HC Deb 05 March 1969 vol 779 cc611-21

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Fitch.]

12.58 a.m.

Mr. John Pardoe (Cornwall, North)

The case to which I wish to draw attention is an extremely tragic one. Raising it causes certain difficulties. It is no part of my intention to pillory individual doctors, but this is a case either of terrifying negligence or alarming ignorance. In either case, doctors, like the rest of us, have to accept the consequences of their actions.

This case shows the medical profession in the worst possible light. There was a conspiracy of silence among those concerned and a banding together and what the coroner called: The schoolboy code". He went on to speak of this idea that you should not sneak; not get others into trouble. This was also exemplified by the Medical Defence Union, which printed a summary of the case in its annual report. I asked for a copy of that report and the union wrote saying that it could not let me have one because it was only for its members to see. I regard that answer to a Member of Parliament as quite inadequate. It merely makes the union look childish, because presumably it thought that I would not have the resources to obtain the report elsewhere, as I did.

I have some difficulty in the case in the naming of names. I have a hatred of using Parliamentary privilege to say things that I would not say outside, but the names I am using of the doctors concerned have already been mentioned in the Press and by the coroner.

For the benefit of the Minister, I should like to spell out my purposes in raising the matter at this stage. My first is to ensure that this can never happen again, and that the training of anaesthetists is such as to ensure that. My second is to ensure that all the necessary action has been taken, including that recommended by the coroner concerning the design of machinery and other matters. My third is to get an independent inquiry, which is my main endeavour. My fourth, is to get answers to questions which have been raised in correspondence between me and the Minister, between my constituent, Mr. Stanley Alderson, and the Minister and in correspondence between him and Lord Robens, Chairman of the Governors of Guy's Hospital. He has had no response to these questions.

I also raise the general problems of the consumer who gets a bad deal from the National Health Service. Perhaps it is necessary in the present climate of opinion to say that none of the doctors involved in the case is an immigrant or is coloured, or has any difficulties in reading the English language.

The facts are not disputed. On 18th September, 1967, at 8.30 a.m. Guy Alderson, aged seven, was operated on at Guy's Hospital for a hole in the heart condition known as Fallot's Tetralogy. It was a successful operation, carried out by Lord Brock. After the operation he was taken to the intensive care ward, where he was connected to a Cape ventilating machine, the purpose being to increase the supply of oxygen. His condition deteriorated rapidly, and he went blue. The surgeon—not Lord Brock, but his assistant who had been handling the case—asked the anaesthetist, Dr. Simpson, to check the machine, and was told that it was working well. By 9.5 p.m. on Monday evening Guy's condition was so bad that Mr. Yates, the surgeon, returned him to the operating theatre, reopened his chest and found nothing wrong. The blueness disappeared, and the boy returned to normal colour. He was returned to the intensive care ward and was reconnected to the same Cape ventilating machine. Almost immediately his condition deteriorated and he went blue again.

At 8.30 a.m. the folowing day another anaesthetist, Dr. Lindsey, took over in the intensive care ward. Guy's condition continued to deteriorate throughout the day. At 5 p.m. that afternoon a Dr. Gerson took over as anaesthetist in the intensive care ward. Just after five o'clock the surgeon, Mr. Yates performed a tracheotomy. Guy was removed from the Cape ventilating machine for this and was transferred to a Boyle's anaesthetic machine. He again lost the blue-ness and regained normal colour.

After the tracheotomy he was reconnected for the third time to the Cape ventilating machine, and almost immediately went blue. At 6.45 that evening Dr. Germon, the anaesthetist in charge, noticed that the oxygen tube was connected to the "outlet" port instead of the "inlet" port of the machine. He corrected this, but the damage had already been done. He then telephoned Dr. Lindsey and told him, and Dr. Lindsey decided not to tell the surgeon or the head of the anaesthetics department. He did not do so until the next morning. In other words, he did not tell one of his superiors, the surgeon or the head of the department, until 14 hours after he knew that the machine was faulty.

On 3rd October, Guy Alderson died after a fortnight in a coma. I quote from the post-mortem examination report: There is complete infarcation of the entire brain, which is semi-fluid in consistency. I direct the hon. Gentleman's attention to the appalling problem facing the parents in such a situation. Imagine what they want done and what they felt like after the first despair had disappeared. First, that such a thing must not happen again. Indeed, how could it have happened at all? What kind of qualifications and training can possible allow this kind of thing to happen? What is the logical inference of blueness? Even someone as untrained in medical matters as I, would, I think, have thought that lack of oxygen was the first logical inference, and since the machine was meant to be responsible for supplying it, surely, therefore, that the machine was at fault.

Perhaps one might have neglected that the first time and even the second time, but surely not the third time. When one was being given basic instruction with the Bren gun in the cadet force, there were things known as first, second and third I.A. It stood for "immediate action".

It should not be necessary to have this kind of immediate action in an anaesthetic ward. The training should be such as not to make it necessary. But it is necessary. The hon. Gentleman should say what instructions are given for the used of such machinery now as a result of this case; what immediate action is resorted to if this kind of thing happens; when it is right in these circumstances that the anaesthetist should report to the surgeon if an error occurs; and when it is right that he should report to the head of the anaesthetics department, to whom he is responsible.

I ask whether the recommended modifications to the design, mentioned in the coroner's report, have been made. I do not want to labour this point, because the fault was human and not mechanical. I also ask a point which I have raised in correspondence with the former Minister of Health and which the father of the child, my constituent, has raised with Lord Robens in several letters. How exactly did Guy die?

According to the coroner's report, Guy died of lack of oxygen, but there is a great deal of conflict in the evidence. If the machine was not connected properly to the oxygen supply, he was presumably—and the evidence says this—breathing ordinary air from the room. In many hospitals, as Mr. Yates said in evidence, it is customary not to use a ventilating machine in this kind of situation, so that in some hospitals Guy would only have been breathing normal air and not fortified air. It is important that the father should be told exactly what happened and how it was that there was a lack of oxygen in the normal air supply. Presumably, there was something rather more wrong with the machine than has been said.

I believe that an independent inquiry must be held. The Minister has refused, in correspondence with me and with the father, to hold one. I do not want an inquiry to be held as Lord Robens said it had been held, by people who, if I may say so, have an axe to grind; people who have employed those concerned, who are now employing the people concerned, and people who like the people concerned. It must be an independent inquiry and include laymen to look into the general state of anaesthetics and the training of anaesthetists in the light of this case.

Lastly, what about the general consumer of the National Health Service? What redress does he have in the light of this case? I would be terrified to put myself in the hands of an anaesthetist. If I go to hospital for a complicated operation, is the surgeon responsible for me? Or is he not even to be told what has happened to me when I have passed out of his immediate care? If I go to hospital, I want to know who is in charge and who is responsible.

I raise again the point made by my hon. Friend the Member for Orpington (Mr. Lubbock) in Questions to the Secretary of State on Monday about the possibility of an Ombudsman for the N.H.S. I note with some satisfaction that the Secretary of State replied that he was actively considering the recommendation of the Green Paper that this should be done, although he added that he could not make a decision until further discussions had been held.

I do not know, if the Secretary of State set up this commissioner, that he would be able to look into cases such as this which have happened, but we cannot wait for these discussions in this case. The Secretary of State has all the powers he needs to hold an inquiry. He must do so for the safety of future patients, which is at stake, for the good name of Guy's Hospital and of the Health Service, which are at stake, and to clear his Department and Lord Robens of the impression that although they started by being immensely horrified—as no one could possibly help being—by these events, and by wanting to do something to help, they were got at by medical interests, and ended by giving the impression that jointly they were usurping the rôle of the Medical Defence Union and were more concerned to defend the doctors' reputations than to give the parents proper satisfaction. This may be a very serious charge and the Under-Secretary may feel that it is unjustified, but it is what Guy's father feels, and after reading the correspondence I have no alternative but to agree with him. An independent inquiry is needed and must be held.

1.14 a.m.

The Joint Under-Secretary of State, Department of Health and Social Security (Mr. Norman Pentland)

I have listened with great sympathy to the speech of the hon. Member the Member for Cornwall, North (Mr. Pardoe). I know from the correspondence that he has had with my right hon. Friend the former Minister of Health that this tragic incident has been of particular concern to him.

As the hon. Member has said, Guy Stephen Alderson, who, at the time of his death, was aged seven years, had suffered with a congenital heart condition called Fallot's Tetralogy. In the latter part of 1966, he was admitted to Guy's Hospital, London, for certain tests which confirmed this condition. It was arranged for him to have an operation and he was admitted to Guy's Hospital on 10th September, 1967.

An operation, which was successful in correcting the boy's heart condition, was performed on 18th September by a consultant surgeon, with the assistance of the senior thoracic registrar. On leaving the operating theatre, the boy's condition was reasonable and he was taken into the intensive care ward for follow-up treatment under the care of an anaesthetics registrar. When the registrar connected the boy to a machine for ventilating his lungs a doctor who had administered the anaesthetic at the operation noticed that the inflation pressure was high and that the valve on the machine's oxygen attachment was tight.

After this valve had been loosened the inflation pressure returned to normal and the registrar subsequently admitted that he had not considered the true significance of this. He maintained that the ventilator was already in the recovery room when the boy was transferred from the operation and, while he did not recollect plugging in the nozzle to the oxygen supply, he accepted that it was his responsibility to ensure that the machine was properly connected.

The senior thoracic registrar noticed that the patient was becoming cyanosed—that is, turning blue, as the hon. Member said. This was an unexpected development following the successful operation and he concluded that the cyanosis was due either to a respiratory or to a cardiac condition hitherto unsuspected. He conducted a number of tests to establish whether or not this was caused by the respiratory condition of the patient. He also asked the anaesthetics registrar if this condition was satisfactory.

The registrar checked the machine and found nothing wrong, but he subsequently stated that he could not recollect whether the "inlet" and "outlet" ports, which were shielded by the corner of the room, were properly connected. In view of this, the senior thoracic registrar consulted the consultant surgeon, explained the unusual post-operative condition of the patient, and it was agreed that the patient's heart should be re-examined in the theatre.

There are many cardiac causes of cyanosis, but this second investigation revealed not only that the original condition had been totally corrected but that there appeared to be no cardiac cause for the cyanosis which had by this time disappeared. The anaesthetics registrar was aware of the result of the second investigation, and although the patient became cyanosed again after he had been replaced on the ventilator, it did not occur to him that the machine was the common factor in the patient's deterioration.

The patient was in the care of the registrar throughout the night of 18th September and was transferred early next morning to a senior registrar in the anaesthetics department, who was told that the patient had been ventilated during the night and that his condition was unsatisfactory. He, the senior registrar, did not, however, suspect that the ventilator might be faulty. That evening, he handed over to a middle-grade registrar in the anaesthetics department. It had by then been decided to perform a tracheotomy on the patient.

After this had been carried out, the middle-grade registrar reconnected the patient to the ventilator, when he again turned blue. The registrar checked the ventilator and noticed that the oxygen tube was connected to the "outlet" port instead of the "inlet" port. He corrected this and noticed an immediate improvement in the patient's colour. He did not know how long the connection had been incorrectly positioned and decided to telephone the senior anaesthetics registrar in the hope that he would be able to canfirm or deny that the machine had been satisfactorily connected when he left. It was clear to the senior registrar that the registrar would have informed the senior thoracic registrar if he had considered another operation advisable.

The registrar was of the opinion that nothing further could be done for the paient and the senior registrar agreed with him that there was no need at that stage to call in any other doctor, and in the circumstances they agreed to see the consultant surgeon and the consultant anaesthetist—neither of whom were at the hospital that evening—early the next morning.

As the hon. Member will recall, it was established at the inquest on the patient's death that whoever had been called or reported to at that time could not, unfortunately, have been of any assistance to the patient. By that stage, he was beyond recovery, and the cause of death was established by the coroner as "cerebral infarction following total correction of Fallot's Tetralogy—misadventure."

I understand that this means that because insufficient oxygen was reaching it, the brain suffered irreversible damage. I admit that this was not made clear at the time to Mr. and Mrs. Alderson, the patient's parents, and as the hon. Member is aware, an apology has already been given for this omission.

I do not think that the hon. Member will dispute the facts of the case. None of the doctors involved wished or attempted to hide the fact that the machine was incorrectly connected. Indeed, the anaesthetics registrar specifically pointed out the mistake to the sister at the time. It is, however, most unfortunate that the mistake was not recognised until it was too late. Action was taken by the hospital to prevent a recurrence and, as the hon. Member is aware—and he has mentioned this tonight—discussions with the manufacturers of the apparatus have resulted in design changes to eliminate the possibility of error.

The hon. Member has also raised doubts about the adequacy of the anaesthetic training facilities at Guy's Hospital. I am advised that junior doctors there are taught the principles of respiratory support at a very early stage of their career, during the period when they are holding the appointment of resident anaesthetist. This teaching takes place in the operating theatres where doctors are attached to a consultant anaesthetist at various operating lists. At the end of their resident appointments, all anaesthetists have had practical experience in both ventilation by hand and in the use of mechanical ventilators.

At registrar level, the same process is continued as much as possible in the operating theatres. Usually, a registrar at Guy's Hospital has had additional experience at other hospitals before he ever obtains an appointment there and he is, therefore, fairly practised on his arrival in the use of a ventilator for mechanical inflation of the lungs. Since his appointment, a consultant at the hospital has utilised two of his weekly sessions solely for improving, maintaining and teaching on the anaesthetic equipment used in the intensive care unit.

Periodically, meetings, which include discussions on the respiratory work in the ward in question, are held between junior staff and at which anaesthetic problems occurring in the hospital are discussed. I will not burden the hon. Member with the considerably detailed standing instructions for the use of respirators, but I have been assured that the greatest care and attention is paid at Guy's Hospital to the training of the junior medical staff in this specialty.

There will never be an ideal training programme, and I am sure that the hon. Member will agree that there is a limit to the safeguards which can be provided to minimise what are human errors. It is, nevertheless, a fact that the anaesthetic department at Guy's Hospital has a reputation for training a considerable number of the consultant anaesthetists in the country.

Independent medical opinion has supported the view of his colleagues that the anaesthetics registrar who first took charge of the patient is an anaesthetist of above average ability, and the inference of disgrace cannot be drawn from his transfer and that of the senior registrar from Guy's. Senior registrars and registrars are normally inclined to change their jobs as part of their training, and neither transfer had any connection with the accident. The hon. Member did not raise that point, but I want to make it clear and have it on record.

In conclusion, I would like to add that all the correspondence in this sad case has been most carefully considered and I have noted that the facts are not in dispute. This tragedy was the result of human failure, and no one could read the papers without a feeling of deep concern and of profound sympathy for Mr. and Mrs. Alderson in their tragic bereavement. As the hon. Member is aware, all the issues here have been considered with great care both by the Department and the Board of Governors of Guy's Hospital.

Perhaps it would be appropriate to mention here that both the chairman and the officers of the Board made themselves freely available to Mr. Alderson, both in person and throughout protracted correspondence in an effort to explain the facts of the case to him. I regret, therefore, that I can only confirm the decision of my right hon. Friend the previous Minister of Health that no useful purpose would be served by instituting any further inquiry into the matter.

Question put and agreed to.

Adjourned accordingly at twenty-five minutes past One o'clock.