or three weeks after the inquest, he expressed the hospital's regret. Mr. Linden told him he was considering taking legal action to claim damages for the child's death, and he was assured that if he decided to pursue this, all appropriate information would be given to him.
§ Mr. Christopher Price
What steps did the hospital take before the inquest to inform Mr. Linden that he might need legal advice and legal representation?
§ Mr. Snow
There might be a difference between my hon. Friend and myself as to where the responsibility lay for initiating any legal action. This is a matter to which I have paid particular attention, but, in certain circumstances, it is normally for a person feeling aggrieved at law to take the initiative himself. In tragic cases like this, and having due regard to the knowledge which a parent may have had about procedures, there is an element of doubt about who should have taken the initiative.
Unfortunately, Mr. Linden did not request the hospital to give any advice. We have given hospital authorities power to arrange and to pay for the burial of patients who die in hospital where the responsible relatives are unable to obtain a death grant and cannot otherwise afford to arrange for burial. The Minister has undertaken to consider most sympathetically an ex gratia grant in this matter. If Mr. Linden has details of the funeral expenses, then appropriate action will be taken, but it may be that Mr. Linden would like to write to my hon. Friend himself in this matter.
896 Mistakes which contributed to this death were human, but extremely rare. Hospital authorities always seek to improve their procedures in the event of a case like this and all matters are taken into the very fullest consideration.
It is for me to express to Mr. and Mrs. Linden the regret of my right hon. Friend and myself in this matter. I cannot say more than that we will see that Mr. Linden is treated in a fair manner. We are looking at the procedures now in the light of this event. There may be a weak link in relation to responsibility for initiating help. I do not accept that this is something which can necessarily be blamed on my Department, but we must try to legislate as far as we can for tragic cases like this.
§ The Question having been proposed after Ten o'clock and the debate having continued for half an hour, Mr. SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at twenty minutes past Eleven o'clock.