Monday, September 04, 2006


The fact that there is no effective penalty for mistakes in the NHS is background you need to understand fully the article below

Arrogance and complacency among doctors could lead to another medical disaster on the scale of the Bristol babies scandal, the Royal College of Surgeons has warned. Five years on, patients are dying on operating tables because some doctors are still failing to act on the lessons of the scandal that led to the deaths of 30 babies, the college says.

This weekend leading surgeons compared the operational failings causing surgical blunders in NHS theatres to the institutional deficiencies that contributed to Nasa's 1986 Challenger and 2003 Columbia space shuttle disasters. Tony Giddings, a member of the college's council and a former consultant surgeon, says the NHS has not changed its practices significantly since poor operating techniques led to the scandal at Bristol. "Do we need to have a second Bristol before we can actually make the cultural changes that are needed?" said Giddings. "We have continued to have avoidable deaths in surgery because the lessons that were so clearly set out in Sir Ian Kennedy's report [into the scandal] have not been acted upon."

Last weekend The Sunday Times disclosed that more than 300 babies a year were being left with brain damage because of oxygen starvation caused by lack of proper care at birth. A government watchdog also warned that more than 2,000 people died last year because of blunders by NHS staff.

Giddings says although most surgeons are now aware of their own limitations, some are still putting patients' lives at risk because they believe they are infallible. "There are some surgeons who have a seriously flawed opinion of their own capabilities," he said. "If you are a surgeon and doing dangerous work you need to have a degree of self-assurance and confidence but it can turn into arrogance. "Surgeons can become too familiar with the dangers of the operating theatre and lose that capacity to be properly respectful of those dangers. "After the first shuttle disaster, although the astronauts changed a few practices, their attitudes and beliefs did not really change and they still thought they were masters of their situation. Nasa had a second disaster and then they really had to change."

The college wants the government to make it mandatory for all surgeons to be trained in skills such as communication and teamwork. In 2001 Sir Ian Kennedy, the chairman of the Bristol inquiry, recommended national procedures whereby surgical teams - including the consultant, anaesthetist, and theatre nurses - should meet routinely to review their performance. This has not happened, according to the college, and, until it does, avoidable deaths will continue.

The college insists that the actual number of avoidable deaths are up to 10 times higher than the 2,159 patient deaths recorded by the National Patient Safety Agency, since only a fraction are reported. Research published in 2004 put the annual number of patient deaths due to medical error at 40,000.

In one notable case, Marc de Leval, a professor of paediatric surgery at Great Ormond Street Hospital for Children, admitted that mistakes he made in surgery resulted in babies' deaths. He volunteered to retrain in the early 1990s after seven babies he performed heart surgery on died. Another surgeon, a consultant urologist from southwest London, admitted this weekend that one of his patients died after he removed the wrong kidney. The patient later died of complications. The surgeon, who did not wish to be named, said it was essential that junior staff were free to speak up if they suspected a mistake. "There are surgeons who are fairly intimidating and people would feel it is difficult to challenge their views," he said.


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