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Mr. Richard Bacon (South Norfolk) (Con): I am glad to have the opportunity to raise the case of Sarah Lynch. The case was originally taken up several years ago by my hon. Friend the Member for Aylesbury (Mr. Lidington) when Sarah's parents, Mike and Sally Lynch, lived in his constituency, but it became my responsibility when they moved into my South Norfolk constituency. Quite simply, the case concerns their 20-year struggle to get an adequate explanation for the severe cerebral injuries that were sustained by their new-born child while she was in the care of the Royal Brompton hospital.
I was grateful for the opportunity to meet briefly the Minister of State, Department of Health, the right hon. Member for Liverpool, Wavertree (Jane Kennedy), and her officials yesterday to explain at least the background to the complex case. I appreciated that and I know that Mr. and Mrs. Lynch did as well. I am delighted that my hon. Friend the Member for Aylesbury has been able to join us for the debate.
On 12 August 1983, Sarah Kathleen Lynch was born at Wycombe general hospital. She was the elder child of twins. Although no problems had been detected with Sarah, her mother, Sally, was not happy with her breathing or feeding. Her mother eventually convinced herself that she was overreacting and there was nothing to worry about, and Sarah was discharged two weeks after her birth. However, concerns grew when Sarah increasingly became unable to keep down food and lost weight.
In September 1983, Sarah was diagnosed with a serious heart defect. After further tests at the John Radcliffe hospital in Oxford, she was admitted to the Royal Brompton hospital under the care of Dr. Elliott Shinebourne, a consultant paediatric cardiologist. On 4 October 1983, Sarah was operated on by Mr. Christopher Lincoln, a consultant cardiac surgeon. She underwent a cardiopulmonary bypass, which requires the cooling of a patient's body. The procedure is complex and dangerous, and Sarah had to be cooled to a temperature that slowed her heart enough to allow surgery to proceed. It is worth saying at this point that the cooling becomes important later in the story, as we shall see.
After the operation, Sarah's condition was noted as "fair". However, between 7.5 and 7.30 pm that day, the south block of the hospital experienced a total electrical power failure that lasted for approximately 15 minutes. Unfortunately, the hospital's stand-by generator failed to provide back-up power as its starter motor had malfunctioned. As a result, Sarah was allegedly hand ventilated for the duration of the power cut, although the hospital has been unable to identify who carried out the hand ventilation. It is worth stressing that Mr. and Mrs. Lynch were not told about the power failure and discovered that it had occurred only some three years later.
An undated discharge summary noted that Sarah was transferred to Wycombe general hospital for convalescence on 15 October 1983 and was deemed to be
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"in good condition." In late November 1983, concern was expressed about Sarah's neurological status. It is worth saying that there is no evidence that a neurologist was involved in the case at any stageon behalf of the hospital at any rateeven though there was, as it turned out, severe brain damage. A computerised tomography scan was performed and it confirmed that Sarah had suffered not only severe brain damage, but, as a result of that, spastic quadriplegia, focal epilepsy, severe motor impairment, developmental delay and near total blindness. As Dr. Richard Newton, a consultant in child and adolescent neurology and one of the medical experts who examined the case later on behalf of Mr. and Mrs. Lynch, put it, as a result of her time in hospital,
Sarah started having fits and spent much of the next two years in and out of hospital. In 1986, the Lynch family received a questionnaire from Mr. Lincoln, the surgeon who had undertaken the operation, asking[Interruption.] I hope that the Minister will listen to this point because it is quite important. The questionnaire asked whether Sarah could perform sports, whether she tired easily and what activities she was unable to perform. The parents found the questionnaire extraordinary. Given that Sarah required 24-hour attention and could not walk, talk or feed herself, and given that the hospital should have been aware of those facts, it was an acutely insensitive thing to do and casts considerable doubt on the hospital's procedures.
The questionnaire and the fact that the hospital had sent it when it should have known of Sarah's condition also led the family, which, frankly, for the previous two years had been struggling on a daily basis to cope with the consequences of her injuries and had been in and out of hospital all the time, to conclude that the time had come to ask for further and broader answers on what had happened. They requested a meeting with Mr. Lincoln and Dr. Shinebourne. It took place in January 1987, but it failed to convince Mr. and Mrs. Lynch that the hospital had not been negligent in Sarah's treatment. In April that year, Sally Lynch began legal proceedings against the Royal Brompton on Sarah's behalf, citing severe irreparable damage and loss. Sadly, Sarah Lynch died aged 11 on 10 February 1995.
The Royal Brompton's failings cover nearly every aspect of Sarah's time in the hospital and long after her discharge. The Lynches felt that they were not informed of the true nature of the risks inherent in the procedure, only the risks of not operating on Sarah, and thus agreed to go ahead with it. In a letter dated 2 February 1987 to Dr. Fleet, paediatric consultant at Wycombe hospital, where Sarah was convalescing, Mr. Lincoln states that after their meeting, the Lynches had given him
When legal action commenced in 1987, the hospital failed to disclose relevant records, only revealing their loss or destruction in an affidavit sworn by the hospital's general manager in August 1989. The affidavit
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confirmed that no search for nursing observations for the post-operative period was undertaken until 1988 and that the generator's maintenance logbook was destroyed in 1987. To date, Sarah's X-ray plates and reports have never been found. One would have thoughtI made this point to the Minister yesterdaythat for such cutting-edge and risky procedures, it would be all the more important to have meticulous record keeping so that in the event of an incident, or simply in order to evaluate the effectiveness of procedures, the hospital would be able to refer back accurately to what had happened in any individual case.
I mentioned that the family consulted a number of independent medical experts, which they did to find out further information. They reviewed the case notes and provided professional opinions. Professor John S. Robinson, emeritus professor of anaesthesia at the university of Birmingham and a consultant anaesthetist for 27 years, stated in his preliminary report into the case that
"The anaesthetic recording . . . is, in my opinion, very poor. There are only five recordings of systolic blood pressure measured over the period of some two and a quarter hours that the anaesthetic is in progress. This is quite inadequate for such a major procedure".
"I believe this to be unlikely because I believe that it is obvious from a rigorous examination of the anaesthetic record, the perfusionist's records and the nursing notes that Mr. Lincoln cannot have been led to that conclusion".
Mr. Keith Roberts, honorary consultant cardiothoracic surgeon for the West Midlands regional health authority, in examining Sarah's case, made exactly the same point when he wrote in May 1990 that if these charts
"The anaesthetic record is abysmally inadequate. Under 'Surgeon' the initials 'EDS' appear. Does this mean that a Senior Registrar actually did the operation with Mr Lincoln's assistance? There are only four readings of blood pressure prior to bypass, the lowest being 22 mm. mercury, and only one when bypass was resumed, of 42 mm. mercury. There is no record of temperature nor the time taken over the period of surface cooling, nor what technique of surface cooling was employed, nor the time at which the chest was opened. This is a deplorable recordor rather, lack of recording."
"In providing care you must keep clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed. You must keep colleagues well informed when sharing the care of patients".
"There is an accurate health record which enables the patient to receive effective continuing care, enables the healthcare team to communicate effectively, allows another doctor or professional members of staff to assume the care of the patient at any time, enables the patient to be identified without risk or error, facilitates the collection of data for research, education and audit"
"and can be used in legal proceedings . . . If this standard of record keeping is not maintained, and professional requirements are not being met, patients are being put at risk . . . and patients' rights, as set out in the Patients' Charter, are compromised. It cannot be emphasised too strongly that in medico-legal cases the outcome is often dependent on the anaesthetic record. An untidy, illegible, scantily completed chart may be taken as indirect evidence of shoddy or inattentive care."
Mr. Roberts had further criticisms in relation to the cooling, which I mentioned at the beginning of my remarks. In noting that the temperature for surface cooling is not recorded, and that the temperature for bypass cooling is not recorded, Mr. Roberts statedthis is an extraordinarily important point
"I find this an extraordinary state of affairs, one with which I personally would not carry out open heart surgery . . . It is highly probable in this case that cooling occurred at too rapid a rate . . . and cooling on bypass from a temperature of 21° C to 14° C in 2 minutes seems unduly rapid (almost impossible)!."
"This to me indicates a terrible lack of back-up facility at the Brompton hospital. In my own unit the cardiac operating theatre and Intensive Care Unit have two separate sub-station supplies of electricity, plus an emergency generator which cuts in after a ten second delay and receives weekly maintenance checks. To carry out cardiac surgery, particularly on infants who are particularly vulnerable, without a guaranteed power supply, seems to me to be irresponsible."
"The management of the encephalopathic illness seems to have been poorly thought out, and the medical team I believe were negligent in not seeking advice on this aspect . . . I feel doctors did fail in their duty, both in not explaining the risk of brain injury prior to the surgery and also the significance of the post-operative events".
I now come to the report of Dr. Dominic Bell. I mentioned to the Minister yesterday that this report was very significant. It was a review of the whole case by an independent fact-finder, commissioned and paid for by the Brompton hospital. There were consultations, and all parties agreed to put the matter before Dr. Bell, a consultant in intensive care and anaesthesia at Leeds general infirmary, honorary senior lecturer at the university of Leeds and a General Medical Council performance assessor. It is worth pointing out that Dr. Bell's review was only the latest of quite a few that had already been undertaken, at the behest of the parents, by various independent medical experts. It was not as though it came out of the blue; it was the culmination of a series of independent reviews by medical experts.
Dr. Bell's remit was to determine whether the family's grievance has any foundation in sub-optimal or negligent practice; whether the grievance indicates a
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shortfall in other professional responsibilities such as communication, responsiveness and respect; whether the grievance has been addressed in an acceptable manner; and whether the grievance can be resolved.
"Deriving the key component of causation is difficult when relevant documentation from the clinical records is missing, staff are untraceable, and the involved medical practitioners consider post-operative events in ICU to have played no part but can identify no intra-operative problems as causal either."
In essence, the position being taken by the Brompton was that the power failure could not even potentially have been a contributory cause of the brain injury, but it was not able to explain what was the contributory cause.
On completion of his preliminary report in October 2001, Dr. Bell came under considerable pressure from the Brompton to moderate the tone of his report, to alter its formatting and to change his interpretation. He was sufficiently concerned by the attitude of the Brompton to place correspondence in the hands of his defence organisation, the Medical Defence Union, which advised him:
"You could be left fairly vulnerable if you produce a final version of the report and do not take into account all the information that was provided to you. I also feel you should be careful that your final report is not influenced by the Trust, otherwise your status as an 'independent' expert may be questioned by the family."
Dr. Bell replied to the trust expressing his disappointment that the trust's attitude was not lending itself to resolving the family's grievance and refusing to alter his position. His final report was issued in March 2003 and was severely critical of the Brompton at almost every level. He found that there was no evidence of any attempt to discuss the nature and origins of Sarah's neurological problems, the outlook, her care needs or planned management. He found that there was a complete failure to provide appropriate information to the parents, stating:
He found that the Brompton had failed to launch an inquiry into the power failure and notes that despite previous failures of activation of the emergency generator there were no protocols in place to direct nursing and medical action in the event of a failure of the power supply.
Dr. Bell puts forward the possibilityI know that this is a most serious chargethat documentation relating to the generator was "lost" along with Sarah's clinical notes in order to obfuscate any inquiry. He notes the statement of 16 March 1991 by staff member P.J. Humphries that a remarkable amount of documentation cannot be traced or foundnamely, dockets for the critical period; the logbook relating to service and maintenance of the generator; the age profile report of Mr. Lee, who was a works officer; the report of Mr. Lee to the finance committee; and documentation relating to the previous episodes of standby generator failure.
"It defies rational thought to consider that all the above could be missing through simple carelessness. It must be entertained, therefore, that if a systematic effort was made to 'lose' relevant documentation and thereby obfuscate any inquiry, that this would constitute evidence that personnel involved believed this episode to be either causal or contributory."
Dr. Bell concludes that the care had indeed been suboptimal, that there had been an absolute shortfall in professional responsibilities and that the grievance of the family was justified, stating that
No amount of fine words can bring back Sarahwords from me, the Minister or from anyone else. I have been struck by the determination of the Lynch family to discover exactly what happened to their daughter Sarah and to expose the failures of the Royal Brompton hospital. The hospital failed fully to inform desperately worried parents of the true nature of the serious operation that their child was to undertake. It failed also to enforce rigorous standards of record keeping by allowing clinical staff to make only the most perfunctory of entries in medical records without regard to their accuracy. Crucially, it failed to ensure that there was a standby generator that was fit for purpose to support the hospital in the event of a power failure. Indeed, a note of 18 October 1983 from the hospital's general manager confirms that the standby generator had not only failed on 4 October 1983 but had failed on at least one other occasion.
The hospital had allowed vital records pertaining to an extremely serious case to be destroyed or mislaid. It provided only the minimum assistance necessary to the Lynches' efforts to uncover the proof, showing that the hospital's management did not understand the distress that their actions have caused. It agreed to consult an independent fact finder in the person of Dr. Dominic Bell, only to pressurise him into altering his conclusions and ignoring unfavourable findings.
The majority of the hospital's failings were just as indefensible in 1983 as they would be today. It is not simply a case of, "We know better now." The hospital should have known better then, in 1983. I would be the first to applaud the excellent pioneering work that the Royal Brompton hospital has done in the field of cardiac surgery. I am sure that the Minister will agree that the standards of treatment given to Sarah Lynch are not befitting of that institution.
However, given the Royal Brompton's continued stonewalling, and its obvious disdain for independent reports and expert opinions, the best way forward is a full public inquiry. There are serious problems with such an inquiry, which can best be summarised as time, money and lawyers. I accept that the Minister may have serious reservations about a public inquiry, but if one were instigated it would not simply be an inquiry into the case of Sarah Lynch. There are wide-ranging problems with cardiac services in the UK. I was not aware of it until recently, because I was concentrating on Mr. and Mrs. Lynch's case, but in August 1999, Mr. Ken Livingstone, then the Member for Brent, East, called for a public inquiry because of widespread concerns about failures at the Royal Brompton. The Bristol royal infirmary inquiry was under way, and 40 or so parents went to the hospital's family support group for advice and assistance. A whistleblower from the Royal Brompton hospital contacted the inquiry, and their evidence was referred back to the Royal
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Brompton, which led it to launch its own investigation. It appointed two cardiologists, who reported that there was nothing untoward. They tried to keep their work confidential, but it was reported in the press in August 1999, and many parents became agitated, because their cases were not considered in the review. At the moment that the review was concluded, therefore, a new one was announced to look at the issues affecting other parents.
We should consider, too, the question of what may have happened at the John Radcliffe hospital in Oxford. In November 2004, The Mail on Sunday reported that there was higher than expected incidence of mortality in paediatric cardiac care at that hospital. The Healthcare Commission refused to entertain the notion of looking further into the issue, but the Minister will know that that is no longer the case. In a report that was published only last week on 5 January 2006 and appears on the commission's website, patients and local people were asked to comment on their experiences of the adult cardiothoracic services provided by the John Radcliffe hospital surgery unit, which is part of the Oxford Radcliffe Hospitals NHS Trust, because of
Four years ago, following the Bristol royal infirmary scandal, there was a public inquiry and recommendations were made. The report was 30 or 40 pages long, and made 198 recommendations, one of which was that the provision of cardiac services should be concentrated in fewer, more specialist centres, where surgeons would perform a greater number of operations, because it was thought that someone who does 50 or 100 operations a year will perform them better than someone who performs only a small number. The Government have explicitly rejected that recommendation. In a reply to my hon. Friend the Member for South Cambridgeshire (Mr. Lansley), the right hon. Member for Airdrie and Shotts (John Reid), who was then Secretary of State, refused to adopt the recommendation in the Kennedy report for the Bristol inquiry because
Plainly, there will be a tension, as the Minister will be aware, between a concentrated expertise-driven approach and a devolved approach. However, that was only one of nearly 200 recommendations, so it would be timely and interesting to consider what progress has been made on the rest. In an article in the British Medical Journal, Dr. Paul Aylin and others looked at paediatric cardiac surgical mortality in England after Bristol, and in their final paragraph they concluded optimistically:
"Mortality at the Bristol Royal Infirmary has fallen markedly after the changes there, and a more gradual reduction in national mortality is evident from the time these data were first available . . . Whatever the reasons for the reduction in mortality, this seems to be good news for patients and parents."
But that article, as the Minister probably knows, is also the one that exposed a potential problem at the John Radcliffe. The John Radcliffe denied that there
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was a problem. It questioned the accuracy of the statistical methods used for this paper. Although as Dr. Aylin, who stands by the findingsI spoke to him only earlier todaypoints out
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