when healthcare goes wrong

by Wendy Moore

Gillian Bean suffered chest pains for years before she was finally diagnosed with a heart condition. On frequent visits to her family doctor, she was repeatedly told she had a digestion problem. Eventually, after hospital tests, a specialist diagnosed a serious heart condition.

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Almost 10 years later, Gillian is still trying to obtain an explanation of what went wrong but has been met with denials, abuse and obstruction. Once, she says, she had 'total faith' in doctors. Now she says: 'We are the present day lepers because we remind doctors of their failures.'

Anyone who sees a doctor with a worrying complaint, expects him or her to put them back on their feet. Anyone going into hospital in an emergency or for a planned operation, expects to leave feeling better.

Yet this does not always happen. Hospitals – and GP surgeries – can be dangerous places. Official figures show that you are more likely to die as the result of something going wrong in hospital than in a road accident, air crash or fire. In addition, many more people suffer injuries or illness due to mistakes happening in hospitals and GP practices. Yet often medical errors go unreported or are even covered up. So what is the truth behind medical accidents?

the scale of medical mishaps

We sometimes hear in news bulletins of tragic accidents happening in hospitals. Recent cases have included:

• A man who died after having his healthy kidney removed in an operation
• A woman who had a part for her right knee inserted in her left knee by mistake
• A teenage boy who died after the wrong drug was injected into his spine.

These are exceptional incidents. Most treatment in hospitals and doctors' surgeries takes place without anything going wrong. And yet medical blunders are far more common than many people think.

one in ten

A landmark government report, An Organisation with a Memory, published in 2000, estimated that one in ten people admitted to hospital becomes the victim of an 'adverse event' – meaning something goes wrong which causes physical or psychological harm. This amounts to 850,000 such incidents every year in England alone – excluding problems in primary care, private hospitals or complementary medicine. The report estimates that about half of the incidents are avoidable.

Many adverse events are trivial and do not cause serious harm. Yet the government's report estimates that mistakes in hospitals could be causing as many as 40,000 deaths a year. This is the equivalent of 130 jumbo jets crashing. Further details from the study on which the government's estimates are based, published in the British Medical Journal in 2001, reveal that two thirds (66%) of the adverse events caused only minor injury or led to recovery within one month. But nearly a fifth (19%) led to an injury or complication causing moderate impairment; 6%caused a permanent impairment and for 8% of patients the error contributed to death.

A further government report, published in June 2002, recorded 27,110 adverse events in 28 NHS trusts – including hospitals, mental health services and general practices – across England and Wales over nine months. The report, published by the new National Patient Safety Agency, was the result of a pilot study aimed at systematically collecting figures on medical accidents. But the study found several problems with the reporting system and could not even calculate how many errors caused serious harm.

Whatever the actual figures, it is clear that medical accidents do happen. Complaints about NHS services are rising year on year. Compensation payouts to patients have increased dramatically. The NHS Litigation Authority, which handles compensation claims against NHS organisations, spent £386m in 1999-2000 settling claims for clinical negligence. It received 5,025 claims in 2000-01. So how do these mishaps occur?

how accidents happen

Most health staff are hardworking, competent and reliable. But nobody is perfect. Doctors and nurses, like the rest of us, can make mistakes – especially when tired, rushed, stressed or under other pressures. In a ground-breaking television programme, Why Doctors Make Mistakes, shown on Channel 4 back in October 2000, leading members of the medical profession confessed they had made serious errors at some point in their careers. One doctor told how he had dismissed a warning on a baby monitor while delivering a baby. The baby was stillborn. Another admitted he had missed important signs of meningitis in a patient who later died.

Human error is a common feature in healthcare accidents. But other things can go wrong too, including equipment breaking down, medicines reacting badly and failures in communication.

medication mistakes

An 18-year-old youth died in February 2001 after a powerful anti-cancer drug was injected into his spine instead of his arm by doctors at Queen's Medical Centre, Nottingham. The boy had been in remission from leukaemia and was expected to make a full recovery. This was the fourteenth case since 1985 in which the same drug, vincristine, had been wrongly injected into the spine. Eleven of these incidents have been fatal.

Errors in giving medicines to patients are one of the commonest kinds of medical mistake. Figures from the Medicines Control Agency reveal there were 21,353 reports of adverse drug reactions reported by doctors using the voluntary 'yellow card scheme' in 2001. These figures include cases where a wrong drug or wrong dosage was prescribed or given, or where a drug reacted badly with another, although not all of the adverse reactions are necessarily caused by the drugs stated.

equipment failures

Despite numerous safety warnings sent to health staff, several people have died from asphyxiation through being trapped between bed rails and mattresses in hospitals and nursing homes.

A huge range of medical equipment is used in hospitals, GP clinics, nursing homes and in people's own houses as part of every day healthcare. Inevitably, sometimes equipment goes wrong, reveals design faults or is used inappropriately.

There were 8,180 cases of mishaps involving medical equipment reported to the Medical Devices Agency (MDA) in 2001-02. These included 145 cases which led to a patient's death and 233 involving serious injury. The figures show an 11% rise on the previous year, although experts at the MDA believe the increase is due to better reporting of problems rather than a drop in safety. Even so, it is thought that errors involving medical devices are still underreported.

misdiagnosis

Misdiagnosis and missed diagnosis – like the case of Gillian Bean – are one of the commonest causes of medical accidents. Delays in diagnosis – including missed heart attacks and meningitis – are at the root of more than half (55%) of legal claims against family doctors, according to An Organisation with a Memory.

what can be done?

Accidents are a fact of life. Human error is unavoidable. So what can be done to reduce the toll of death and harm caused by medical errors?

learning from mistakes

When something goes wrong in healthcare, a typical response is to single out an individual nurse or doctor for punishment. This 'name and blame' mentality means health professionals are afraid to admit mistakes, because it may jeopardise their careers, and they may cover up for colleagues too. So patients are often left in the dark over what has happened and may find it difficult to get answers.

the big cover-up

After her own experience of being misdiagnosed, Gillian Bean co-founded the pressure group, Sufferers of Iatrogenic Neglect (SIN), to support other people damaged by health treatment. She believes the majority of medical mistakes are still kept quiet. Patients who believe they are victims of a medical error (iatrogenic patients), face aggression and abuse when they try to seek answers or make complaints, she says.

'The unpalatable truth is if you are an iatrogenic patient there is a culture of denial and cover-up,' she says.

For many people, the only way of finding out what has gone wrong is by taking out a formal complaint or going to court, according to Mike Stone, chief executive of the Patients' Association. Yet this is often very time-consuming and – if courts are involved – expensive.

'What patients really want, if they are the victim of a medical error, is not huge payments. They are looking for an explanation of what actually happened and an assurance it will not happen to others,' he says.

making mistakes matter

More and more doctors and healthcare experts want to see a different approach. They argue that since mistakes are inevitable, systems are needed to prevent errors where possible and learn from mistakes when they happen. They point to the aviation industry, where accidents are routinely logged, trends monitored and changes made on the basis of lessons learned.

Charles Vincent, who conducted the UK research on medical errors cited in the government's report, is now professor of clinical safety research at Imperial College, London. He explains that while sometimes a single person may be to blame for an error, usually a whole chain of events has led to the problem. Often there are gaps in the system which allow errors to happen.

Setting up systems to learn from mistakes, and fostering a culture where mistakes can be admitted, are the best ways to prevent history repeating itself, he says.

a new approach

Following the groundswell of opinion, the government has committed itself to changing the approach to medical errors. It has promised to encourage an open and honest culture where mistakes are routinely admitted, and to set up systems which routinely report and learn from mistakes.

The National Patient Safety Agency (NPSA) has been given the task of creating a national reporting system to collect all records of accidents and near-misses and learn from these mistakes, as well as coordinating the work of other agencies involved in reporting errors. The NPSA is also encouraging patients to report medical errors either by telephone, letter or e-mail and – although it does not follow up individual cases – it will use these reports to monitor trends.

The NPSA also has the job of encouraging an open culture in the NHS. Joint chief executive Susan Williams says: 'Unless people feel they can raise something as a problem without getting disciplined it will just get buried.'

Doctors and nurses should be able to admit errors when they happen and should apologise to patients affected, she argues. That should mean patients will not be forced to sue doctors simply to gain an explanation of what went wrong. 'That is horrendous for them and horrendous for everyone,' she says.

what to do when things go wrong

If you believe you are the victim of a medical mistake there are a number of options open to you. It is helpful to decide in advance what you want to come out of your experience as this may affect what you do. You may want to pursue the issue informally – perhaps by talking to your doctor or reporting what has happened to an official agency. Otherwise you can take up a formal complaint, although this can be time-consuming and confrontational.

There are several organisations which can help and advise you. The old system of community health councils (CHCs) has been replaced by a new system of patient watchdogs. There are now nearly 600 Patient and Public Involvement (PPI) forums, which have been given powers to monitor and inspect health services from the patient's perspective. The forums are made up of patients and members of the public and are independent of the NHS.

Sufferers of Iatrogenic Neglect (SIN) offers support to patients who have suffered from sub-standard medical care or a medical mistake. You may also want to contact the Patients' Association, which represents patients' views. There are several leaflets that set out the complaints system in detail. See help and info for details of all these.

reporting mistakes

If you don't want to make a formal complaint, you may still wish to report what has happened to an agency which will log the problem. General problems can be reported to the National Patient Safety Agency. Problems with medical equipment or medicines can be reported to the Medicines and Healthcare Products Regulatory Agency (see help and info).

making a complaint

There are basically three ways to make a complaint:

The NHS complaints procedure
This process has several stages. Firstly, you need to complain directly to the practice manager of your general practice or the complaints manager of the hospital involved. Attempts are made to resolve the problem locally. If you are not satisfied, a convenor can be appointed who can try again for local reconciliation, decide on no further action, or order an independent review. If you are not happy with the outcome of a review, you can take your complaint to the health service ombudsman (see help and info).

NHS Direct can advise you if you wish to make a complaint about the NHS.

Professional disciplinary bodies
If you want disciplinary action to be taken against the health practitioner involved you need to take your complaint to their professional body (see help and info for details):

• The General Medical Council: doctors
• The General Dental Council: dentists, dental hygienists and dental therapists
• The Nursing and Midwifery Council (NMC): nurses, midwives and health visitors
• The Health Professions Council: art therapists, chiropodists/podiatrists, clinical scientists, dietitians, MLSOs, occupational therapists, orthoptists, paramedics, physiotherapists, prosthetists & orthotists, radiographers, speech & language therapists.

Legal action
If you want to take legal action to pursue your complaint you should find a solicitor experienced in medical negligence law. Going to court can be lengthy and expensive. Action for the Victims of Medical Accidents can give you advice and recommend a solicitor. The Law Society has an online directory of law firms and solicitors in England and Wales (see help and info).

help and info

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organisations

Action for the Victims of Medical Accidents (AVMA)
44 High Street
Croydon CR0 1YB
Helpline: 0845 123 23 52 (Mon-Fri 10-12pm and 2-4pm)
E-mail: admin@avma.org.uk
Website: www.avma.org.uk
Action for Victims of Medical Accidents is the only charity supporting people injured by medical accidents. Offer free practical help and advice to anyone who has suffered injury or harm as a result of inappropriate medical care, poor treatment, or misdiagnosis/failure to diagnose.

Commission for Patient and Public Involvement in Health
7th Floor, 120 Edmund Street
Birmingham B3 2ES
Tel: 0845 120 7111
E-mail: enquiries@cppih.org
Website: www.cppih.org
The Commission's role is to make sure the public is involved in decision making about health and health services in England. There are 572 Patient and Public Involvement (PPI) Forums, one for each NHS Trust in England and they are putting into practice improved health which will only come through continuous engagement of people and communities.

General Medical Council
Regent's Place
350 Euston Road
London NW1 3JN
General enquiries: 0845 357 8001 (Mon-Fri, 8am-5.30pm)
Website: www.gmc-uk.org
Holds general and specialist registers of doctors practising in the UK. The registration department can provide registration details of specific, named doctors, free of charge.

General Dental Council
37 Wimpole Street
London W1G 8DQ
Tel: 020 7887 3800
E-mail: complaints@gdc-uk.org
Website: www.gdc-uk.org
The GDC's purpose is to protect the public by regulating dental professionals in the United Kingdom. Among other things they register qualified professionals, set standards, ensure professionals keep up-to-date and help patients with complaints about a dental professional.

Health Professions Council
184 Kennington Park Road
London SE11 4BU
Tel: 020 7582 0866
E-mail: info@hpc-uk.org
Website: www.hpc-uk.org
A new independent, UK-wide regulatory body set-up to safeguard the health and well-being of patients using the services of the 12 professions it regulates (from physiotherapists to paramedics) and to ensure that the public has access to and are treated by health professionals who are qualified and competent. The HPC does not regulate the following professions: doctors, nurses, dentists, opticians or pharmacists.

Health Service Ombudsman
13th Floor, Millbank Tower
London SW1P 4QP
Enquiries: 0845 015 4033 or 020 7217 4051
Textphone: 020 7217 4066
E-mail: OHSC.Enquiries@ombudsman.gsi.gov.uk
Website: www.ombudsman.org.uk/hse
The Health Service Ombudsman investigates complaints about the National Health Service. The Ombudsman is completely independent of the NHS and the government. There is no charge for the Ombudsman's service.

Medicines and Healthcare products Regulatory Agency (MHRA)
10-2 Market Towers
1 Nine Elms Lane
London SW8 5NQ
Tel: 020 7084 2000 (Mon-Fri 9am-5pm; or 020 7210 3000 at other times)
E-mail: info@mhra.gsi.gov.uk
Website: www.mhra.gov.uk
The executive agency of the Department of Health, protecting and promoting public health and patient safety by ensuring that medicines, healthcare products and medical equipment meet appropriate standards of safety, quality, performance and effectiveness, and are used safely. Use the central contact details above as a starting point for issues involving medical devices or medicines.

National Patient Safety Agency (NPSA)
4-8 Maple Street
London W1T 5HD
Helpline: 0800 015 2536
E-mail: enquiries@npsa.nhs.uk
Website: www.npsa.nhs.uk
A Special Health Authority created in July 2001 to co-ordinate nationwide efforts to report, learn from and help prevent adverse events and professional errors occurring in the NHS. Aims to create a safer NHS for patients and promote an open and fair culture within the health service. The NPSA is not able to comment on or investigate individual cases but will act on issues of patient safety at a national level.

NHS Direct
Helpline: 0845 4647 (24 hours)
Website: www.nhsdirect.nhs.uk
The NHS 24-hour service provides expert health advice from trained nurses. An extensive database of medical information is available on their website. They can also advise you if you wish to make a complaint about the NHS.

Nursing and Midwifery Council
23 Portland Place
London W1B 1PZ
General communications: 020 7333 6666 (avoid peak times Mon 9am-5pm, Tue-Fri 8.30am-11.30am)
E-mail: communications@nmc-uk.org
Website: www.nmc-uk.org
An organisation set up by Parliament to ensure nurses, midwives and health visitors provide high standards of care to their patients and clients. The NMC is responsible for maintaining a live register of nurses, midwives and health visitors, and has the power to remove or caution any practitioner who is found guilty of professional misconduct. In rare cases (e.g. practitioners charged with serious crimes) it can also suspend a registrant while the case is under investigation.

Patients Association
PO Box 935
Harrow HA1 3YJ
Tel: 020 8423 9111
Helpline: 0845 6 084455 (Mon-Fri 10am-4pm)
E-mail: mailbox@patients-association.com
Website: www.patients-association.com
Represents the consumer voice in UK healthcare.

Sufferers of Iatrogenic Neglect (SIN)
Tel: 01924 407195 or 0115 9431 320
E-mail: sinfo@cwcom.net or mag@sinfo.freeserve.co.uk
Website: www.sin-medicalmistakes.org
An independent, voluntary support and pressure group for patients and their relatives who have suffered from sub-standard medical care or a medical mistake. SIN's campaign for patients' rights includes: the patient's right to know the truth about their medical condition and to receive appropriate remedial medical care; control over medical records; an end to the present denial and cover-up culture to one where doctors will be able to acknowledge their mistakes, and a victim's compensation fund.

websites

The Independent Complaints Advocacy Service (ICAS)
www.dh.gov.uk/PolicyAndGuidance/...
This service, launched in 2003, supports patients and their carers wishing to pursue a complaint about their NHS treatment or care. It provides information, support and guidance, helping people to articulate their concerns and navigate the complaints system.

NHS: Making a Complaint
www.nhs.uk/england/aboutTheNHS/complainCompliment.cmsx
Information on making a complaint against the NHS.

Make Time for Health: About PPI Forums
www.maketimeforhealth.org/about.html
Information about Patient and Public Involvement Forums and contact details if you want to get involved.

The Law Society: Find a Solicitor
www.lawsociety.org.uk
An online directory of law firms and solicitors in England and Wales.

The Public Law Project
www.publiclawproject.org.uk
The Public Law Project (PLP) is an independent, national legal charity which aims to improve access to public law remedies for those whose access is restricted by poverty, discrimination or other similar barriers.

reading

Adverse Events in British Hospitals by Charles Vincent (British Medical Journal, 3 March 2001)
Can be accessed at http://bmj.bmjjourna/cgi/content/extract...

Building a Safer NHS for Patients (Department of Health, 2001)
Available at www.dh.gov.uk

How to Make a Complaint (Patients' Association)
This booklet guides you through the national complaints procedure across all areas of the NHS.
Available free at www.patients-association.com/publications...

(October 2002, resources updated January 2005)