Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Caroline Buckley (PM 54)


  My name is Caroline Buckley I am the daughter of the late Carole Burwash who died in October 1995 at 53 years old following a catalogue of errors at the private Princess Grace Hospital in London. My mother was killed owing to medical negligence for which the hospital admitted full liability.

  I myself am 34 years old and have four children aged eight, seven, five and three. I am also a fully qualified nurse, having trained at the Middlesex hospital in London. I have not worked however since the birth of my first child in 1990.

  I feel that it is relevant to give this information so that the committee is aware of my understanding of the situation; not only as a now unfortunately knowledgeable bereaved relative, but also from my previous medical knowledge and experience.

  Being a founder member of APROP (Action for the Proper Regulation of Private hospitals) I obviously wholeheartedly support, represent and uphold everything noted and recommended in the first file, but this is my personal statement on my mother's death alone and the lessons to be learned from it.

  Our case has had an enormous amount of press coverage and prior to APROP's formation my father and I pursued meetings with the Department of Health. We tried to ensure that proper inspections were carried out at the Princess Grace hospital so that the systems that had let us down so badly were changed and new protocols put in place.

  I then became more and more aware that there was a much wider issue surrounding my mother's death at a private hospital. It was obvious that not only was my mother's death not an isolated incident, but that it had been an accident waiting to happen. The Princess Grace although totally negligent in its own right was merely symptomatic of all private hospitals.

  I feel very strongly that the whole private sector in this country urgently needs to be shaken up and regulated so that I can ensure that my mother did not die in vain and that something good has come from our tragedy. We must prevent other families going through what we have had to endure.

  I enclose for your information a copy of the report by the independent medical witness Professor Felicity Reynolds who was asked by the coroner to give evidence at the inquest after my mother's death[18]. It backs up all of my points.

  My mother was admitted to the private Princess Grace hospital for a routine hysterectomy owing to menopausal problems. She was otherwise in very good health.

  She was admitted early on Wednesday 15 October 1995, with her operation scheduled for 5.00pm that afternoon. She was put in a room at the end of a corridor, a long way from the nurses' station, with a door that did not stay open owing to a faulty mechanism.

  During the afternoon she was visited by her anesthetist Dr Lim and was advised that the best post-operative pain relief with minimum sickness would be an epidural directly into her spinal column administering opiate drugs.

  I spoke to her just before the operation and then spoke to her again post-operatively at about 21.45 when she was back in her room. The operation had apparently been successful and she was very relieved to have come through it and to be in so little discomfort.

  My father and one of my brothers were with her, and I suggested that when they left she should "buzz" the nurses and ask them to settle her for the night. I assumed that a top-up would be given to her epidural. I phoned back about twenty minutes later and spoke directly to the nurses' station, as I did not trust my mother to have called them for fear of disturbing them. I was told that she had indeed been seen and that she had been given 30mg of diamorphine to settle her for the night.

  I specifically remember querying this with my husband (who is non-medical) as I recalled much smaller quantities of diamorphine being administered when I was nursing. We agreed however that I had been out of nursing for a little while and that we should trust her care to the professionals at the Princess Grace. We eventually went to sleep.

  I was woken at 01.30 that night (very early Thursday morning) by a telephone call from my father who told me that my mother's surgeon Mr Pugh had phoned him to say that there had been an accident, my mother had been given an overdose and she was now in intensive care. I left for my father's house immediately after working out childcare with my husband as we had four children under five and a half, our youngest being only five months old and still being breast-fed.

  I collected by father and we drove straight to the Princess Grace. Both of my younger brothers joined us later on in the night.

  We were eventually told that my mother had been prescribed 3mg of diamorphine but had been given a ten times overdose of 30mg directly into her epidural. She had lost consciousness, resuscitation had been initially unsuccessful, and she was unconscious in a very serious condition in the intensive care facility at the Princess Grace. We all (both family and medical staff) agreed that the intensive care unit at the Princess Grace did not have the experience, staff or equipment that we needed and so my mother (still unconscious) was transferred to the Middlesex Hospital at 05.30 that Thursday morning.

  We stayed at the Middlesex for the next three days where the NHS staff tried valiantly to pick up the pieces and save my mother. Despite all their best efforts this proved impossible and at 12.55pm on Saturday 21 October my mother was pronounced brain dead and her life support was switched off.

  We had all of her organs donated.

  She was only 53 and had been needlessly killed. It devastated our family. My father and my two younger bachelor brothers were very reliant and dependent on her. Her four young grand-children could not understand what had happened and would now never have their adoring and adored grandmother as part of their lives.

  Being the eldest child and only daughter I held the family together and resolved to find out exactly what had happened and to ensure that it could never ever happen again.

  I will briefly list the main issues concerning my mother's death, and then expand on some of the key areas, but they all fall under one heading—REGULATION. If private hospitals in general and the Princess Grace in particular were properly regulated I believe that my mother would be alive today.

  It transpired that what had happened in my mother's case was:

    —  as mentioned Dr Lim decided on epidural opiates as the best form of pain relief;

    —  that night at the Princess Grace once the operating doctors had left there was only one doctor on the premises, a RMO (Resident Medical Officer) Dr Hornabrook;

    —  Dr Lim never checked with Dr Hornabrook whether he was familiar with and comfortable with epidural opiates. In fact Dr Lim never spoke to nor met with Dr Hornabrook at all before my mother's operation;

    —  Dr Lim never checked with the nursing staff either;

    —  Dr Lim prescribed 3mg of diamorphine post-operatively;

    —  Dr Hornabrook and the nurse in charge of that floor (staff-nurse Hatcher) being unfamiliar with epidural opiates and Dr Lim's methods and hand-writing mis-read the drug chart and gave my mother a 30mg injection, a ten-times overdose;

    —  the nurses visited my mother twice after the over-dose and found her "un-rousable". This was put down to a heavy sleep. They missed all the signs of respiratory depression;

    —  finally they realised she was unconscious and had stopped breathing and pushed the emergency buttons;

    —  the only doctor on duty (Dr Hornabrook) rushed to her room and began attempted resuscitation;

    —  Dr Hornabrook, the only doctor on duty, had not taken nor had been required by the Princess Grace to have the ACLS (Advanced Course in Life Saving techniques);

    —  for forty minutes Dr Hornabrook was unable to put an air-tube into my mother's throat in order to resuscitate her;

    —  finally Dr Lim was recalled from his home to the hospital where he was able at the first attempt to put the air-tube in; and

    —  it was too late as my mother never regained consciousness and had her life support machine switched off three days later.

  I repeat that if private hospitals in this country were properly regulated my mother would be alive today. I believe that most private hospitals fall below standards of care achieved in the NHS and the lack of inspections and regulation means that this will continue until there is a change in legislation to ensure that these hospitals must adhere to certain laid-down criteria, standards and protocol.

  I also know that this is a feeling well believed within medical staff working within the NHS. Ask any doctor at any level whether he would have his operation privately or on the NHS and he will play safe, ignore the lack of privacy and the standards of hospital cleanliness and pick the NHS every time. The private sector simply cannot give you the required back-up.

  If the inspectors that do go into private hospitals (such as the one I met at a meeting at the DOH) were better qualified, better informed, but most importantly had a laid-down code of practice they could enforce, then the private hospitals would have to improve their standards.

  The current legislation covering Private Hospitals (the Registered Homes Act 1984) is currently so archaic that none of the acute clinical issues are addressed at all. There are simply no standards for these hospitals to adhere to in this area. One just wonders how many more mothers need to die??

  To re-visit some key areas where my mother's situation would have been improved or avoided with proper regulation:

  Communication: in the NHS the patient is looked after by the team of their consultant who post-operatively will pass down information to the team looking after the hospital over-night. As mentioned my mother's anesthetist never spoke to the RMO nor the nurses pre or post-operatively. He simply performed his duty in the operating theatre and went home. Only to be called out for the emergency later.

  The current system whereby consultants "rent" rooms and facilities in private hospitals for the duration of a patient's stay but then leave without checking is very negligent. They are putting their patient's care in the hands of mainly unknown individuals (especially if agency staff are involved) whose standards are unknown, un-regulated and are not maintained.

  The use of complicated analgesia by unknowledgeable and inexperienced staff: my mother's was the first epidural that Dr Hornabrook and staff nurse Hatcher had ever topped up with an opiate and indeed was only the second epidural that year that they had dealt with. Indeed when questioned by me about the 30mg dose the nurse showed a distinct ignorance and lack of basic knowledge of opiates.

  Had my mother been in a NHS hospital she would have been nursed in intensive care to enable the staff to monitor the unpredictability of this drug regime. Even the originally prescribed dose of 3mg can cause complications in some patients.

  Post operative observations: the nurses checked my mother twice after the overdose had been given and failed completely to spot the obvious signs of respiratory depression. Had they noticed and acted upon it she may well be alive today.

  At the inquest it was discovered that there were no laid down procedures for post-operative observations. There should be some protocols for the inexperienced nurse. The nurses should have spotted the very quick nature of my mother's onset of "sleep". Alarm bells should have rung.

  Adequate training, specifically in resuscitation: to have one resident medical officer on duty over- night within a large hospital with over 100 beds with acute patients and post-operative surgery to look after is ridiculous. More ridiculous however is that he was not (and was not required to be) qualified in resuscitation techniques, including intubation. Every patient at the Princess Grace that night (and indeed any other night when Dr Hornabrook was on duty) was at risk.

  I do not hold Dr Hornabrook (who I have met twice) personally responsible. Nor does Professor Reynolds in her independent report. Obviously he made a grave and careless mistake but he should not have been put in such a position. He needed back-up. I believe that all RMO's left in charge of a hospital overnight should have as a minimum the ACLS course which is a short course in refreshing doctors' memories in resuscitation techniques specifically intubation. It must be remembered that many doctors are able to and indeed do get to this level with very little resuscitation experience. This course should be part of the standards and rules that every hospital has to adhere by.

  Room positioning: a major abdominal operation at the end of a corridor with very few post-operative observations to refer to? Why not ensure that all major cases are centrally positioned and that all of these rooms and patients have alarmed pulse-oximiters to alert staff of problems arising. One of the main reasons that people use the private sector is the privacy of their own rooms and on-suite facilities: but they are unaware of the risks. If someone had been with my mother or been alerted just before she stopped breathing she may well be here today.

  The total injustice of all these points is worsened by the fact that when mistakes happen these private hospitals cannot cope and simply dial 999. An ambulance arrives and the private patient is transferred to the local NHS hospital that has to pick up the bill from then onwards. The private hospital declines all responsibility from that point.

  As mentioned I have attached the report prepared by Prof Felicity Reynolds for the inquest, and I have highlighted key areas of interest. She is very understanding and sympathetic of our cause as are many doctors at her level.

  I have not even touched upon the other major area of concern involving private hospitals and that is a lack of a proper complaints procedure. Although this has affected many other members of APROP, we were "lucky" in that the Princess Grace admitted full liability (even though it took them four months) and so we never had to make a formal complaint.

  I finish my statement in the hope that I have managed to relay clearly our family tragedy and that I have pointed out in a balanced way how this could and would have been avoided had proper regulation been in place at the Princess Grace that night.

  I would welcome the opportunity to give oral evidence to the Health Select Committee whom I have observed at a sitting. I was very impressed by their diverse knowledge of wide areas of information.

  I thank you for taking the time to read this and hope to hear your feedback and ideas in due course.

18   Not printed. Back

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