§ Ann Taylor (Dewsbury)
I am pleased to have the opportunity to raise a matter that started as a constituency issue but has wider implications. The reason why I requested the Adjournment debate is the tragic death in my constituency of Sheila Creighton, who lived at Norristhorpe and who died last April in tragic circumstances.
Sheila was an active and fit 61-year-old. She was 18 months into her retirement when she had what seemed a simple fall in her garden and cut her head on a step. She went, as anyone would in those circumstances, to an accident and emergency unit, where she received prompt attention and the cut was cleaned. Sheila was sent home and at first all seemed well. Her family and even she did not realise how serious the situation was. Unbeknown to her family, friends and doctors, Sheila had contracted tetanus. She soon developed serious problems and had to return to hospital.
Tetanus was not diagnosed instantly, however. There were several factors in that, all of which had some justification. There was some doubt at the time about how long ago Sheila had last been vaccinated against tetanus. Indeed, I think that some confusion still surrounds that. In addition, many of the symptoms that she displayed could have been attributed to other aspects of the fact that she had fallen and hurt her head. It was not clear that the symptoms were pointing in one direction as opposed to another.
The other factor that undoubtedly played a part was that tetanus is extremely rare in Britain. Very few doctors in hospitals or elsewhere think of that as the first diagnosis for someone with Sheila's symptoms. Indeed, it was a doctor with experience of working abroad who first indicated that tetanus might be a diagnosis in the case. It is not for me to comment on the balance of those factors, but I think that they all contributed.
As I said, Sheila was not diagnosed with tetanus quickly. Once the diagnosis was made, it was not possible to save her life, and tragically she died as a result of what at first seemed a simple fall in the garden. I am sure that the Under-Secretary of State for Health, my hon. Friend the Member for Salford (Ms Blears), will join me in expressing sympathy to Sheila's widower, Ronnie, and the whole family. I have spoken to Ronnie, to another relative, to the family GP, Dr. David Findlay, and to the coroner involved in the case, Dr. Roger Whittaker. I am grateful to them all for the time that they have given. Obviously, each of them has thought about this exceptional case a great deal.
The case raises a couple of basic questions, which I shall raise with the Under-Secretary so that Ronnie Creighton and his family can feel that all possible lessons have been learned from what seemed like a simple accident leading to tragic consequences. First, is enough being done to raise awareness among people generally of the need for protection from tetanus? My second question is somewhat different. It is relevant to this case and many others. Are our individual medical records as patients, including our vaccination records, sufficiently available to those who need them when they need them?
65WH I am aware that tetanus is relatively rare in Britain. It is a common cause of death in developing countries, but thankfully not in the United Kingdom. The Under-Secretary probably has more up-to-date figures than I have. Mine are from the Library, which recorded 145 cases in a 10-year period up to the mid-1990s. Of course, most of those cases were not fatal, but that was the incidence of the disease during that time. The fact that we have so few cases is thanks largely to immunisation, higher hygiene standards and probably other factors, such as greater mechanisation in farming. We could discuss that, but it is important to register that it is a rare disease.
In the decade for which I have figures, 53 per cent. of all cases involved people over 65, and two thirds involved women. The fact that the younger section of the population is less affected by tetanus must be due at least partly to the vaccination programme that has been in force since 1961. It is now commonplace for infants to be vaccinated against tetanus and to receive other vaccinations when they are very young. Booster injections are also commonly given at different points in a child's school life. I have figures suggesting that, in 2001–02, 94 per cent. of children who reached their second birthday at that time were immunised against tetanus when they were immunised against diphtheria and polio. I understand that 95 per cent. is the target and that that was the first time in nine years that the figure had been below 95 per cent. Perhaps that tiny chink in the numbers needs to be watched, so that the figure does not go any lower.
I want to ask the Under-Secretary about the fact that there are no formal targets for the reinforcer or booster doses, which come later. According to the figures that I have seen, not all those who receive early vaccinations successfully are covered when it comes to booster injections. It is commonplace for people to receive some protection, but not everyone will realise that vaccination in early childhood or the injections that people receive after an accident do not necessarily provide protection for the whole of their lives, and that they need booster injections from time to time. Lifelong immunity is not easily achieved. I saw a report—perhaps the Under-Secretary will comment on it—that we need five full doses on different occasions before we have lifelong full immunity. I am not sure how many people have that.
Will the Under-Secretary look again at whether more can be done to ensure that everyone receives the advice that they need and that everyone considers vaccination? I understand that there are sometimes reasons why vaccination may not be recommended and why it is sometimes decided that not everyone in an A and E department should be routinely vaccinated against tetanus. However, many people do not even consider the matter unless they are travelling abroad and they take advice then.
I looked up what information was available on the NHS website and the Department of Health website. I also tried NHS Direct. Its advice was helpful, as are programmes such as "Gardeners' Question Time", which occasionally mentions the need for people to seek protection against tetanus. However, many people, particularly those potentially at risk, such as those over 65, do not necessarily search out that information and do not come across it. Is the Under-Secretary satisfied with the immunisation programme and, in particular, 66WH the follow-up programme for return booster injections, which are critical for long-term protection? If we get the early vaccinations right, it is easier to continue. Is she satisfied that more mature adults who have never had any vaccinations are being encouraged at least to be aware of the need for appropriate information and immunisation? They should not panic or queue up for injections that they do not need, but they should get the advice that they need from GPs or elsewhere.
That brings me to my other concern. When my constituent went to hospital for the first time after the accident, there was no easy and immediate way of checking if or when she had last been vaccinated. Many of us could say that that would happen for other illnesses or vaccinations. We often cannot recall exactly when we had different vaccinations and would probably have to get our vaccination records checked before we travelled to certain countries, which is the most likely time that we think about vaccinations.
My concern is therefore about accessibility to medical records and whether more could be done. In particular, will the Under-Secretary share her latest thinking about the possible use of smartcards? I know that there is a European Union dimension to the issue, which can be a red rag to a bull, but that does not mean that we should not consider it. Many EU countries have incompatible health smartcard technologies, but there are incompatible technologies within Government, and computers cause us problems.
We have an opportunity to do something. I understand that there have been pilot schemes in the United Kingdom. Whether such a development is UK based or wider, there must be scope for improving access to information. If my constituent had had a smartcard with all the information about her vaccinations, what she told the doctors or whether she could remember having a vaccination would not have been an issue. The information would have been instantly available, and a routine post-accident tetanus injection would have been considered necessary, and would have made a difference.
My constituent Ronnie Creighton has suffered a great loss, and his family were devastated by the incident. Obviously, there is nothing that we can do for Sheila, but it would help the family if we met some of their anxieties about the need for more awareness of the dangers of tetanus and about information getting to the point at which it is most needed. If we made progress in both improving access to information and increasing people's awareness, so that they consider having tetanus vaccinations, and younger people know about keeping up to date with their booster vaccinations, some good could come out of this tragic incident and more people could get better protection in future.
§ The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears)
I congratulate my right hon. Friend the Member for Dewsbury (Ann Taylor) on securing this important debate. I extend my sympathy to the family of Sheila Creighton, in particular to her widower Ronnie. Sheila died tragically in the spring of last year after contracting tetanus following a fall in the garden, and it is safe to say that the majority of the undoubtedly rare cases of tetanus arise from incidents in the garden.
67WH It is incredibly sad that someone should die of tetanus in the 21st century. The disease has largely been eradicated from this country, and the circumstances are unusual. The inquest into Sheila's death found that the treatment delivered by the two hospitals that she attended—Dewsbury and district hospital and Pinderfields hospital—was acceptable and although the diagnoses were incorrect, they were perfectly reasonable given the rarity of tetanus. Several different doctors saw Sheila, and her condition was recognised only towards the end. Mrs. Creighton's tetanus status was investigated as soon as she presented at the accident and emergency department, and it was indicated that she had had a booster within the past five years, so in accordance with hospital policy and Department of Health guidelines, no tetanus injection was given.
I want to deal with the immunisation system generally and how that protects younger people and consider the position of older people, which my right hon. Friend has rightly emphasised. I will then examine the information technology issues and look to the future and how we can have systems to minimise such events.
A national childhood tetanus immunisation programme was introduced in the United Kingdom in 1961. Since 1990, vaccination coverage at two years of age has exceeded 90 per cent. in England and Wales. I am pleased to say that in the Calderdale and Kirklees area, the percentage of children immunised by their second birthday is in excess of the national average at 96 per cent. and the percentage of children who have had diphtheria, tetanus and polio immunisation at the age of five years is 97 per cent. A good job is being done in that area to ensure that children are immunised at two and then have their boosters later in childhood.
Due to the success of the programme, tetanus disease almost disappeared in children under 15 years of age by the 1970s, so the majority of cases are in unimmunised adults, as in the case of Mrs. Creighton. To increase the vaccination uptake in adults who remained at risk, it was recommended in 1970 that immunisation should be routinely offered in the treatment of tetanus-prone wounds, so that when people presented with any wound or burn that showed various symptoms of tissue damage, doctors routinely offered immunisation.
That is still the position today. If there is any doubt about someone's tetanus immunisation status, it is recommended that the patient receive a tetanus jab. The difficulty in the case in question was that the hospital believed that the doubt was eradicated by Mrs. Creighton's indication that she had had a booster jab. However, if there is any shadow of a doubt, the patient should have the injection straight away to build the immunity.
It is incredibly important to us that the childhood programme is maintained and, when possible, opportunistic vaccination takes place in adults who have not been able to complete a course of the vaccine. In that way, we can approach the problem from both ends: ensuring that the children are properly vaccinated and getting the patient immunised on every occasion that they present with a tetanus-prone injury. Tetanus is not passed from person to person. It is picked up from spores in the soil, so it cannot be completely eradicated, which is why vaccination remains so important.
68WH My right hon. Friend is right that it is recommended that people have five doses of vaccine at appropriate intervals to give lifelong immunity, which is what the childhood immunisation programme aims to achieve. The vaccine is now given in three doses one month apart for infants at two months old, so they receive their first three doses early on. They then receive a pre-school booster dose of diphtheria, tetanus and pertussis together. That is recommended for three to five-year-olds, is given with the polio vaccine, and is the fourth dose of tetanus. Finally, a reinforcing dose of tetanus and low-dose diphtheria is recommended for young people between 15 and 19 years of age, which is the fifth dose of tetanus vaccine.
§ Ann Taylor
Will my hon. Friend confirm whether targets exist for those other two categories? There are clearly targets for the young infants, but my information was that targets do not exist for three to five-year-olds or school leavers. I would have thought that it would have been useful to have targets for those groups, particularly as school leavers may remember having the vaccine in later life and go back for subsequent booster injections.
§ Ms Blears
At the moment, these are recommendations, not targets. The programme is extremely successful in relation to childhood immunisation, which involves the four doses that I mentioned up to the age of five. As I said, the figure in England is up to 94 per cent., and is even higher in my right hon. Friend's area. There are no targets for the dose for 15-year-olds, which remains to be recommended. I assure my right hon. Friend that I shall examine the current state of affairs more closely to see how much of the population we are reaching to ensure that they have that final booster dose that will give them the lifelong immunity that it is so important.
Tetanus has occurred only exceptionally rarely in fully immunised individuals. The relatively small number of cases that continue to occur in this country are among unimmunised or partially immunised people. The tetanus immunisation programme has been very successful. The annual incidence of tetanus is now 0.2 per 1 million people—the lowest figure ever recorded in this country. We have driven down the figures for the disease; there is a real record of success in the UK. There are no longer any cases of tetanus reported in children under the age of five, although we should remember that tetanus infection is still a common problem in parts of Asia and Africa, especially in newborn babies due to infection of the baby's umbilical stump. Tetanus is an important cause of death in many of those countries.
The situation is regularly surveyed by the Communicable Disease Surveillance Centre, which is part of the Public Health Laboratory Service. Between 1984 and 2000, it carried out a survey in which 175 cases were reported. As my right hon. Friend pointed out, 91 of those cases were people over the age of 65. We are therefore seeing a concentration of the admittedly few cases among older people.
Since the 1930s, cases of tetanus have been more common in women. One of the reasons is that in 1938, men in the armed forces started to be immunised. Women obviously did not have the same access to that immunisation programme. Recent surveillance data
69WH suggests that men and women are now equally at risk. Tetanus is more common in older people. Because the national infant programme was introduced only in 1961, many older people have not got the immunity that they need. It is very important for older people to ensure that they are protected.
It may be possible to intervene around the time when older people go for their flu jabs to ensure that awareness is raised. We have a major campaign among older people to ensure that they receive a flu jab every year. Injection rates are now quite good; probably more than 65 per cent. of older people are now being immunised every year. It would be an excellent opportunity for general practitioners to check with their older patients that their entire immunisation is up to date. I assure my right hon. Friend that I shall undertake to see whether we can dovetail that raising of awareness with the times when patients go to their GPs to receive their flu jabs.
The guidance that we give to staff at accident and emergency departments is that they should give a tetanus injection to the person who is being treated if there is any doubt about their immunisation status. There are clear guidelines that anti-tetanus immunoglobulin should be given to someone who is not immunised, or if their immunisation is not up to date, as it gives immediate protection. It is not about the future, but about the there and then, and ensuring that the antibodies are stimulated and that tetanus is prevented from taking hold.
Immunoglobulin contains ready-made antibodies against the tetanus toxin that work immediately—one does not have to wait for the body to make its own antibodies. It is a course of action that can be taken to try to minimise tragic events such as that involving Mrs. Creighton, and should be taken in hospitals where there is any doubt whatsoever. Ideally, people will receive lifelong protection through immunisation, but an emergency response is also very important.
It would be extremely useful to have more accurate and up-to-date information about patients' immunisation records. In the case of Mrs. Creighton, the coroner, Mr. Whittaker, said:What I am concerned about is the lack of knowledge available to doctors. I shall be recommending that electronic medical cards with a computer chip be introduced which will contain all the details of a patient.For some time now we have been working with the NHS on the idea of developing an electronic patient record that travels with a patient. The professionals—the doctors, nurses and therapists—can have access to a patient's medical history wherever that patient accesses the NHS. That would be of immense value in improving the health outcomes for patients wherever they are.
As I am sure my right hon. Friend knows, major information technology projects are fraught with difficulty and have varying success. That is why we are committed in the health service to managing that process as much as we can in a co-ordinated way to ensure that all the computers talk to and interact with each other, and that electronic patient records are a fully integrated system throughout the health service.
§ Ann Taylor
I am grateful for my hon. Friend's encouraging remarks on raising awareness among pensioners about the possible need for a tetanus injection when they receive their flu jab, and on the need for information to be available. I agree that computers can cause difficulties, but will she update us on any possible time scale, especially in view of the fact that we have had pilot projects and that other countries are using the technology now?
§ Ms Blears
My right hon. Friend is right. Several trusts have been able to install information technology to help them with electronic patient records. However, it will be some time before that is rolled out throughout the country. The state of technology in our NHS varies dramatically, as different places have invested in their infrastructure at different rates. Many of our GPs still use a wide variety of IT systems that need to be co-ordinated throughout the NHS. In the NHS plan, we have made a commitment to ensure that electronic records are available throughout the service, but I understand that we will not be in a position to ensure that all patients can access their records through IT until 2005.
The situation is encouraging in that more and more GPs, community-based organisations and primary care trusts are starting to realise how much investment in IT can help them to carry out their functions more efficiently and effectively. We need to make swift progress on the programme, but we must also ensure that the massive investment in IT, which will run to hundreds of millions of pounds, is money well spent and is effective. The public sector has too much history of investment in IT that does not serve the purpose for which it was designed. The NHS is therefore determined to ensure that our IT programme is effective and achieves value for money.
We must ensure that the electronic patient record travels with the patient wherever they may be and that it provides the widest possible range of medical information for patients when they access the health service. It is an ideal way of empowering patients themselves: they too will have that knowledge and information.
The electronic patient record will also be extremely useful in medicine management. If patients and doctors know the sort of medication that patients have been taking, their care will be much more appropriate and effective when they arrive at the accident and emergency department.
My right hon. Friend has made some extremely important points today on behalf of her constituent. I am only sorry that Mrs. Creighton died in such tragic circumstances, but if doctors can cope appropriately and effectively with patients in those circumstances, we may learn lessons from that tragic case for the future. I hope that my right hon. Friend's constituent will feel that the NHS has learned from that tragedy and will take it very seriously.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-nine minutes past Four o'clock.