§ Motion made, and Question proposed. That this House do now adjourn.—[Mr. Thomas Cox.]
§ 4.40. p.m.
§ Mr. Christopher Brocklebank-Fowler (Norfolk, North-West)I should like to place on record my sympathy with the injured person and his or her relatives, Mr. Deputy Speaker, following the incident earlier within the Palace precincts. The House will understand, in the circumstances, if I add diffidence to my natural sadness in raising the topic for debate this afternoon, but I also recognise that it is my duty, as a Member of this House, to represent my constituents' interests even in the prevailing circumstances.
The purpose of the debate is to bring to the attention of the House the circumstances of the death of one of my young constituents in the Royal orthopaedic hospital, Stanmore, in the hope that the Minister will take this opportunity to report progress on his negotiations with the medical authorities about extending the power of the Ombudsman to include the consideration of clinical judgments.
The basic facts surrounding this tragic case are these. Kathryn Averil Hooker—Katie Hooker—suffered from slight curvature of the spine for about seven years up to her death, during which period she was observed for this condition. The intention was that she should have an operation which was designed to cure it. She died during the course of pre-operative treatment in hospital as a result of cardiac arrest on 9 March 1977, at the age of 13.
The substantial complaints against the hospital arise out of incidents which hap- 897 was to take place. The complaints are of two kinds, the first of which is administrative. A complaint has been made about the arrangements for Mrs. Hooker to stay in the hospital while her daughter was undergoing treatment, and particularly during the period immediately prior to the operation. The manner in which she was subsequently informed of her daughter's collapse and subsequent death is also the cause of complaint. Once her daughter had been accommodated in the hospital, Mrs. Hooker went to bed. Shortly after lying down to sleep for the night, she was awakened by a loud banging on the door. It was the nursing superintendent, who said "We are doing everything to save your daughter's life. Are you a Christian? If so, pray for your daughter's life." This was a very abrupt introduction, in the circumstances, to the fact that her daughter was lying grievously ill at the time.
There is also the fact that the hospital informed the mother of another patient that it was her child who died. Subsequently, that woman, a Mrs. Home, not only confirmed the appalling shock that she received as a result of the error by the hospital but also confirmed the fourth point of administrative complaint, namely, that the hospital did very little to give support and care to Mrs. Hooker following her daughter's collapse and subsequent death.
The second group of complaints against the hospital is largely medical. The first of these is that there were minor incidents of an unsatisfactory nature about the child's treatment prior to the operation. For example, the pre-operative treatment required that the child should be in a plaster cast. The plaster of Paris jacket which was part of this cast had a bolt on it which caused Katie's arm to be bruised and scratched. There was an easy solution to this problem, but it was attended to only after it was brought to the attention of the hospital authorities by the parents, Mr. and Mrs. Hooker.
The second and more serious aspect of medical criticism is that it subsequently transpired that Kathryn Hooker suffered her cardiac arrest before the operation was due to take place, and at the subsequent inquest the anaesthetist, Dr. Sylvia Duckworth, admitted that a ventilator had not been properly switched on, with the result that oxygen was not coming 898 through the circuit in sufficient quantity to sustain the child's life. From information which Mr. and Mrs. Hooker have subsequently obtained, there seems to have been a delay of several minutes before resuscitation could start, because of the plaster of Paris jacket and the fact that it had to be cut away to enable cardiac massage to take place.
Those are serious allegations, particularly the medical ones. Since the publicity surrounding this case, a woman living near Colchester, not a constituent of mine, has telephoned to inform me that her daughter survived a collapse in similar circumstances during a similar operation only as a result of the vigilance of the anaesthetists on duty. Therefore, it is not only a matter of my constituents' case, but also one of wider public interest, that the risks inherent in the pre-operative treatment for this operation should be the subject of independent scrutiny.
After the unfortunate death of their child, Mr. and Mrs. Hooker sought to secure an independent inquiry into the circumstances of their daughter's death. They initially took legal advice, and were advised that they were entitled to the somewhat nominal damages due under the provisions of the Fatal Accidents Acts. Nevertheless, my constituents were not interested in any sum of damages because they could not bring back their daughter. Indeed, their case today is that they are not interested in any figure of damages because nothing can replace the life of their daughter. However, they would like to know more about the circumstances of her death in order that other people will not suffer the loss that they have suffered or, indeed, the anguish that they have subsequently suffered since their daughter's death.
After further consultations with solicitors, my constituents approached the hospital, through their solicitors, for an inquiry. After correspondence between their solicitors and the hospital solicitors, the hospital finally agreed to hold an internal inquiry specifically limited to the administrative matters as opposed to the clinical ones. In due course, a hearing took place of a board of inquiry that was set up by the hospital. The members of the board of inquiry freely admitted to Mrs. Hooker that they had not carried out such an inquiry before. Their inexperience showed during the conduct of 899 the inquiry, but Mr. Hooker and to a lesser extent Mrs. Hooker were reasonably satisfied that their allowed complaints were properly investigated.
However, the report that followed this investigation was so brief as to be almost to the point of discourtesy. The original letter of complaint to the hospital from their solicitors ran to about four pages. The report of the governors was less than two pages long, the whole of the first page of which consisted of details of witnesses, their terms of reference, and so on. The inquiry made four recommendations to improve facilities at the hospital, and although in small measure these dealt with some of Mr. and Mrs. Hooker's complaints, the main complaints were still unanswered.
Subsequently, on my advice, the whole case was referred to the Health Service Commissioner. After going into the matter in considerable detail, and having meetings not only with myself but also with the Chairman of the Select Committee on the Parliamentary Commissioner for Administration, officers of the Health Service Commissioner went to Kings Lynn to meet Mr. and Mrs. Hooker, at which point the Commissioner regrettably came to the conclusion that this was not a case which he could usefully investigate, because the main complaints arose out of matters of clinical judgment which he was not empowered to investigate.
I again re-emphasise that Mr. and Mrs. Hooker have all along wanted a full and proper inquiry into the circumstances of their daughter's death. Another course of action that they have considered with their legal advisers is to institute legal proceedings, but they have been advised both by solicitors and by counsel that the maximum damage they would be likely to recover if they successfully prosecuted that course of action would be in the region of £1,500, plus £250 to Mrs. Hooker for nervous shock.
In compensation terms, this is a relatively small sum. But, as I have already pointed out, my constituents are not interested in compensation. However, it is perhaps worth pointing out that this is less than one would expect to receive for losing a finger in an accident. It is the sort of sum that would be awarded 900 to a plaintiff who suffered minor injuries with minimal permanent effect.
Mr. and Mrs. Hooker's legal advisers take the view that, if proceedings were started against the hospital, the hospital and the doctor concerned would make a payment into court in excess of what they expected the damages to be. The advice which legal advisers have given to my constituents is that if they were to win the case and to be awarded less, or to lose the case, they might subsequently become liable for the whole costs of the case, which in the event of its being in the High Court and lasting three or four days could amount to about £10,000. That is clearly beyond their resources. Although they have limited resources and have applied for legal aid, they have been refused it.
Putting it crudely, the possibility of the Hookers prosecuting their case through the courts provides them with the opportunity of damages of around £1,500 now and no subsequent inquiry, or the possibility of an inquiry with the very real risk that they might be called upon to pay damages and the sum of £10,000 at the end of it. This clearly is substantially beyond their means—and not only that. I should have thought it is substantially beyond what any member of the public should be at risk of in circumstances of this kind.
Neither the inquest nor the hospital inquiry, nor the Ombudsman or the courts, seem likely to give Mr. and Mrs. Hooker the full facts surrounding the case.
I return now to the first report from the Select Committee on the Parliamentary Commissioner for Administration in Session 1977–78, published on 6 November 1977, and the subsequent debate initiated by my hon. and learned Friend the Member for Colchester (Mr. Buck) on Friday 1 December last year. During that debate, the Minister himself reminded the House of the whole chain of action which had taken place—first of all, the Davies report; then the fact that in the initial remit of the Health Service Commissioner clinical judgment was to be excluded; then the request by Ministers that the Select Committee should review the jurisdiction of the Health Service Commissioner; and then, of course, the report, which the Minister himself recognised in that debate as having been a 901 very valuable report, putting forward the need for a simple and straightforward procedure at hospital and health authority levels which would be easily understandable by people who wished to complain and by staff involved in handling complaints.
The Minister went on to say that he was in the course of setting up such a procedure and then he referred to the Select Committee's suggestion, which I certainly support in the light of this case—that the Health Service Commissioner should have his jurisdiction changed in order to enable him to investigate cases in which clinical judgment is involved.
At the time of that debate, on 1 December, the Minister himself reported to the House that the Government had not yet reached a conclusion about these recommendations. He said that the Department had been having meetings with representatives of the joint consultants committee and that he hoped early in the new year to report on what those recommendations might be.
I believe that the tragic case of Katie Hooker deserves examination, not only to give solace to her parents but also in the public interest. I hope that, in the light of my remarks this afternoon, particularly my reference to the Minister's speech on 1 December, the Minister will now accept that point and tell us how it can be carried out, preferably by extending the powers of the Health Service Commissioner to investigate matters involving clinical judgment.
§ 4.52 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Eric Deakins)I begin by expressing my heartfelt sympathy for Kathryn's family in their distress at this tragedy. It is particularly sad when a young child, with all that life has to offer before her, is struck down in this way. All parents will feel for Mr. and Mrs. Hooker in their sad loss.
There is, I think, no dispute about the facts of this regrettable accident. Kathryn was admitted to the Royal National orthopaedic hospital, Stanmore, on 6 February 1977, and an operation was arranged for 8 March 1977. The usual arrangements were made for Kathryn's mother to stay in the mothers' home in the grounds of the hospital so that she could be near Kathryn to help and com- 902 fort her during the first trying days following the operation.
Kathryn was given a general anaesthetic at 4 p.m. on 8 March, but before the start of surgery Kathryn had a cardiac arrest. Immediate resuscitative measures were successful and she was transferred to a ward for further supervision. At 8 p.m. her general condition improved, but there was some evidence of neurological change. At 10 p.m. her condition appeared to have somewhat improved, but at 10.15 p.m. it deteriorated and external heart massage was started. Unfortunately, her condition continued to deteriorate and Kathryn died at 6.35 a.m. on 9 March 1977. At the subsequent inquest the cause of death was given as cerebral anoxia due to or as a consequence of cardiac arrest, and a verdict of misadventure was returned.
Solicitors acting for Mr. and Mrs. Hooker wrote to the Royal National orthopaedic hospital in June 1977, pressing for compensation for Kathryn's death, saying that on the information they had and on the basis of evidence given at the inquest it was, in their view, plain that Kathryn's death was caused by the negligence of the employees of the hospital. They also alleged there were serious shortcomings in the way that the hospital dealt with Kathryn's case quite apart from the negligence which in their view led to Kathryn's death.
In September 1977 the same solicitors wrote to solicitors acting for the hospital informing them that they would now be issuing proceedings against the anaesthetist and, as the hospital was not concerned in this matter, would be dealing direct with solicitors acting for the consultant anaesthetist's Medical Defence Union. My information is that those proceedings have not been concluded and I am sure it will be appreciated that it would not be right for me, in these circumstances, to make any comments in relation to allegations of professional negligence. Nevertheless, I have taken note of the statement of the hon. Member for Norfolk, North-West (Mr. Brocklebank-Fowler) that Kathryn's parents are now in a dilemma about taking legal action, but I have no information to show that they have withdrawn from proceedings.
The hospital was, of course, much concerned about the general complaints made 903 by Kathryn's family and set up a committee of inquiry made up of members of the board of governors to look into these matters. Kathryn's parents were invited to give evidence, and they did so. They also heard all the witnesses and were encouraged to ask questions or to raise matters of interest arising out of the witnesses' interviews.
The more serious complaints made by Mr. and Mrs. Hooker concerned events immediately following Kathryn's cardiac arrest in the theatre. They included such matters as Mrs. Hooker not being advised to contact her husband; that there were no means of communication between the mothers' home and the hospital, which resulted in members of the hospital staff arriving with messages for Mrs. Hooker; that telephones were not readily available; and that neither Mrs. Hooker nor her daughter Jane, who was staying with her, received any care or support from the staff of the hospital. There were other complaints about poor facilities such as inadequate lighting of the grounds of the hospital and lack of heating in the mothers' home.
All these matters were investigated by the committee of inquiry and I think it fair to say that in discussions with the committee the parents recognised that their recollection of events may not have been wholly accurate, or could have been open to different interpretations.
To mention examples, it had been said that there were no means of communication between the hospital and the mothers' home. But the facts are that when Kathryn's condition deteriorated at 10.15 p.m. on 8 March the night superintendent nurse decided to tell Mrs. Hooker personally, rather than by telephone, so that she could give not only a full explanation but also provide comfort and practical help in such matters as contacting relatives.
There were also factual matters such as a complaint that the doors of the rooms in the mothers' home were not numbered, which would have made it easier to establish which parents were occupying the different rooms. The rooms were numbered, but the hospital recognises that it would be an additional help if name labels were also attached to the doors, and this has been put in hand.
904 The committee found four complaints that could be substantiated. First, it accepted that there was a need for better arrangements for the emergency contacting of individual mothers occupying rooms in the mothers' home. Secondly, it is also accepted that improvements in the external telephone arrangements in the mothers' home, either by facilitating calls via the hospital switchboard at night or by the installation of a coin-operated system in the mothers' home, are required. Thirdly, the hospital accepts the need for emergency room heating in the lounge of the mothers' home during periods when the central heating has been switched-off. Lastly, a more effective means needs to be found to enable mothers using the mothers' home to find their way about what are, to them, unfamiliar grounds covering a wide area. The board of governors has already put the first three items right and the remaining matter will be dealt with during the next financial year.
As the nursing staff were involved in the more serious of the complaints, I believe it right to state that the committee of inquiry found no grounds for complaint against them. I should also record that the parents thanked the house governor of the hospital for the way in which the inquiry had been conducted.
I should tell the House that the Health Service Commissioner also received a submission from the solicitors acting for Mr. and Mrs. Hooker, but he has explained to them that the action taken by doctors in deciding how to treat a patient is solely a matter of clinical judgment and he has no power to investigate such actions.
I now come to the major point raised by the hon. Member for Norfolk, North-West. The hon. Member quoted from the debate on 1 December in which I took part, as did the hon. and learned Member for Colchester (Mr. Buck), who was Chairman of the Select Committee, and asked what action the Government were taking on that report on an independent review of hospital complaints.
As I told the House on 1 December 1978, when it was discussing the motion of the hon. and learned Member for Colchester, we are having discussions with representatives of the medical profession on the Select Committee's proposals. Until those discussions are completed, I am 905 afraid there is nothing further I can say about the Government's position as regards the Select Committee's recommendation. I think that I indicated in the course of that debate some of the difficulties; and, indeed, they were appreciated by the Select Committee.
As regards complaints about facilities, the Health Service Commissioner noted that the hospital had acknowledged that there were shortcomings and had undertaken to introduce measures to remedy them. That being so, he did not consider any investigation by him would achieve more than the board of governors had already done.
It is, of course, open to my right hon. Friend the Secretary of State to order a formal committee of inquiry to look into the circumstances of Kathryn's death. But such committees are set up only if the facts cannot be ascertained by other means. Not only have I received copies of the findings of the committee of inquiry and seen statements made by members of the staff, but I also have before me copies of the evidence given at the inquest which set out the facts about events in the operating theatre in unequivocal terms. In the circumstances, I do not propose to advise my right hon. Friend to set up an independent committee of inquiry.
Accidents in hospitals fortunately do not happen very often. That statement will 906 be no comfort to grieving parents. They ask "Why do they happen at all?" and their immediate response—I share the hon. Gentleman's concern—is to establish what went wrong and to seek assurances that it will never happen again. It is, of course, possible to prevent some recurrences—for example, if equipment is being used incorrectly or some fault not detected in design comes to light. My Department is keenly aware of these kinds of mishaps; and a system is in being whereby such faults are reported to the Department which, in turn, issues advice to employing authorities. But it has to be recognised that no matter how well trained, skilled and experienced hospital staff are, there is always a risk that a mistake will be made, human fallibility being what it is.
It is my sincere hope that time will soften the grief felt by Kathryn's parents and her family. The death of a child, always felt most keenly, must be particularly hard to bear when it is so unexpected. I am sure I speak for the hospital, too, when I say that we understand the family's distress, and I hope I may ask the hon. Gentleman to convey to them my deepest sympathy and that of my Department in their sad loss.
§ Question put and agreed to.
§ Adjourned accordingly at one minute past Five o'clock.