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I welcome the Bill, which aims to ensure that patients and their families can obtain redress by way of an investigation, apology or compensation when something has gone wrong with NHS treatment or care. I particularly welcome the broadening of the scope of redress specified in clause 3 to provide for explanations and apologies. It is extremely important
for a patient or a patient’s family to be offered an explanation and an apology when things have gone wrong.
Like other hon. Members, in the 13 months since I was elected I have dealt with a number of cases in which the provisions of the Bill would make a considerable difference for constituents. One case stands out for me as a perfect illustration of a situation in which a patient’s family desperately need explanations and apologies. Many hon. Members are familiar with such situations among their constituents. In that case, there was inadequate and delayed diagnosis of a condition that was terminal, leaving the family feeling that the patient’s life ended prematurely and with little time for the patient or his family to prepare for his death. The family feel that the treatment and care that the patient received as a hospital in-patient were “totally disgraceful”.
I shall describe the case in a little more detail, as it shows the extent of systemic failure and why my constituent, Mrs. Dawn Smallman, feels that she desperately needs an answer and an explanation for what happened. Most importantly, the hospital in question needs to admit its errors and take measures to ensure that what happened to the patient, Mrs. Smallman’s father, does not happen to anyone else. Regrettably, the hospital seems unable to do that.
The case is that of Mr. Stanley Collins, who died on 30 August 2005, three days after being discharged from the Royal Bolton hospital. Specific areas of complaint were raised by Mr. Collins’ daughter. Mr. Collins had a stomach cancer which proved terminal. It was finally diagnosed only a week before his death. He had, however, been attending the hospital as both an in-patient and an out-patient since October 2004 and had undergone colonoscopies, endoscopies, biopsies, scans and X-rays. There seemed to the family to be signs of a serious illness. Mr. Collins was in great pain, he was very ill for the last few months and he was anaemic, but hospital staff insisted, almost to the last, that his condition was neither serious nor terminal.
Mr. Collins felt that his condition was not taken seriously. When he was taken in great pain to the accident and emergency unit, the triage nurse merely referred him to the unit’s on-call GP. The GP called for some tests to be done by the family GP to identify the causes of pain, but the request for tests was lost in the hospital’s administrative system. That was just a month before Mr. Collins died.
A few times during the last two months of his life, Mr. Collins was admitted to the Royal Bolton hospital as an in-patient. During these stays, the family felt that he was treated very badly. They felt that he was neglected and left to suffer great pain and a lack of dignity. Many aspects of this inadequate patient care involve basic standards of care and professional practice. First, throughout the last weeks of his life, Mr. Collins suffered great pain, yet medical staff dealing with him did not respond with adequate pain control. His family tell me that they repeatedly asked for pain relief, yet observed that he was often kept waiting hours to be given that.
Secondly, in Mr. Collins’ condition, he needed help at times—for example, to use a commode—yet even that help was not available when he needed it, although
it is a basic aspect of care for the seriously or terminally ill. Thirdly, a ward where Mr. Collins stayed during the last few weeks of his life was described by his family as filthy, with dead insects and even toenail clippings not being cleaned away. Next, basic needs such as the provision of clean drinking water and a clean glass were not provided by the staff on the ward.
Perhaps most serious of all was the way in which hospital staff dealt with Mr. Collins in the last week of his life. In this respect, lessons must be learned. A week before he died, Mr. Collins’ family attended a meeting at which the consultant was to give the diagnosis and prognosis for him. The news that Mr. Collins had a cancer that was now terminal, with no real treatment options, was delivered to him and his family on an open ward in the hearing of other patients and visitors. Indeed, Mr. Collins’ daughter found that the news of her father’s condition was overheard by a relative of a work colleague of hers. Mr. Collins had to ask how long he had to live in the hearing of other patients, and he was told that he had a very short time.
Perhaps unsurprisingly, given that low standard of professional practice, hospital staff also failed to deliver the palliative and nursing care that might have made Mr. Collins’s last seven days of life more tolerable. With very little time to live, he wanted to be at home with his family, but even that was not handled well. First, it took from Tuesday to Saturday to get a hospital bed at home for Mr. Collins and for the palliative care consultant to arrange his medication.
Secondly, hospital discharge was arranged on Saturday 27 August by emergency ambulance, but the ambulance never came. Eventually, Mr. Collins’s family came into hospital and found him left in a chair with no help with toileting, no pain control—his drip had fallen out and had leaked all over the floor—and no opportunity to summon help, because the emergency button was out of reach. Disgusted by that treatment, Mrs. Smallman and her mother, who is disabled, signed a form to discharge Mr. Collins themselves by car. Mrs. Smallman said that trying to bundle her father into the car was the worst thing that she has had to do in her life.
Finally, hospital staff discharged Mr. Collins with oral medication rather than the intravenous medication that he needed. On a bank holiday weekend, the district nurses told Mrs. Smallman that it would be practically impossible to get the drugs that Mr. Collins needed for pain relief—it is, of course, particularly difficult to get oral morphine post-Shipman. Mrs. Smallman and her sister spent the bank holiday weekend, which comprised the last few days of their father’s life, driving around on-call doctors and dentists in Bolton trying to get prescription forms signed and to obtain the necessary permissions for the district nurses to administer the medication that their father needed.
The district nurses who were trying to help Mr. Collins contacted the C4 ward of the Royal Bolton hospital, which told them that Mr. Collins was “no longer their responsibility”. Mrs. Smallman has said:
“You cannot imagine the burden placed on us to get this medication in order to relieve his pain. There were times when he was in agony. You cannot imagine what it was like racing back to him with his medication, never knowing if you would be back in time or if he would die while you were out.”
On the day that Mr. Collins died, his GP visited him. Astonishingly, the hospital had sent no information on Mr. Collins’s diagnosis to his GP.
On her father’s death, Mrs. Smallman has said:
“I wish I could say that his death was peaceful, but it was not—he died in pain with absolutely no dignity whatsoever”—
thanks, she feels, to the Royal Bolton hospital. Lack of information from the hospital even made it difficult for Mr. Collins’s GP to certify Mr. Collins’s death, as he had been sent no information about the diagnosis.
Much of the evidence that I have recounted clearly indicates poor standards of nursing and medical care, bungled administration and very poor communication. However, the situation has been made worse over subsequent months by the inadequate response by the Royal Bolton hospital to complaints from Mrs. Smallman. Since raising her complaint with the hospital on 3 October, Mrs. Smallman has found that responses from the hospital have not been sent to agreed time scales and have often been three to four weeks late, that copies of responses have not been sent to me—I have had to chase every single response from the hospital—and that the responses have been inadequate, which is the worst thing for the family. The delayed answers and prevarication by those investigating the bereaved family’s complaints have left the family feeling more angry and upset. The family’s feelings of anger were originally due to what it regarded as undue delay in diagnosing Mr. Collins’s terminal condition and the poor standard of treatment and care that he received both in hospital and on his discharge home to die.
In making her original complaint, Mrs. Smallman knew that nothing could bring back her father or change how he was treated. She raised the complaint to obtain explanations and an apology and to help prevent any other patient or family from suffering in the same way. It is clear to me and my constituent that the current system for redress is inadequate, and I welcome the change introduced by the Bill. Standards of professional practice were patently not met in that case.
The Government cannot manage the practice of every NHS consultant, but we need to bring about a change of culture to allow acknowledgement when a whole system of treatment and care fails a patient and his family, which seems to have happened in this case. When standards of both professional practice and communication fail, we need a system of redress in the NHS which acknowledges and investigates such failures, explains what has happened and apologises to those affected.
We know that cancer care is improving, but we also know that it is still patchy. It is more than three years since the Commission for Health Improvement report “NHS cancer care in England and Wales” highlighted the fact that some consultants have poor communication skills in giving bad news. What happened to my constituent’s father, Mr. Collins, and his family should be seen as an unacceptable standard in communicating such bad news. Indeed, good communication is a key part of the cancer plan. Cancer patients and their families increasingly want help to enable patients to die at home without pain and with some dignity, which did not happen for Mr. Collins,
who died in pain and with no dignity. He did not receive the palliative care which he should have received and which many other patients now receive.
The Healthcare Commission has reprimanded some NHS hospitals for failing to pay sufficient attention to complaints, and the number of complaints that went to independent review doubled in 2005. The commission felt that too many trusts were failing to respond promptly and effectively to complaints. That has unfortunately been the case for my constituent, Mrs. Smallman, in her complaint against the Royal Bolton hospital. There is still time for the hospital trust to change the situation and handle the complaint more effectively, and I hope that it will.
I welcome the Bill and the new scope for redress, which will offer the explanation and apology that my constituent and her family need, and benefit other patients and their families.
6.16 pm
Mr. Nick Hurd (Ruislip-Northwood) (Con): I rise to support the Bill in the form in which it has been sent to the House from the other place.
It is a particular pleasure to follow my hon. Friend the Member for Broxbourne (Mr. Walker) and the hon. Member for Worsley (Barbara Keeley), who, in their very different ways, brought home vividly through their constituency case studies some of the human problems faced by a minority of our constituents.
Unlike the hon. Member for Crawley (Laura Moffatt), I do not have personal experience of working in the NHS, but, like most hon. Members, I keep in close contact with my local hospitals. Last year, I had the opportunity to work—I use the word loosely—the night shift at Hillingdon hospital in the accident and emergency department on a Friday night. I said that I was there to “work”, but I shadowed the senior nurse through the course of that evening, which covered a period of peak demand for the department. When I left the next morning, I was astonished and impressed by the capacity of staff to cope with the pressure and the flow of decisions—hundreds of decisions were taken that night, and a huge number of decisions are taken throughout the system every day. In his report, “Making amends,” Sir Liam Donaldson, the chief medical officer, states that 50 medical decisions are taken every year on behalf of each person in this country. Given the increased complexity and pressure of the environment in which NHS staff work, it is not surprising, as the hon. Member for Crawley said, that mistakes are made.
I have been surprised by the scale of the problem. The trend in the debate has been to downplay the issue, but I hope that we have not given out the signal that we are complacent. Sir Liam Donaldson’s report informs us that the level of adverse effects during in-patient episodes in the UK runs at about 10 per cent., of which about 50 per cent. are preventable. On my maths, there are more than 400,000 preventable adverse effects a year, which, again using the figures in the report, cost about £1 billion a year in additional bed delays—those are big numbers. The report also points out that the health care sector has been historically tolerant of error, certainly compared with other industries that have had to be a great deal more robust on
accountability for health and safety. I hope that we are not in danger of being complacent in the face of the challenge of driving down the scale of the problem.
The stress caused on both sides of the decisions that I have discussed is not in doubt. Anyone who read the report and the account of the mother whose child died as a result of a GP’s failure to diagnose meningitis could not fail to be moved by the thought of how much pain that incident caused on both sides.
I recently met my constituent, Jean McFarlane, a cancer patient who is in remission. She was seriously injured by an overdose of radiation, which left her semi-paralysed and in chronic pain for life. Such was her determination that that should not happen to anyone else, that she joined forces with other women who were injured at the same hospital to form a group called RAGE—Radiation Action Group Exposure. She said, “Sadly, we are now the forgotten hundreds, who get no help from anybody to maintain daily lives. Our injuries are unrecognised, or pushed under the carpet.” Her driving motivation is that what happened to her should not happen to anyone else.
Given the scale of the problem and the consequences for those who are unfortunate enough to suffer from it, we need to be sure that we have a complaints system that is seen to be effective and a system of redress that is seen to be fair. Those are surely hugely important pillars on which to build public confidence in the NHS. I suspect that they are underrated and underestimated within the system; the evidence certainly suggests that they are not as strong as we would wish.
The case for reform of the redress system is not seriously disputed. Although it is clear that progress has been made as a result of Lord Woolf’s recommendations and the actions of the NHS Litigation Authority since 1995, three trends are of particular concern, the first of which is the rising number of clinical negligence claims and the associated costs. The number of claims has risen from 392 in 1996-97 to more than 5,000 in 2004-05, and the associated costs have risen from £235 million in 1996-97 to more than £500 million in 2004-05. I am sure that no one in the House wants to go down the route of the USA, which spends a staggering 0.2 per cent. of its gross domestic product on medical litigation costs. That is a future that we must reject—not least because, as my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) said, every pound wasted in this area is a pound that could be redirected to front-line care.
The second trend that concerns me, and other hon. Members, is the length of time that it takes for claims to be settled. According to the NHS Litigation Authority, the average is 1.4 years, but the National Audit Office has suggested an average of five years for 2004-05. That is too long, as other hon. Members eloquently stated. During that time, there is a great degree of suffering on both sides involved in decisions.
The third trend that concerns me is the waste of time and money wrapped up in the following statistics: 38 per cent. of cases are abandoned, 43 per cent. are settled out of court, and 75 per cent. of claims under £25,000 cost more to settle than the amount that is claimed in compensation.
All those factors conspire to create the wrong culture: defensive, obstinate, and confrontational. It becomes a game in which the patient holds few cards—truly a situation of David against Goliath, as my hon. Friend the Member for Broxbourne put it. I add my voice to the consensus that something needs to be done to speed up the process of claims and to generate a culture that is more conducive to transparency, co-operation and improvement.
We do not hear enough about the need to reduce the size of the Bill. Some £500 million of taxpayers’ money has been redirected. Primum non nocere, “First, do no harm”—I hesitate to introduce Latin into the Chamber—was the motto of Florence Nightingale. I am afraid that we have not heard enough about that this afternoon. For example, how successful has the National Patient Safety Agency been since it was set up in 2001 in helping to reduce the size of the problem, in learning lessons and in identifying risks and mechanisms to track progress with solutions?
I understand that reducing costs is not the main driver of the Bill. Its aim is to provide a simpler means of obtaining compensation in lower value cases. Costs might rise depending on the various assumptions that might be made about future claims. I am happy to applaud that objective, but the test of any new legislation is to ask what it will add to what is already there. What gives us reason to think that it will succeed in its objectives, particularly when one of those objectives is to change the culture? We know how hard that is. How can we be confident about it, particularly given that there is currently nothing to stop the NHS from offering compensation, remedial care, an explanation or apology? That is within its power today. How can we be sure that the Bill will be a turning point in changing that culture so that those options are used more? The frank answer is that it is hard to say because, as the right hon. Member for Berwick-upon-Tweed (Mr. Beith) said, there is so little detail. That point is also made by the Law Society, the British Medical Association and the Constitutional Affairs Committee.
We are told that the NHS Litigation Authority will manage the scheme, so why is it not named in the Bill? The bottom line is that it will still need to be established regardless of whether injuries have been caused by negligence, but what criteria will be used? Who will decide or advise on which cases are eligible? How will proceedings start? Will they be independent of the complaints process? Why was the £20,000 limit chosen? What does it include? Does it include only legal costs or does it include remedial costs? Exactly what type of independent advice will patients and families be entitled to?
Even in the vacuum of detail in which we are asked to debate this afternoon, one real concern stands out: the need for independence and for the process to be seen to be genuinely independent, in terms of judgments being made and of the access that patients will have to independent opinion, not just at the end of the process. The Government are, in effect, bringing everything in-house into the hands of an agency the main purpose of which is to defend the NHS. The model is fatally flawed, because it will remove trust and confidence in that process. If I were a patient who had gone through some of the experiences that hon. Members have described, and I was told that that the
NHS was to be the judge and jury in my case, I would not enter that process with confidence or trust.
How will the new system change the culture? Currently, the clearest way of changing culture and raising accountability is to throw a harsh spotlight on matters from outside to break down the culture of stubborn defensiveness that seems to pervade the NHS, as comes through in the evidence from Action against Medical Accidents. Underlying this is a general feeling that the Government know best and that people should take what they are given. That is why I supported our amendment, which seemed to be a victory for common sense. We should separate the redress process into two parts: find the facts and find the fault. An independent redress system that is overseen by the Healthcare Commission is essential for building confidence. The hon. Member for Crawley mentioned the importance of defining the status, training and legal skills of independent investigators.
It is rich for the Government to complain about cost. The figure bandied around for the cost of this scheme is about £14.5 million at the bottom end of the range. It is ironic that today, in Committee Room 15, the Public Accounts Committee is investigating the shambles that is the Paddington health campus project, which the Department of Health failed to supervise over five years, with a cost to the taxpayer of £14.5 million and an opportunity cost that runs into hundreds of millions of pounds. Given that kind of cavalier attitude to taxpayers’ money, it is ridiculous say that the price of a genuinely independent system that will generate confidence is too high at £14.5 million. Only by building a system and a model that can inspire confidence in the independence of decision making can the Government truly say that this Bill is for and about patients.
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