HC Deb 24 October 1975 vol 898 cc987-98

4.54 p.m.

Mr. Ivor Stanbrook (Orpington)

The National Health Service is currently undergoing many difficulties. Those difficulties are mostly connected with its financing and the size and nature of the private sector. In my constituency of Orpington we also suffer from the handicap of atrociously antiquated hospital buildings, about which I have previously spoken. However, these problems pale into insignificance beside the desperate need for a proper standard of medical skill in our hospitals.

It is painful to have to raise this matter publicly. I do so knowing of the dangers of undermining public confidence in a vital service which has hitherto served my constituents well, and which still includes many practitioners of immense skill and devotion to their patients' welfare. I regret to say that the standard of medical skill in at least one department of the Bromley area hospitals has fallen alarmingly in recent months. My constituents are particularly worried about two tragedies involving anaesthetics which have received the maximum of local publicity recently but the minimum of action to allay public anxiety.

Adam Grier was nine when on 19th August last year he went into Orpington Hospital for what his parents were assured was a routine operation for appendicitis. During the operation the surgeon noticed something wrong with his colour, but, tragically, did nothing about it until it was too late. What was wrong was the tube inserted into the boy's throat by the anaesthetist, a locum trained abroad and secured that very day from an agency run by an overseas-trained doctor. It was the wrong tube for the purpose, made of the wrong material and inserted in the wrong way, with the result that it kinked, interrupting the passage of oxygen to the brain.

In its Annual Report for 1975, at page 41, the Medical Protection Society speaks of "The Vital Airway" as follows: It is the prime responsibility of the practioner who administers a general anaesthetic to maintain a satisfactory airway. This responsibility can only be discharged by a clinical and appropriate monitoring of the patient and a considerable degree of self-discipline may be required to maintain critical observation of both patient and anaesthetic apparatus during the course of a long surgical procedure. Even in the most skilled hands a crisis may supervene during an operation, yet tragedy is averted because appropriate signs are recognised at once and the situation rectified. It is this degree of constant alterness that is the hallmark of the good anaesthetist. Failure to note immediately inadequate ventilation and resultant hypoxia comprises the largest group of successful claims against anaesthetists. By the time the surgeon realised what was wrong, little Adam had suffered serious and irreversible brain damage. His parents were hastily summoned. One can imagine their shock and anguish as, despite the devoted efforts of the doctors spread over six days, their litle boy died.

There was no doubt an immediate inquiry at the hospital. The use of the agency was suspended. At the inquest the jury returned a verdict of manslaughter against the anaesthetist after hearing the medical evidence, which was reported fully in the Press. After a full hearing of the evidence at the Bromley magistrates court, the anaesthetist was committed for trial at the Old Bailey on that charge.

Then, to the surprise of almost everyone, at the opening of the trial on 14th March prosecuting counsel offered no evidence, and the case was dropped. It transpired that he had previously spent some hours at Orpington Hospital, where doctors persuaded him that a criminal charge, as opposed to simple negligence, was not maintainable. I make no comment about that professional legal opinion, but this was a matter of acute public anxiety aroused by two hearings before public tribunals, each of which had decided in a contrary sense. So the words used by Mr. Justice Chapman in acceding to the prosecution's decision were particularly significant. He said: There is no doubt that the cause of death of the child was for some reason due to the supply of oxygen, and there was resultant damage as a result of it not getting into his brain. How and why that occurred is very mysterious, and whose fault it was we do not really know. We still do not really know Despite acute anxiety felt locally by all who have read and know of this case, the reassurance offered by the local and regional health authority has been minimal.

There was obviously a failure of the system at Orpington General Hospital which enabled an incompetent anaesthetist to take up the wrong instrument and use it in the wrong way. All that we have had so far from the regional authority is the announcement of an inquiry, in effect into how the anaesthetist came to be appointed as a locum. One of the four members of the committee of inquiry into this case is a consultant who, before reorganisation, was in the Bromley Group. The scope of the inquiry appears to be almost wholly internal and professional. It therefore seems to be intended more to allay the fears of the professionals than those of the public.

This is the main point of my appeal today, that cases of this kind demand public reassurance. For the parents of Adam Grier, nothing can console them for the loss of their little son. They are, however, anxious, as I am, that their experience is used to help prevent any similar tragedy recurring. Unfortunately it already has. Robert Quickenden aged 18, a constituent of my hon. Friend the Member for Beckenham (Mr. Goodhart), went into Farnborough Hospital, also in my constituency, and also in the Bromley Health Authority district, for an appendicitis operation last July.

There was an error on the part of the anaesthetist, whose name we do not know. We do not know what the error was because the regional health authority has not seen fit to give those particulars. As a result of the error, Robert suffered brain damage of an apparently irreversible kind. He is still under treatment. No one knows what his future will be. In that case the anaesthetist was trained abroad. But it was not a locum and so her capabilities should have been well known. The health authority has accepted responsibility but refused an inquiry. Once again the need for public reassurance has been ignored.

It is true that we have been told that the anaesthetist had an ECG and an X-ray of the chest taken to try to find out what was wrong with the patient. But by the time these were taken the brain damage was apparently irreversible. Any similarity with the case of Adam Grier has been denied by the regional health authority. Yet in both cases the anaesthetists were foreign-trained, the nature of the operation was the same, the injury done to the patient was the same and the cause—incompetent anaesthetists —was the same. Small wonder that statements issued by the health authority about these cases are generally disbelieved.

Recently I have been told of another case of comparative failure in the anaesthetics department of Farnborough Hospital, the details of which I have already given to the Minister of State. A constituent, in the hospital for a post-natal operation last December, recovered consciousness twice during the operation because of a failure in the anaesthesia. She suffered some internal injury and was taken to the intensive care unit where, fortunately, she eventually recovered. She now lives a normal life and I suspect that that is only because, unlike a child, she possessed great strength and stamina. In her case there has been no inquiry and so far no repercussions beyond a private apology. Cases of this kind should never occur in a well-run hospital, in so far as they can be humanly prevented.

My constituents are right to demand that these incidents should not recur. They want to know what went wrong and above all what has been done to prevent a recurrence. Reluctance to give information about such cases only breeds a suspicion that matters are being hushed up.

If the National Health Service is to enjoy the confidence of the public, it must not try to conceal its failures. If those failures are due to the incompetence of inadequately trained foreign doctors, those doctors should not be allowed to practise in Britain. The standard of British-trained doctors is as high as any in the world. We should pay them properly and give them the conditions appropriate to their excellence rather than drive them abroad and rely on imported substitutes, who are often of inferior quality, on inferior pay. Above all, matters must be brought out into the open and explained.

I therefore ask for an inquiry into the standards of anaesthesia practised in the Bromley area in the light of these cases. Whether it is held in public or private does not matter as long as it is independent and publishes its report. If the Health Service Commissioner is able and willing to undertake such an inquiry, I should welcome that. In any event we must have an assurance, as far as humanly possible, that tragedies such as this will never recur.

5.8 p.m.

The Minister of State, Department of Health and Social Security (Dr. David Owen)

I am grateful to the hon. Member for Orpington (Mr. Stanbrook) for bringing this matter to my attention, since the subject of the standards of medical care must be of concern to anybody occupying my position with responsibility for the day-to-day running of the health service.

The hon. Gentleman said that concern had been especially expressed in Bromley as a result of the two tragic incidents in local hospitals. Adam Grier was admitted to Orpington Hospital in August 1974 for an emergency operation but an interruption of the oxygen supply during the operation caused his death. Various theories have been put forward for the interruption of the oxygen supply—probably that the tube used was of the wrong type and kinked, or possibly that the tube used was in error installed in the oesophagus instead of the trachea. Despite variations, the theories all centred on a mistake by the anaesthetist. He was a locum who had been engaged from an agency. The facts of the case pointed to deficiencies in the area health authority procedures for the engagement of locum staff, and an inquiry, which is expected to report in December, has been set up to look at these procedures.

There appears to be a misunderstanding about the exact terms of reference of the inquiry, because it will not only look into the procedures involved. It will investigate the procedures by which locum medical staff are appointed, with special reference to those engaged through medical agencies. More particularly, it will examine the circumstances of the case which gave rise to the inquiry. The committee of inquiry will look into the specific aspects of the Grier case as well as the much wider aspects of the situation of the locum service and medical staff agencies. I hope that that case is already being investigated fully.

The question of Robert Quickenden is different. He was admitted to Farnborough Hospital for an emergency operation on 11th July 1975 but an interruption of the oxygen supply led to brain damage, although the patient is still alive. It seems fairly certain that the interruption was caused by a mistake in the installation of the oxygen tube. Again it would seem that the tube was passed down the oesophagus instead of the trachea, but in this instance the anaesthetist was a full-time employee engaged through normal procedures. There has been a full admission of responsibility by the area health authority.

At first glance I understand why both cases may appear to the hon. Gentleman's constituents to be similar. Both involve anaesthetic incidents with young patients at neighbouring hospitals in the same area health authority, and can be traced to mistakes by doctors in the installation of an oxygen tube. It may even be that the same mistake was involved in each case. On the other hand, the coincidence of the hospitals involved should be seen as no more than that, as entirely separate consultants and medical staff were involved in both cases. The Grier case involved a locum, but in the Quickenden case the anaesthetist was a senior house officer who had been engaged in the normal way and had, in fact, already worked four months of a six-month contract before the incident happened.

The hon. Gentleman also mentioned a third case, involving a constituent, which occurred a year ago, but it would appear that the issues here, involving as they do a matter of fine clinical judgment on the part of the doctor concerned and to some extent of the anaesthetist, are not really comparable with the other two cases. I also understand that the constituent has never made any approach to the area health authority, and that is why there has been no inquiry. The authority assures me, however, that it will investigate any complaint which is brought to its attention.

I shall deal with the wider issues raised. The hon. Gentleman said that reluctance to give information breeds suspicion that matters are being hushed up. I very much agree with that. He went on to say that for the National Health Service to have the confidence of the public it must not try to conceal its failures. The fact is that failures occur. Doctors, like any other part of the human race, are capable of error, but I agree that, when an error is made, public confidence is restored by frankness and by what the public consider to be an impartial investigation.

The type of investigations that are available to us are not fully adequate. The tendency is to hold only the formal inquiry, in which individuals are often legally represented which takes a long time. In many cases that is an inappropriate mechanism to deal with an indivdual case. The House in its wisdom has tried to introduce a different mechanism in the rôle of the Health Service Commissioner. He holds an independent office, established under Act of Parliament, for the carrying out of investigations into complaints concerned with hospitals and other health services.

The commissioner has a team which is sent out and visits the complainant as well as the health authority, talks to anyone who may be able to shed light on the matter and examines all the relevant documents. The commissioner is, therefore, uniquely well placed to get all the facts and form an independent judgment. He has the same powers as the High Court to examine all relevant documents and to take written and oral evidence from anyone who may be able to give useful information.

However, it is necessary to point out that the commissioner is excluded from investigation of action taken in connection with the diagnosis of illness or the care or treatment of a patient if, in the opinion of the Commissioner, it was taken solely in consequence of the exercise of clinical judgment. There is this interface between maladministration, which lies within the terms of reference of the Health Service Commissioner, and the problem of identifying whether the matter arises solely in consequence of the exercise of clinical judgment.

The House in future years may well wish to examine the exact terms of reference of the Commissioner. I do not disguise from the hon. Gentleman that I believe that the Health Service Commissioner offers a valuable and flexible form of inquiry, but if he were to be used as the main vehicle for inquiry into the health service the question would arise whether the restrictions and exclusions currently applied would satisfy the House as giving him sufficient scope for inquiry.

There is a Select Committee of the House which keeps under review the operations of the Parliamentary Commissioner and the Health Service Commissioner. The Government are studying this issue carefully at the moment in the light of many other reports, including the Davies Report on Hospital Complaints Procedure.

In my judgment, both the Quickenden case and the other case of the hon. Gentleman's constituent would possibly fall within the terms of reference of the Commissioner. It is not for me to determine whether they do. The Commissioner alone decides whether he can investigate a complaint. He cannot normally investigate a complaint unless the responsible health authority has already had an opportunity to do so. If the Commissioner investigates a case, he can and does interview the area health authority.

In some cases there is statutory provision for a health authority to ask the Commissioner to investigate a complaint. Health authorities may avail themselves of this opportunity in cases where they feel that a fully independent inquiry is the best course or that the person making the complaint is unlikely to be satisfied with anything less than a completely independent inquiry.

There have been occasions when as Minister I have sought, either through encouraging the Member of Parliament concerned or through talking to the area health authority, to invoke the services of the Health Service Commissioner, because I believe he has already proved that he has a valuable rôle to play.

The Commissioner began work in 1973. Since then I have been fully convinced of the value of having an ombudsman for the health service. He provides a completely independent means of investigating complaints about failures in the service. His reputation in the House of Commons and the way in which he has dealt with cases in his other rôle as a Parliamentary Commissioner has shown this. He makes an independent report, which is published for Members of Parliament, on matters of complaint.

In his last report covering the 12 months up to the end of March this year, the Commissioner records issuing over 100 reports on complaints referred to him which came within his scope. The complaint was upheld in half these cases. In many cases the Commissioner has invited the health authority to review its practices and procedures. The complaints covered such matters as failure of communication between patients or their relatives and hospital staff, delays in admission to hospital, and failure to provide an adequate service, which covers a large number of areas.

It is, of course, the job of management in the first place to look into things that go wrong in hospitals or other parts of the health services and only they can put matters right in many cases. The great majority of complaints about health services are dealt with satisfactorily in this way. However, there will inevitably be occasions when those who complain remain dissatisfied with the explanations given by the health authority and who may from the outset make it clear that they want an independent inquiry to be held. In those cases an independent inquiry by the Commissioner may often be conceded late when sometimes it would have been better to concede an inquiry earlier.

The area health authority, following discussions which the hon. Gentleman and I had about the possibility of using the Health Commissioner, has expressed interest about whether the Quickenden case should be referred to the Commissioner. I suggest that the hon. Gentleman discusses this either with his constituents to see whether that is what they wish or with the area health authority chairman. The result of such a meeting with the area health authority might be that it would decide to look into the matter.

There are problems in this case because there is a possibility of litigation, although an admission has been made, about the matter of compensation. The Health Commissioner, in his terms of reference—I quote from his leaflet: cannot investigate any matter in respect of which the aggrieved person has appealed to a tribunal or has taken proceedings in a court of law. Nor can he normally investigate the matter if the person has, or had such a right of appeal or of recourse to the courts, but has not used it; but he may nevertheless decide to investigate in an individual case if he is satisfied that it is not reasonable in the particular circumstances to expect the person to use or have used it". It would be possible to take either course, but it is for the Commissioner to decide.

In the other case which the hon. Gentleman raised perhaps there is more evidence of a purely clinical judgment having been made. I have not seen evidence of any maladministration. I am less certain that that would fall within the terms of reference. If either the hon. Gentleman or his constituents wished to take up this matter with the regional or area medical officer, they would be able to do so.

In summary, I point out that mistakes are made in the National Health Service. Mistakes will be made in any health service. We need a flexible, independent mechanism for investigating complaints which is sympathetic to the problems of doctors who often work extremely long hours, and to the possibility of human error, which can occur in any profession, but which satisfies people outside that the investigation is not a cover-up or hush-up or is not held internally within one profession. The appointment of the Health Service Commissioner was an important start in ensuring that sort of independence and it might well be something on which we can build in the light of experience.

The hon. Gentleman said that many of the people concerned were foreign doctors. That was certainly so in one case: the doctors were trained abroad. It is right that we should tighten up on the procedures in respect of the question of language, but do not let us forget the invaluable debt which the National Health Service owes and will owe for many years to doctors who have been trained overseas and whose standards in the vast majority of cases are of the highest. English-trained doctors who have worked alongside foreign doctors would pay tribute to the work which they have done.

I have noticed a tendency in recent months to highlight cases of error, which have perhaps occurred with foreign-trained doctors. We must ensure that we have the highest standards and that no doctor is able to practise in this country unless he satisfies the regulations of the General Medical Council, which is an independent professional body. But we must recognise that the standards of foreign doctors have been very high.

I thought that the hon. Gentleman implied that the foreign doctors in question received a lower rate of pay. That might be so under the agency arrangements. However, the doctors in this case were paid at the normal rates.

The House has a great sympathy with the problems of the junior hospital doctors. They work extremely long hours. However, the present dispute, which I very much regret, is not of the Government's making. It is purely and simply a question of the need to counter inflation. The Government have never had any intention of singling out the junior hospital doctors in counter-inflation policies which did not apply to the whole population—far from it. We have considerable sympathy with their case and wish a contract structure to be agreed with them which will reduce the number of hours they work. The longer the hours they work, the greater the possibility of human error.

I hope that what I have said will have reassured the hon. Gentleman and his constituents. I am sorry that the coincidence of cases has caused concern. I understand the concern. I believe that it is a question more of coincidence than of anything else, but we should not be afraid to try to ensure, whether by tightening the procedures or by making changes in practice, that tragic errors of this sort are reduced or, as I hope, totally eliminated.

Mr. Stanbrook

I thank the hon. Gentleman for what he has said and look forward to co-operating with him in securing adequate inquiries into both the cases I have raised.

Question put and agreed to.

Adjourned accordingly at twenty-three minutes past Five o'clock.