Examination of Witnesses (Questions 139-159)
THURSDAY 24 JUNE 1999
MRS ANN
DOWLING, MR
JOHN ELDER,
MS KARIN
PAPPENHEIM, DR
REG PEART,
MR WILLIAM
POWELL AND
MR DAVID
THROWER
139. From your knowledge of other patients within
your group and the common theme issue that I was referring to,
is a major concern the fact that people had unnecessary surgery?
(Mrs Dowling) Yes.
140. Or was it a competence question? It was
unnecessary intervention?
(Mrs Dowling) I would say it was 50/50, unnecessary
surgery and incompetence.
141. Are we talking about hysterectomies or
bladder operations?
(Mrs Dowling) Yes, all of those.
142. Thank you very much. Mr Elder, can you
say a little more about your own background and concerns?
(Mr Elder) I am not sure how far I can go into it
because the two complaints I made are currently being considered
by the Health Service Commissioner. Do you have any guidelines
you can give me as to what I can and cannot say?
143. I would say that it is in your interests
to tell us what you feel is appropriate. Within our terms of reference,
we want to learn of your concerns and why you feel this Committee
needs to look at possible recommendations about changing the existing
system. We are anxious to learn lessons from the experiences that
you have had.
(Mr Elder) I would not like in the process to throw
a spanner in the works of the two complaints under consideration.
144. I do not think that is a problem, from
our point of view.
(Mr Elder) Okay. My wife had a stroke and the GP on
call was called. He admitted her to the local community hospital.
That was in the evening and when I left my wife later that night
I asked to be informed if there was any deterioration whatsoever,
no matter how small or big. Quite reluctantly I left for reasons
which are not worth going into at this stage. I was not informed
about her deterioration at any stage, despite my request for this
to be done. I was advised only when I phoned the hospital the
next morning and this was some four hours after my wife had got
into difficulties. At the time of my phone call, she had been
in a deep coma for an hour. The duty doctor had not been called.
He eventually arrived three hours later and even though he had
been at the nearby casualty ward directly opposite he did not
attend. For the four hour period of my wife's serious and increasing
difficulties, no doctor had been called by the nursing staff whatsoever.
The ward sister who had come on duty an hour or so before I phoned
said that she was unable to tell me why I had not been informed;
nor could she provide any answers to the rather simple questions
that I asked. In mitigation, she said that she had not been on
duty long enough to give me this information but that she would
look into it and let me know. Four hours later I still had no
answers. Six hours later my wife died almost before my eyes. It
was clear that my concerns were not being taken seriously—that
is to say, not until my unscheduled call at the ward about a fortnight
later. Nothing materialised until a further three weeks following
correspondence from me. However, a week prior to this, I approached
the regional health authority who advised that I should take my
complaint to the trust complaint manager. The trust, who were
apparently unaware of my complaint, even though five weeks had
by then gone by, acknowledged my correspondence and sent me a
leaflet about the NHS complaints procedure. Until then, I had
not been aware of the existence of a formal complaints mechanism.
Following that, I tried to get some answers from the GPs concerned
and I got no real answer. I had a couple of letters from the GP
who was not even my wife's GP, who involved himself in the investigation.
He passed on my correspondence to my wife's GP and there was no
response. I contacted him and asked him if he could spare me a
few moments. He said, "Yes, okay. Come and see me."
I went to see him and after about three or four minutes he was
telling me that effectively she had come to the end of the line;
there was no hope and that was it. She had died. He kept jumping
up and down in his seat, looking through the glass panelled door
and I then realised that I was the first in a surgery queue. I
was not told that. I thought he was seeing me privately. I thought
it was a waste of time and after three or four minutes I just
left. After that, I wrote a lot of letters and so on and there
was a lot of stalling etc. About a year or so later, there was
the first independent review.
145. Of your wife's case?
(Mr Elder) Yes.
146. That was a full clinical review, was it?
(Mr Elder) It was a full clinical, independent review
to deal with the nursing element because there appeared to be
some very serious questions to be answered.
147. What was the date when this occurred? How
far back are we going now?
(Mr Elder) When which occurred?
148. When your wife died.
(Mr Elder) On 2 March 1997.
149. I am trying to work out the procedures
that applied because the procedures have changed somewhat obviously.
You presumably pursued your concerns with the regional executive
of the Department of Health to get this clinical review. I am
trying to establish how you obtained this clinical review. What
is interesting from our point of view is that you had pursued
a particular course of action and received a particular response.
We have taken evidence already in this inquiry in two parts of
the country where very few people, in not dissimilar circumstances,
seem to have had the opportunity to obtain a review of the kind
that you are talking about. We are interested in apparent inconsistencies
between one part of the country and another, within the same region.
(Mr Elder) Having written to the chief executive of
the regional trust in the end—this was about a month after
my wife died—I was given a very detailed report of the circumstances
in which she died. After some months, I then had the trust report
signed by him and again it was, to a large extent, a whitewash
really. I then said, "No, I cannot accept this". I gave
the reasons for it and I said, "I would like the complaint
to be taken to independent review." There was no hesitation
in accepting it for review. This was in about September 1997.
April 1998 was the review panel session itself. Meanwhile, there
was a linked complaint, a further complaint, against two GPs.
This was very strongly linked with the nursing element because
the GPs were involved at the community hospital. This had to be
a separate complaint. Originally, they were going to do it as
a single investigation but they felt it was the wrong thing to
do and it was round about October last year—
150. It does not matter about the precise details.
Obviously, you have given us a substantial amount of written evidence,
which is helpful. I wonder if you could just concisely sum up
the key concerns you have about what happened in your wife's circumstances
as they relate to our terms of reference and the areas we are
looking at. I want to give the other witnesses chance to set out
briefly where they are coming from as well.
(Mr Elder) During all this time, I had no real support.
There was stalling as well and the investigation seemed to be
unnecessarily protracted. Correspondence was delayed. I was not
getting responses. I kept having to telephone them or write and
say, "You said you would respond" and so on but anyway
it did not happen. This was the case in both the complaints that
I made. When the review occurred, there were many admissions made
and the nursing staff were severely criticised, even castigated,
because there were some very severe mistakes made. It was clear
negligence, which was accepted in the review panel. Having done
all that, they then said that my wife got adequate care and attention.
Dr Stoate
151. You said you made complaints against two
GPs. I was not quite sure why that was.
(Mr Elder) There were two GPs involved, the GP who
called at our home and the one who admitted her to the community
hospital. My wife should have been admitted to the district general
hospital, the acute hospital.
152. You are making a complaint against the
GP because you think he sent her to the wrong hospital?
(Mr Elder) Yes.
153. Why are you complaining against the other
GP?
(Mr Elder) That was the GP who was at the hospital
and it took him three hours to tend to my wife when he was in
the ward just next door.
154. It was a community hospital run by GPs.
Is that right?
(Mr Elder) Yes.
Chairman
155. Could you briefly conclude where you are
at now?
(Mr Elder) The other review took place early on this
year and again one of the GPs concerned was severely criticised.
It came out in the report that my wife should have been admitted
to the district general hospital. He even stated in the report
that, given the situation again, he would have done so, particularly
as at the time of her first stroke five years earlier her own
GP had no hesitation in admitting her to the district general
hospital. The second time around, particularly as by then she
had had other difficulties associated with stroke, she should
have gone there. Having criticised and castigated them, they said
once again that she had had proper attention.
156. The matter is in front of the Ombudsman?
(Mr Elder) That is why I said, "I cannot accept
this" and it was in both cases put to the Ombudsman.
157. Basically, you have worked your way up
the structure?
(Mr Elder) Right the way through.
158. You are now with the Health Service Ombudsman?
(Mr Elder) That is right, yes. As a direct result
of the first review, some major changes have been implemented.
159. Locally?
(Mr Elder) Locally, yes. I asked to be informed on
1 January of this year when they were due to be implemented but
I have not heard. I wrote three months ago to the chief executive
and he still has not responded.
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