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Hospital safety-how soon is now?
[ by Niall Hunter, Editor www.irishhealth.com]
When it comes to upholding hospital safety in Ireland, we seem to be experiencing the law of diminishing returns.
The more scandals that emerge, and the more inquiries, reviews and assurances that emerge from them, the more worried we become about whether our health service really is as safe as it should be.
The parents of the young boy who was the victim of the wrong kidney removal at Crumlin hospital have called for lessons to be learned from the case.
But have Crumlin Hospital, the health service in general and those who run it, really learned lessons from this tragic incident?
Last week's Medical Council Fitness to Practise Committee hearing into the Crumlin case will do little to assuage public concerns that hospitals, the HSE and Health Minister Mary Harney are really doing all they can to make our hospitals as safe as possible.
In addition, questions will be asked, and indeed have already been asked, as to why the Committee decided to end its hearing prematurely and rule that no professional misconduct finding would be made against the surgeons concerned on foot of a guarantee from them on their future clinical performance.
While the committee's decision was perfectly legal and within the terms of Section 67 of the Medical Practitioners Act, the Council chief executive officer's legal representative balked at the absence of more stringent sanctions given the evidence presented, the gravity of the incident, deficits identified in medical and hospital practice and the admitting of the error by those responsible.
The Committee's hearing into professional misconduct charges against Prof Martin Corbally and Dr Sri Paran ended before any further witnesses could be called or closing submissions made. The two doctors would have no finding of professional misconduct made against them, on the basis of their giving assurances about their future professional practice.
It was a brave call by the Committee and perhaps in some ways a pragmatic one, but also a very controversial one. The Committee felt that there had been a "series of catastrophic errors" but malicious intent had not been demonstrated, and it even queried whether a professional misconduct hearing was an appropriate way to deal with what was obviously a catastrophic incident for all concerned, but especially the child and his parents.
Some members of the medical profession and the public may agree with this stance, but others will feel that the Committee's avoidance of going down the route of a misconduct finding and associated sanctions sends out the wrong message about putting right what went wrong on that fateful day in a theatre on Crumlin hospital - (Read more on this here)
Questions too, will be asked about whether it was appropriate to invoke section 67 of the Medical Act so late in the proceedings. Some feel that the option of not going down the road of a professional misconduct ruling should only happen much earlier into an investigation of a complaint against a doctor, not after the case was deemed serious enough to go before a full fitness to practise hearing at which some damning evidence emerged.
This is ultimately a topic for much legal debate. The facts are the doctors concerned, both of whom are highly regarded, have not had a professional misconduct judgement made against them and have agreed to improve their practice.
But can the parents of the young patient and others who have been the victims of medical mishaps gain solace from what happened at the Medical Council hearing?
Turning to the evidence presented at the hearing, much of it reads like a textbook on how not to run a hospital, and some of the failings observed would also probably be found at other hospitals from time to time given the outdated and inefficient structures in which they operate.
We were told of among other things about:
* Poor communications between medical staff and patients/parents and between medics.
* Deficits in x-ray checking and delays in filing x-ray reports.
* The hierarchical nature of the hospital system in which consultants' directions are seldom challenged.
* The lack of the promised "consultant-provided service." The case raises issues about the level of supervision of trainee doctors by their more senior colleagues.
* No obvious "safety nets" to minimise human error. For example, at the time of the incident, there was no "site marking" policy for operations, according to a previous independent review of the incident.
The evidence presented at the hearing and in that review of the Crumlin error also pointed to under-resourcing, understaffing and pressure of work at the hospital.
And this brings us to perhaps the most worrying statement made at the Council hearing. The Chairman of the Fitness to Practise Committee said the findings of this independent review of the error, published in October 2008, have not been implemented fully.
This is not an isolated incident.
Some of the safety recommendations for hospitals that followed the Michael Neary probe report of 2007 and of a 2004 inquiry into a child's death in A&E, have yet to be acted on by the HSE North-Eastern region.
Only last week we heard that out-of-date ultrasound scanners are still being used in hospitals in the same region, despite faulty scanners being cited in the recent miscarriage misdiagnosis scandal.
Obviously,"learning from mistakes" as far as the HSE is concerned, is a system for slow learners.
And nationally, we are still waiting for proper systems in place which would guarantee as far as possible that hospital care is safe. We do not even have a transparent system whereby hospitals' clinical results, for example surgery outcomes and mortality rates, can be compared and acted upon where necessary.
We are long overdue a licensing system and an effective interventional monitoring and inspection scheme for acute hospitals.
In a recent EU survey, 55% of Irish people said they believed patients can be harmed by hospital care. And given recent events, who would try to convince them that our health system is safer than they think?
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