Infectious Diseases (Transport of Patients) (Hansard, 6 April 1981)

§ Mr. Hugh Dykes (Harrow, East)

I am glad to have the opportunity tonight to raise what was originally a local constituency issue which confronted me at the turn of the year but which raises wider questions of a general London and indeed a general national interest. I am glad that my hon. Friend the Under-Secretary of State is present to deal with the debate. I am sorry that it is at a slightly later hour than we had originally expected.

On 16 September last, a constituent of mine, Mr. Coulter, who is a taxi driver from Kenton, was asked through his company's radio system to go to a doctor's surgery in Pimlico to convey a passenger to St. Pancras Way. I have a copy of the taxi company's docket which specifies that, without referring to any medical institution or hospital. That is an important point. A letter dated 26 September from the managing director of the taxi company to the BMA describing the incident states: Upon arrival"— that is, at the surgery— our driver was asked to convey a patient to St. Pancras Hospital for Tropical Diseases. except that this was done by referring only to the name of the street. When our driver arrived at the Hospital"— which he was not originally expecting— the doctors there requested that he should remain until tests for malaria and lassa fever had been carried out. They also stated that should the tests prove positive then they would have to keep our driver in under observation. The doctors at St. Pancra said that an ambulance should have been used, and that they would inform Doctor Marheine of this fact. That was a misquotation of the name of the doctor who had sent the patient in the taxi, but that is not the important point.

The letter continues: Fortunately the tests proved to be negative, and our driver was allowed to return to work. We subsequently complained to the Gloucester Street surgery"— belonging to Dr. Marheine or Dr. Mohan and Dr. Clark— but was met with an attitude of 'its none of our business what happens once a patient has left our surgery.' I question the responsibility of this particular doctor in allowing a possible carrier of a serious tropical disease to ride in a vehicle that carries members of the public. I also question his total lack of concern after the event. That is the background. I decided to make various inquiries. The British Medical Association, slightly later, replied to the managing director of the taxi company saying, reasonably, that it was not directly a matter for the BMA since it is so to speak the doctors' trade association. It suggested that the General Medical Council might be interested.

On 5 January the General Medical Council replied to the managing director of the taxi company, saying: In reply, the Chairman has asked me to explain that although he is concerned about the matters which you have brought to his attention, he has been unable to identify the doctor concerned. That is because of the confusion over the name.

The letter went on to say that if the names could be supplied correctly perhaps the matter would be considered further. It is important to note that the chairman appeared 790 to be extremely concerned about the incident because by then Mr. Coulter and his taxi company were extremely frustrated at the rather casual attitude. At the hospital the tendency was not to remember the incident. That is understandable in some ways, but it adds to my own concern.

I wrote to the Minister for Health on 19 January and said: Mr. Coulter and the taxi company are very disappointed that the BMA and the GMC do not appear to be very interested as is shown by the accompanying enclosures"— that is, in the letters which I have just quoted— although I appreciate the GMC may be in difficulties because of the confusion over names. I welcomed the Minister's detailed answer. However, the procedures for complaint through the family practitioner committee system allow only for a direct complaint from someone who is applying for medical treatment.

The general provisions for a complaint from someone who is indirectly affected—in this case the taxi driver—are too wide and general to be applicable.

This was a potentially alarming incident. An ordinary taxi-cab was used to transfer someone who could have been a carrier of a serious and terrifying disease. The mode of travel might have been suggested by the medical practitioners concerned, Dr. Mohan and Dr. Clark, on the basis that they were not quite sure. That would be understandable. However, the idea that a person could be conveyed in an ordinary conveyance which could be used later by others, and what would have happened to the taxi driver if the tests had proved positive is unnerving and terrifying. Thank goodness that the tests were negative.

There is serious cause for concern at the highest levels—in the Health Service, in the Department and in the medical committees. I hope that the Minister shares my view. What might seem to have been a small, passing incident which fortunately did not have disastrous consequences could have been a tremendous matter of public importance, particularly since there had been a lassa fever scare. Britain, with its natural and historic worldwide links, is bound to take people who may be carriers of non-temperate diseases which could have a lethal and devastating effect if they were to spread.

I commend the fact that our medical authorities have been good at isolating individual incidents in care. However, it must surely be an obligation on all medical practitioners and anyone engaged in such matters--including the nurses and the staff in surgeries—who deal with members of the public who may come to them on a casual basis to make sure that they know the procedures for the transportation of people suspected of suffering from tropical diseases. Otherwise per se strict procedures should be laid down. That is my main reason for raising the matter.

I hope that the Minister will give a public reassurance that strict procedures either are in existence now or will be laid down in the future to make sure that that sort of incident cannot happen again. Inevitably, in those circumstances there should be a decision by a medical practitioner to summon an ambulance or a similar vehicle containing the necessary medical protection system so that someone could be conveyed in the appropriate protected manner—protecting both himself and the rest of the public.

The procedure for admission to a hospital should include a proper sense of record and memory so that 791 someone like my constituent who was harassed to frustration by being unable to find anyone to recall the incident will be sure that there is a clear record of what happened.

My hon. Friend will agree that Mr. Coulter and the managing director of the taxi company, Mr. Kaley, are to be highly commended. It would be understandable, even if one was temporarily alarmed at such an incident, subsequently to shrug one's shoulders and forget it. However, Mr. Coulter not only made his own investigations into the case, but, feeling a sense of frustration that he was not getting anywhere and was facing a series of bureaucratic replies from the medical committees, came to me as the Member of Parliament. He said that he was so disturbed by the potentialities of that unfortunate matter that he thought that it should be raised. I entirely agree with him.

I was grateful for the ministerial reply which I received, but I believe that we need to have more of an official Government response to such a matter so that the public may be reassured. There has already been widespread interest in the affair in the media. It behoves the Minister to try to give us a greater sense of confidence in the future that such an occurrence will not be allowed to happen ever again, short of the very remote possibility of an accidental procedure. Even that would be too much for the public to accept.

I hope that my hon. Friend will give us renewed confidence that in a country to which many people are coming from all parts of the world and from which many people are going we shall be careful in future to avoid incidents of this sort. I hope that the doctors concerned will give a proper explanation of why they seem to have been negligent and careless in their procedures on the occasion of which I have spoken.

§ The Under-Secretary of State for Health and Social Security (Sir George Young)

I am grateful to my hon. Friend the Member for Harrow, East (Mr. Dykes) for raising the matter. My hon. Friend, his constituent Mr. Coulter and his employer have had to go to considerable lengths to pursue their concern on that matter. They are all to be congratulated on their perseverance.

I know that my hon. Friend's concern goes much wider than the immediate personal risks to which his constituent feels he was or may have been subject. I have every sympathy with Mr. Coulter and his sudden predicament. I appreciate the concern that has been shown over the wider public health implications of the case. I am glad that we shall have the opportunity to consider them tonight. I hope to give my hon. Friend the assurances which he rightly seeks.

In reply, I should like to refer briefly to the facts of the case and the follow-up to it and then to say something about the arrangements generally for the control of infectious diseases, including those concerning the transport of patients.

As I shall explain, we are still waiting for a further report on the facts and circumstances of this case from the family practitioner committee concerned. But we know that my hon. Friend's constituent, Mr. Coulter, a taxi driver, was called to the premises of a general practitioner on 16 September to take a patient—a young girl aged 7—to the Hospital for Tropical Diseases, St. Pancras. The girl was accompanied by her father. She had apparently 792 arrived in this country on 13 September and became ill on 16 September with vomiting, headache and a temperature. The general practitioner accepted her as a temporary resident before referring her to the hospital. We made inquiries about what happened at the hospital, but without the name, age, sex or address of the patient concerned, which were not available at the time of the inquiries, the hospital was not able to make a definite identification of the patient from the out-patients' records of 16 September last. That explains why—as my hon. Friend said—the hospital could not be of great help. However, we shall let the hospital have this information and we shall seek any further details that it can give us about the case.

It so happens that the staff nurse on duty that day remembers this episode happening, and the following sequence of events appears to have occurred. Upon arrival at the hospital on that afternoon, the taxi driver brought the patient into the foyer. No warning appears to have been given to the hospital of the patient's arrival. The patient appeared to have a slight fever and it is thought that she had been abroad in a tropical country within the previous three weeks. In such circumstances, it is standard practice to carry out tests as a precaution in order to exclude certain serious diseases.

If, after the tests, there had been grounds for suspecting some serious communicable disease, the taxi driver would have had to be traced as a contact. Since he had accompanied the patient into the hospital, he was, quite understandably in the circumstances, asked to stay in the hospital until the preliminary results of the tests were known. In the event, those tests gave no grounds for concern and the patient was discharged. The staff cannot recall whether the hospital doctor on duty did, in fact, subsequently telephone the general practitioner concerned.

I do not know—I shall explain why—whether there was any suspicion in the mind of the general practitioner that the patient was suffering from an infectious disease, whether lassa fever or anything else, or even whether there were any strong grounds for such a suspicion. Had the general practitioner entertained the possibility of Lassa fever, he would have been well advised to consult the medical officer for environmental health and special ambulance transport could have been arranged, but such action would have been unnecessary if, for example, he suspected the presence of malaria. Lassa fever itself occurs only in a very few parts of Africa and, indeed, no patient suffering from it has come to this country for several years.

In the event, the use of a taxi did not—happily—present any threat to public health. However, it must have caused the taxi driver great anxiety. My medical advice is that in general it would be inappropriate to use a taxi if there were real grounds for suspecting the presence of any communicable disease. That is the first assurance that I can give my hon. Friend. I would certainly like to express my regret that, because of the reasonable precautions taken at the hospital, Mr. Coulter was put not only to inconvenience but, no doubt, to considerable worry and distress.

Mr. Coulter's employer subsequently complained to the medical practice concerned but was, apparently, met with a response which seemed to him to convey indifference. The employer then wrote to the British Medical Association. In its reply—as my hon. Friend said—the association indicated that it was not in a position to investigate complaints or advise members of the public on 793 such matters. The association did, however, go on to point out that the name given to it by the employer in his letter was not listed in the medical register and that it was possible, therefore, that he was not a medical practitioner. Accordingly, the association suggested that the employer might like to write to the General Medical Council, as the council is the registering body for doctors. It is also, of course, the body charged with statutory disciplinary functions regarding doctors generally.

On 7 November, Mr. Coulter's employer wrote to the General Medical Council. Its reply of 5 January said that the matter had been brought to the attention of the chairman of the preliminary proceedings committee. That is a committee of the council that decides whether a matter involves an allegation of serious professional misconduct and should therefore be the subject of attention by the professional conduct committee, which has disciplinary powers. The council went on to say, however, that there was not on the medical register anyone of the name—or any similar name—which the employer had quoted. It added that if the correct spelling of the name could be provided, together with initials or forenames, so as positively to identify the person in question, the matter would be considered further.

Mr. Coulter accordingly then made further inquiries but was not successful in contacting either the original doctor or anyone in the hospital who remembered the incident. He then wrote to my hon. Friend with a view to further investigation being undertaken. My hon. Friend wrote to the Minister on 19 January.

The Department then got in touch with the Kensington and Chelsea and Westminster family practitioner committee as the body responsible for the administration of general practitioner services in the area. As we were able to give the family practitioner committee the address of the practice concerned, it was able to tell us the name of the principal practitioner and that of his assistant, himself a registered medical practitioner. It was then apparent that it was the assistant's name which had been misquoted by Mr. Coulter's employer to the British Medical Association and the General Medical Council. The immediate question then for my hon. Friend the Minister for Health was what, if any action he could properly take as far as any complaint against the GP was concerned.

The general practitioner's terms of service in the NHS require him to render to his patients all necessary and appropriate personal medical services of the type usually provided by general medical practitioners. Such services include arrangements for referring patients as necessary to any other services provided under the Health Services Acts". Ordinarily, that covers the referral of a patient to the hospital and specialist services. It does not, however, specify how the arrangements for referral shall be effected.

If a patient, or someone acting on his behalf, considers that his doctor has failed to comply with the terms of service, he may make a written complaint to the family pracitioner committee. The committee's medical services committee has power to investigate such complaints and report to the committee, which then decides whether the doctor is in breach of his terms of service. If he is, the committee will recommend to the Secretary of State what, if any, action should be taken by the Secretary of State. Usually, such action would be a warning to comply more 794 closely with the terms of service in future or a recommendation that an amount be withheld by the committee from the doctor's remuneration. There is statutory provision for either party to appeal to the Secretary of State against an adverse decision by the committee.

It was against that background that my hon. Friend the Minister for Health wrote to my hon. Friend the Member for Harrow, East on 3 February on the following lines. He explained that the relevant regulations provided that a complaint should be investigated if it related to an alleged failure by the practitioner to comply with his terms of service in respect of any person who was, or who claimed to be, entitled to the provision of general medical services". My hon. Friend the Minister for Health went on to say that Mr. Coulter could not be regarded by the family practitioner committee's medical services committee as such a complainant as he had not been seeking medical services. The Minister pointed out that there was, nevertheless, provision for the medical services committee to investigate any matter referred to it by the FPC which related to the administration of general medical services. He arranged, therefore, for a copy of the correspondence and his reply to my hon. Friend to be sent to the Kensington and Chelsea and Westminster family practitioner committee for its consideration.

I should add here that in his reply to my hon. Friend the Minister felt bound to point out that the decision whether the matter should be referred to the medical services committee for investigation is entirely for the family practitioner committee as the doctor would have a right of appeal to the Secretary of State. The Minister also pointed out that while, for the reasons given, neither Mr. Coulter nor his employer could be accorded the status of complainant with the attendant right of appeal, they could be regarded as material witnesses at a hearing before the medical services committee. Finally, the Minister added that if Mr. Coulter and his employer wished to take up the matter again with the General Medical Council—on the question of professional conduct—the names and initials of both doctors should, of course, be quoted.

The family practitioner committee considered the matter at its next meeting, which was on 19 March. On 25 March, the committee wrote to inform the Department that, having discussed it, it had decided not to refer the matter to the medical services committee, Its reason was that the doctor concerned—who was answerable also for any acts or omissions by his assistant—could not be held to be in breach of his terms of service by any of the circumstances known to the Committee.

However, the committee's letter went on to say that, following its decision, the chairman had instructed the committee's administrator to arrange to visit the doctors in order to ascertain the circumstances surrounding the incident so that the committee could then make a report to the Department. I understand that the administrator has been in touch with the principal doctor and learned from him that the doctor more personally concerned, the assistant doctor, is at present on holiday. When he returns, the administrator will see both doctors and then report back to the chairman. A report will then be made to the Department.

There is a possibility that, in the light of further evidence, the medical services committee will be asked to review the matter again. The House will appreciate that in 795 the circumstances I cannot comment further on the role of the general practitioner in this case as the matter could still come to the Secretary of State on appeal, following a medical services committee investigation. However, I undertake to keep my hon. Friend fully in the picture on future developments; and it is still open to Mr. Coulter to refer the matter to the General Medical Council.

Whatever may be the outcome in this particular case, our consideration of it tonight highlights the need for there to be clearly established arrangements for the handling of persons with, or suspected of having, infectious diseases and these must be known to GPs and others in the health services who may be concerned with such treatment. Members of the public, including those who may otherwise be especially at risk such as taxi drivers, need to have protection as far as possible from the hazards of infection. Such arrangements in fact exist within the statutory framework for the control of infectious diseases. I hope that it will reassure my hon. Friend and the House if I refer briefly to this framework and the related arrangements.

Provisions for preventing the spread of infectious diseases are contained in the Public Health Act 1936 as amended by the Health Services and Public Health Act 1968 and in various sets of regulations. Under these provisions, medical practioners are obliged to notify certain diseases to the local authority. Under the 1936 Act as amended there are only five notifiable diseases—cholera, plague, relapsing fever, smallpox and typhus. However, regulations provide that a further 23 infectious diseases must be notified to the local authority, including malaria, and lassa fever.

I should emphasise that in law we refer to notifiable diseases or diseases which have to be notified; they are mostly communicable, that is, infectious diseases. The law does not refer to tropical diseases as such and many infections which occur in tropical countries are not notifiable. Patients coming into this country with one of most such conditions would create no hazard here.

As for the transport of persons suffering from notifiable diseases, legislation requires that no one having the care of a person whom he knows to be suffering from a notifiable disease shall permit that person to be carried in any public conveyance used for the conveyance of persons at separate fares; or in any public conveyance without previously informing the owner or driver thereof that that person is so suffering. There are fines for contravention, and provision for payments to cover losses incurred by those providing transport.

I am advised that taxis, which are hackney carriages, qualify as public conveyances. I hope that my hon. Friend will accept the legislative framework which will help to avoid the unacceptable risks to which he referred.

The two diseases quoted by my hon. Friend in the correspondence he sent on 19 January to my hon. Friend 796 the Minister of State for Health were malaria and lassa fever. Medical practitioners are required to notify these diseases to the local authority—that is, to the medical officers for environmental health—but I must point out that the provisions regarding public transport to which I have referred apply to lassa fever but not to malaria. It should also be noted that, for an offence to have been committed under the Act knowledge rather than mere suspicion of a disease is required; and lassa fever, for example, is not easy to diagnose without various tests which have to be carried out in a designated laboratory.

In addition to these statutory provisions" the Department issues advice from time to time on specific diseases. The memorandum on lassa fever, issued in 1976, gives guidance on the action to be taken on the discovery of a suspected or known case of lassa fever. The memorandum advises medical practitioners that if they have reason to suspect lassa fever in certain circumstances the medical officer for environmental health should be alerted and an expert in tropical medicine or a consultant in infectious diseases should be consulted. The memorandum goes on to specify the subsequent action to be taken by the medical officer for environmental health, including isolating the patient in designated hospital accommodation using a special ambulance if transport is required. The memorandum advises that the ambulance control station should always be told in advance that lassa fever is suspected so that the necessary safety measures may be taken.

When making a request for an ambulance, a doctor would be expected to give sufficient details of the patient's condition for the ambulance controller to determine the type of transport required—and, in the case of an infectious disease patient, for special precautions to be taken. The transport of infectious disease patients is one of the subjects dealt with in the basic training of ambulance men.

Those are the general provisions for the protection of the public and those who may be involved in the transport of potentially infectious patients. As I have said, there are still uncertainties surrounding the facts of the case raised by my hon. Friend. It is not possible to say at this stage whether what happened reveals any potential weakness of those arrangements and, if so, what remedial action might be appropriate. But it is certainly a matter to which we shall, if necessary, give further consideration when we have the further report from the family practitioner committee to which I have referred.

I am grateful to my hon. Friend for raising this important matter in the House.