APPENDIX 25
Memorandum by Caroline Buckley (PM 54)
THE BURWASH CASE
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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