§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Ainger.]
7.10 pm§ Mr. John Denham (Southampton, Itchen)I am very grateful for the opportunity to have this Adjournment debate this evening. The question that I would like my hon. Friend the Minister to consider is this: how is it possible for two doctors to be convicted of manslaughter as a result of medical negligence or incompetence, yet still be allowed to practise medicine in this country without any action whatever being taken by the General Medical Council? I have great respect for my hon. Friend, and I suspect that if I had put that question to him hypothetically before he had been briefed for tonight's debate, his initial reaction might have been, "That could not possibly happen." Yet, as I shall set out, that is precisely what has happened.
Having been an MP for 14 years, I sometimes think that constituency cases that come into surgeries are losing the power to shock, but the case that was brought to me by my constituent, Annabel Grant, on behalf of herself and her six-year-old son Mitchell, genuinely shocked me. Annabel Grant's partner, Sean Phillips—Mitchell's father—died in 2000. An apparently routine knee operation in June 2000 was followed by infection. His condition was not properly identified by the doctors concerned, Dr. Amit Misra and Dr. Rajeev Srivastava, and, tragically, Mr. Phillips died a few days later.
Following the death, Southampton University Hospitals NHS Trust contacted the General Medical Council in August 2000. A professional advisory panel at the hospital had concluded about Dr. Misra:
On the basis of your involvement in the case of Sean Phillips there are serious questions about your competence to look after the general medical needs of sick patients. Your involvement in other cases"—I have no knowledge of those other cases, but there clearly were some—
suggests that your note keeping is poor and that you require remedial training and assessment.I am not clear as to what information was provided about Dr. Srivastava, although the GMC tells me that it received information about him at the same time.In October 2000, Hampshire police became aware that the hospital had sent papers to the GMC regarding Dr. Misra, and they began their own investigation. More than a year later, in January 2002, both doctors were arrested and charged with the manslaughter of Sean Phillips. Their case was heard in April 2003. At the trial, an expert for the prosecution, Dr. Wilcox, gave evidence. I am relying on a letter that I have received from the Crown Prosecution Service for this summary of the evidence that he gave. In that evidence, I am told that he made it clear that he would have expected a third or fourth year medical student to have appreciated the fundamental importance of the basic vital signs of life, in terms of pulse, temperature and blood pressure, and to have realised that Sean Phillips was suffering from a serious sepsis from about 12 noon on Saturday 24 June 2000.
In his summing up, the judge referred to Dr. Wilcox's remarks, saying that if, in an oral examination, Dr. Wilcox had given a third or fourth year medical student 979 only the observations on Sean Phillips, and the fact that he had had an operation on his left knee, and the student had failed to answer that the diagnosis was an infection, Dr. Wilcox would have thought of failing the student on that basis alone. Dr. Wilcox also made the point in the expert evidence that every mother knew what a high temperature meant, and that if a high pulse and low blood pressure were added, basic aspects of medical care should tell a doctor—whatever his training—that the patient was seriously ill.
Obviously, I cannot rehearse here every point made in the trial, but that gives a flavour of the evidence. At sentencing, the trial judge, Mr. Justice Langley, stated that manslaughter was a very serious crime, and that it was for the jury to determine whether the defendants' conduct in relation to Sean Phillips was so exceptionally bad that it should be characterised in that way. The jury decided that it should. The judge passed a sentence of 18 months, suspended for two years. In doing so, he said:
you are both men with young families and your future in the medical profession is now in doubt and that is a real loss to both of you".The implication, and what the judge expected, was clear. It was what Mr. Phillips's family expected, and it appears to be what Dr. Srivastava seems to have expected, as his barrister told the court:
His career in this country, which only a short time ago showed so much promise, is now bound to come to an end.Yet, today, both doctors enjoy full registration, without restriction, with the General Medical Council. I understand from press reports, at least, that both are still working for the national health service, one in the Newcastle upon Tyne area and the other in Dundee.Let me turn to the history of the General Medical Council's handling of the cases of those two doctors. The GMC was first alerted to the case in August 2000. As I have said, irrespective of any police investigation, it had been told that a professional advisory panel in Southampton had concluded that Dr. Misra required remedial training and assessment. It seems, however, that no action was taken or considered for a further 16 months, despite the fact that from November 2000, the GMC was aware that the police were investigating.
In February 2001, the General Medical Council met Hampshire police in Southampton, where it was handed papers including a summary of the investigation, a chronology of events, the police witness and exhibit lists, the trust internal review, an external review of the trust action plan, a medical report by the director of orthopaedics, and a copy of the statement of Professor Robert Forrest, which had been produced at the request of the police regarding Sean Phillips's treatment.
At some point in that period, although no action was being considered by the General Medical Council against the doctors, the GMC decided to extend Dr. Srivastava's time-limited registration from July 2001 to July 2002. I do not know exactly when that happened, but certainly, it was after the GMC was aware of the police investigation, and probably after it received those documents. The GMC told me that the chair of registration extended registration because of
the lack of evidence from the police".980 I will come back to that.Not until the doctors were arrested—in 2002—does the GMC seem to have considered any action. However, the medical screener at the GMC
felt that despite their being charged by the police, he was unable to refer Dr. Misra or Dr. Srivastava to the IOC without at least having had sight of the police expert report.I am familiar with the IOC—the interim orders committee—because, as a Health Minister, I took through the House the order that gave the General Medical Council the power to issue interim orders. When I introduced the debate on those new regulations, on 6 July 2000, I told the Committee:
Urgent action is needed to widen the powers of the GMC, so that it can deal quickly and more effectively with doctors whose fitness to practise comes into question. This action is the first step in repairing the damage to the bond of trust between doctors and their patients".—[Official Report, Standing Committee 2DL, 6 July 2000; c. 1–2.]Obviously, I was far too optimistic. Despite the arrests, the case and the available information were not even referred to the interim orders committee of the GMC.Again, in correspondence with me, the General Medical Council seems to suggest that it was the failure of the police or the Crown Prosecution Service to supply information that was the problem. I want to say to my hon. Friend the Minister that that is an absolutely unacceptable attitude, and I hope that if that case is put to him, he will reject it. Let me explain why.
First, the General Medical Council clearly had a substantial body of information, including the initial report from the hospital, on which it could have taken action. There were a whole series of meetings between the police and the GMC at which the case was discussed and information shared. Secondly, as the Crown Prosecution Service has pointed out in a letter to me, although it might have been debarred from releasing a witness report at a time that could have prejudiced a prosecution, the GMC could have sought a court order to obtain it.
I agree with what the CPS told me—that
the integrity of the prosecution must take priority and …the supplying of further statements or reports might be argued by the defence to have caused them prejudice and hence render any future trial unfair. It was considered that the GMC could apply to the High Court for an order seeking disclosure if it saw fit and the High Court would then be in a position to impose appropriate restrictions on the use of the evidence".In other words, I believe that, had the GMC taken the initiative, it could have obtained the evidence when it wanted it, in a way that would not have prejudiced the trial, but the GMC chose not to do so. It is worth saying, though, that by the summer of 2002 a number of pieces of evidence had been provided to the GMC.Let me make a third and equally fundamental point about the GMC's attitude to CPS information. It undermines the principle of self-regulation of the General Medical Council if the GMC is not willing to take responsibility for investigating the conduct of doctors. Here we had two doctors, both arrested for manslaughter, and the GMC position seems to be that it was under no obligation to take action if it did not get information on the investigation provided by the police. That is not acceptable. In any case, by August 2002, the GMC had been provided with the report that I 981 mentioned earlier from Professor Forrest, as well as the further detailed conclusions of another prosecution expert, Professor Healy.
When that information came through, the GMC finally referred both doctors' cases to the interim orders committee. It met in the autumn of 2002 in the case of both doctors, in private. The interim orders committee concluded that no action was necessary. This is the rub: tonight we do not know what was said at those meetings. We can reasonably assume, however, that it was the same evidence that a few months later would lead a jury to convict both doctors of manslaughter.
I spoke earlier of the bond of faith that needs to exist between doctors and patients. The gap between what the jury thought was appropriate when the case came to trial and what a group of the GMC in private thought was appropriate could not be wider. That is deeply worrying.
Let me make it clear that the interim orders committee does not have to strike doctors off. It can take lesser actions. It can suspend a doctor. It can restrict a doctor's ability to practise without supervision, for example. I believe that it could have required the retraining that the Southampton NHS trust thought was necessary. But the interim orders committee did nothing.
Finally, the trial was held and both doctors, having been convicted, were referred back to the interim orders committee. I assume that when the cases came to the interim orders committee a second time, the GMC had available to it all the necessary information. I know that the Crown Prosecution Service provided the prosecution case summary, a bundle of witness statements, the medical records, further prosecution expert medical reports and defence expert reports. What I do not know is whether the GMC had transcripts of the trial—the judge's remarks and so on.
I know that advice on how to obtain the information was passed to the GMC after the trial, but no one from the GMC attended the trial. After the trial the GMC did not ask the police for any material in respect of either doctor. The GMC did not take up the offer made by Hampshire police that after the trial the case officer would supply any or all relevant information. So I can only assume that the GMC had all that information when it decided to take no action, as it finally did. If not, it was grossly negligent. Both doctors went back to the interim orders committee, having been convicted of manslaughter, and the GMC again decided on no action at all.
It is important to put on record that both doctors have the right to appeal against their conviction for manslaughter and that the GMC will not complete its consideration of either doctor's case until that appeal has been heard. I accept that. There may be the possibility of further action and it is possible that the Appeal Court decision will be different from that of the original trial judge, but the whole point of the interim orders committee was to allow the GMC to act quickly, in the public interest, in cases that by their very nature usually take years to conclude. It was the fact that, in previous years, the GMC said that it could do nothing until the legal process was completed that led me, when a Minister, to introduce interim orders—but they have not been used.
982 As far as I can tell, only two things have happened since the trial. First, a Dr. Gaangophadhyay, who appeared as a witness in the case, was reprimanded by the GMC. The witness is the only doctor to have suffered action at the hands of the GMC. Secondly, Dr. Srivastava's registration was upgraded to full registration. The GMC tells me that because of the conviction a question arose as to Dr Srivastava's "good character". Many members of the public might have taken a different view from the one that the GMC seems to have taken—that being convicted of manslaughter as the result of medical poor practice did not mean that someone was not of good character and was thus no bar to full registration.
My constituent, Annabel Grant, is appalled at the way that she has been let down by the system. Not surprisingly, she feels that neither doctor should ever practise again. I need to be consistent, however. When I occupied my hon. Friend's position as a Health Minister, I accepted that one mistake need not always cost a doctor their career and that we should have a system that offered individuals the chance to retrain, to work under supervision and to learn from their mistakes. But manslaughter is a very serious offence. The gravest thought must be given before allowing doctors convicted of manslaughter to practise and if they are allowed to do so, it can be only under the tightest possible controls. Instead, in this case, no action was taken, despite the jury's decision and despite the clear implication in the judge's words, when he passed sentence, that the doctors' careers were in doubt.
I want to make some final points. The GMC tells me that its procedures will change later this year with the introduction of its fitness to practise review. I asked the Library for advice about that and I agree with it that
Even if we did have the final outcome of the current reforms, it would be hard to comment on how these would affect the specifics of the two cases with which you are concerned. For example, I understand that where there has been a serious conviction, the case would, under the new procedures, go directly to the 'fitness to practise' panel but that by itself would not necessarily alter what they decide.That is the key point. We can have as many procedures as we like, but if we are not prepared to use them they mean nothing.The crux of the matter is that, on the same evidence, a jury convicts yet the GMC decides there is no problem. That is the challenge that faces my hon. Friend the Minister. I have been impressed by Annabel Grant's determination to pursue injustice but depressed by her story. When I took through the House the new regulations that established the interim orders and gave the GMC new powers in 2000, I genuinely believed that it had at long last recognised that the power of self-regulation carried with it the responsibility to do so effectively. It seems from this case that less progress has been made than I hoped.
If I am right and the GMC had the power to act but failed to do so, will my hon. Friend the Minister take up this tragic case with the GMC and ask why it did not use the power Parliament gave it? If I am wrong and there were legal obstacles to effective action, he must bring in changes, as I tried to do four years ago, but this time we must make the system work.
§ The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman)I congratulate my right hon. Friend the Member for Southampton, Itchen (Mr. Denham) on securing a debate on this important subject. I congratulate him, too, on the measured and thoughtful way in which he put his case. I freely confess that he has given me much to think about. In case I do not get a chance to make this point at the end, I assure him that everything he has said will be considered by all those dealing with the case and I shall ensure that we all reflect on the points that he has made. I will also ensure that all his points are brought to the attention of my right hon. Friend the Minister of State, who normally deals with issues such as this.
It will hardly surprise my right hon. Friend—who, as he said, was a distinguished health Minister himself—that I begin by paying tribute to the vast majority of doctors and other health-care professionals who give a first-class service to the huge majority of patients and the million people who are treated safely and successfully every day in the national health service. Yet experience tells us that no matter how dedicated and professional staff are, things do go wrong in complex health-care systems, with serious repercussions for patients and their families. Although small in proportion to the volume of good health care delivered daily, such events can, as my right hon. Friend said, erode public confidence.
Patients deserve high-quality health care and must have the utmost confidence in the services that are provided—and, crucially, in the health-care professionals involved in their delivery. In situations involving life and death, when they are vulnerable, patients want and are entitled to expect doctors on whom they can rely. I understand how the tragic events that occurred at Southampton General hospital and afterwards may have combined to undermine that confidence. I also understand why the family of Mr. Phillips feel let down, both by individuals and by the system. At this point, let me add my condolences, albeit belatedly, on their loss.
As the General Medical Council's case against Dr. Misra is still going on, my right hon. Friend will understand that it would not be appropriate for me to comment on these events in detail. He will be aware that the GMC's professional conduct committee is unable to proceed further until Dr. Misra's appeal against his conviction has been heard. The GMC's interim orders committee has considered whether it was necessary for the protection of the public, or in the public interest or Dr. Misra's own interest, to impose restrictions on his registration pending the PCC's hearing. The committee decided, in the light of all the evidence before it, that interim action was not necessary in this case. Dr. Misra therefore remains fully registered with the GMC.
As for Dr. Misra's appeal against his conviction for manslaughter, I am informed that at a directions hearing on 15 June, the Court of Appeal decided that preliminary legal arguments relating to the legality of the offence of gross negligence manslaughter— particularly in relation to the field of medicine—and its compatibility with the European convention on human 984 rights would be determined at a hearing on 20 and 21 July. Following that decision and any subsequent appeal to the House of Lords, and should the convictions stand, further issues will be determined at a court hearing, which will be listed not before September this year.
§ Mr. Deputy Speaker (Sir Michael Lord)Order. I am reluctant to stop the Minister in mid-flow, but I am a little concerned about the sub judice rule. Can the Minister tell me that the matter has been thought through, and that nothing he says this evening will prejudice either the GMC or, more particularly, court cases that may arise in future?
§ Dr. LadymanYou are absolutely right, Mr. Deputy Speaker. That is why I am being more circumspect than I am sure my right hon. Friend would want me to be. I have said all that I am going to say about the specific case; now I am simply putting on record the timing of the case, and when decisions relating to it will be made. I shall describe the generality of the position and justify the way in which we have reached it, rather than talking about the specifics. I am sure that that will disappoint my right hon. Friend and his constituent, but I hope they will understand.
Let me return to the theme of confidence. A key strand of the NHS quality agenda is assuring patient safety. Patients need to be confident that the NHS is doing all it can to prevent and detect errors early, before tragic consequences occur. They also need to be confident that the NHS can learn from such incidents and prevent them from re-occurring, and to have confidence in the professional regulatory framework that is responsible for ensuring that health-care professionals are competent, up to date and trustworthy. As we have seen from other high-profile incidents and investigations, public confidence in the NHS is almost synonymous with confidence in the medical profession.
I am sure that the House will agree that however effective systems are in reacting to an incident, it is clearly preferable that measures be put in place to help detect such incidents, and to prevent them from occurring in the first place. Concerns about a doctor's performance could emerge from a number of sources even before a serious error or incident occurs. It is essential, therefore, to have systems in place to recognise these problems early on and to deal with them effectively, so that the risks to patients are minimised and doctors in difficulty can be helped and supported.
The Government established the National Clinical Assessment Authority in April 2001 as part of a package of measures aimed at underpinning and improving the quality of clinical care in the NHS. The NCAA aims to improve public confidence in the performance of doctors and dentists by helping local organisations to manage performance problems swiftly, effectively and sensitively; by promoting the development of excellent local and national procedures for preventing, identifying and resolving performance problems; and by assessing individual doctors and dentists and recommending practical ways in which their performance can be Unproved.
Such efforts involve striking a balance between the central importance of protecting patient safety by addressing performance problems, and not needlessly 985 "writing off" doctors and dentists who could be returned to safe and valued practice. The NCAA has shown that it can help the NHS to strike that balance; indeed, my right hon. Friend acknowledged the importance of doing so. In 2003–04, the NCAA received 524 referrals, of which 93 per cent. reflected specific performance concerns. In terms of advice, assessment and support, its approach is unique among health care systems.
Sadly, as experience has shown, no system can be entirely error-free. However, evidence has also shown that when things go wrong, the causes can often be traced back to a systems error, rather than to the fault of an individual. As the case of Dr. Misra sadly demonstrates, some groups—particularly junior doctors—may, through inexperience or lack of training, make errors that other, more experienced colleagues would usually avoid. $The consequences for the patients concerned can be severe—that is clearly the most important issue—but the consequences for the doctor involved can also be serious, as we have seen. That highlights the critical importance of establishing robust systems for supervision and training, and the need for those who supervise students and junior doctors to take those responsibilities seriously, as the GMC's document "Good Medical Practice" clearly points out. An automatic decision to blame and punish staff makes it more likely that errors will be covered up, and that the right lessons will not be learned. The evidence shows that if an organisation's culture is open and fair and people are encouraged to speak up about patient safety incidents, patient safety is improved, as those organisations learn about what has gone wrong and are able to put things right in the future.
In July 2001, the Government established the National Patient Safety Agency. The role of the NPSA is to improve the safety of NHS patients by promoting a culture of learning from, and reporting, patient safety incidents, and to manage the national reporting system that supports that function. Again, the NHS is leading the world by introducing the first truly national reporting system for adverse incidents. The NPSA has already begun to have an impact on patient safety, and it is working on a range of practical solutions to help make care safer for NHS patients.
One such solution is the "incident decision tree", which was launched recently as a web-based toolkit. It has been designed to assist managers in dealing openly and fairly with staff who have been involved in patient safety incidents. As I have said, a culture based on 986 individual blame and punishment makes it more likely that problems will be driven underground and the root cause not tackled. However, there will clearly be times when individual clinical performance must be addressed and staff held accountable for their actions; this toolkit aims to help managers to pose the right questions in order to establish whether that might be the case. It provides a clear path through which to identify cases where deliberate harm, reckless behaviour or criminal act has been involved, to ensure that the right action is taken.
If such behaviour is found to be the root cause of an incident, the regulatory body must then consider whether the individual concerned is fit to remain on the professional register. Patients and professionals alike need to be confident that the procedures for making those decisions are effective and fair. We are therefore in the process of modernising and strengthening professionally led regulation, particularly in respect of the GMC. The GMC exists to protect patients and the public interest by regulating and guiding the medical profession. In response to pressure from both the Government and the public, and in consultation with patients, the GMC has developed the most far-reaching reform package in its history. The foundations for change were laid when Parliament approved the Medical Act 1983 (Amendment) Order in December 2002.
§ Patients and the public will benefit from simpler GMC proceedings and rules, speedier and more efficient processes and greater openness than before—
§ The motion having been made after Seven o'clock, and the debate having continued for half an hour.
§ Adjourned at twenty minutes to Eight o'clock.