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Lord Swinfen: I am grateful to the noble Baroness for giving way. Is there a definition in law of "senior doctor"? I am not aware of one. It may be understood within the National Health Service and the hospital system, but for the purposes of legislation we need a definition.

Baroness Finlay of Llandaff: I am grateful to the noble Lord for that comment. I shall bear it in mind in terms of any revision that occurs.

As to working hours, a doctor needs to work on a rota. Doctors need to decide with whom they work on that rota. It must be someone with similar competencies.

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They also have junior staff to act on their behalf. That is the concept of delegated responsibility. It happens all day and every day in every part of the NHS.

When a doctor in training sees a patient and undertakes procedures, the consultant is de facto responsible even though he is not present at that process. If the consultant does not trust the junior doctor, it is his responsibility to state that that duty is no longer delegated in clinical care. The situation is similar with other colleagues. So there is a need to allow delegated care. I used the wording in order to avoid the situation in which a clinician from another team, or someone clinical who is not a doctor, could step in and stop a management plan without knowing the patient and knowing and being a party to the discussions that had taken place. It was precisely to stop someone coming in and wanting to clear a bed, as has been implied, that I used such wording.

I turn now to the issue of prosecution. I am grateful to the noble Lord, Lord Joffe, for highlighting the current law. When cases are reported to the police they have a duty to, and do, investigate them. I am concerned about the possibility of vexatious litigation. That occurs in the United States. It is in the process of destroying healthcare there. I do not think that it contributes anything to care.

There have been some serious allegations about people being "done to death" in hospitals around the country. They are extremely serious allegations and warrant proper investigation. But I do not think that allegations on the Floor of the House without adequate evidence really contributes a great deal. My picture of patient care does not correspond with that.

Baroness Knight of Collingtree: I wish to understand what the noble Baroness is saying. Is she saying that when information has come to us—and information has been given to us because of the public position we hold, even information from as good a place as from a Member of Parliament in the other place—we should not bring it out? Is she saying that we should not be angry or try to do something about it? Knowing where her heart is, she cannot mean that we have no right to bring forward cases that we know perfectly well have happened. I waited very patiently for objections to be raised to what I said. Not one came.

Baroness Finlay of Llandaff: I ask forgiveness from the noble Baroness, Lady Knight, if she feels that that is what I have been saying. It is not. However, I am concerned that allegations are being made about cases that warrant investigation and which should have been investigated. Evidence should have been sought and if prosecutions by the police were warranted, they should have been brought.

However, I return to the amendment. I accept that it needs redrafting. I continue to have a concern that, without clarification, vexatious cases could be brought, which would not contribute to patient care. I

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have a concern that the patient's wishes must be considered and that those wishes must be paramount. It was for that reason that I was so keen to include consent in the amendment. At this stage I do not wish to press the amendment. I beg leave to withdraw it.

Amendment, by leave, withdrawn.

8.45 p.m.

Baroness Finlay of Llandaff moved Amendment No. 6:

    After Clause 1, insert the following new clause—

There shall be a general duty on all those caring for a patient to offer sustenance to the patient which is appropriate to—
(a) the patient's clinical condition, and
(b) nutritional needs of the patient."

The noble Baroness said: The amendment is in line with the statement of the director-general of the United Nations Food and Agriculture Organisation that the right to food is fundamental to human existence. The amendment was inspired by the speech of the noble Baroness, Lady Masham of Ilton, and the fears expressed by the noble Baroness, Lady Park of Monmouth. It also recognises that the consultant or general practitioner does not control what happens on the ward, in the nursing home or in a similar place of care. Many other healthcare professionals are involved.

The amendment is designed to drive up standards of institutional care of patients everywhere. It is aimed at reaffirming society's respect for life and ensuring that that is an obligation in care. It is aimed to ensure that those with a stroke or other disability do not have their food left out of reach, receive assistance with feeding and drinking, and that fluid infusions are instigated or replaced in a timely manner, without delay. I beg to move.

Baroness Knight of Collingtree: I have no objection to the general tenor of the amendment, but I wonder whether it could not have been better phrased. It does not specify those caring for a patient in hospital. There is an army of excellent ladies outside hospitals who care, and who call themselves carers of patients. Without those helpers, many sick people who are crippled or in some way unable to run their homes could not manage. Those carers may have no idea of what are the nutritional needs or clinical condition of the patient. They are not doctors or nurses.

With the greatest respect, the amendment needs more care in its framing. As with the previous amendment, I understand exactly what the noble Baroness is trying to achieve by it. I support much of what she said, but I submit that the amendment would benefit from more careful thought.

Baroness Andrews: As I understand it, the amendment is intended to clarify that all those caring for patients have a duty to offer sustenance to them appropriate to their clinical condition and nutritional

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needs. I understand that the noble Baroness is concerned—as many of us have been throughout the Bill's passage—that a distinction is made between poor nursing and medical care that leaves patients to die in distress and withholding or withdrawing artificial nutrition and hydration where doctors do not consider that to be in the patient's best interests.

It is worth restating that we all believe that poor and neglectful care of dying patients is inexcusable. It should not happen. Indeed, causing death by gross neglect could amount to manslaughter. The Bill is not about gross neglect, as the amendment makes clear. The amendment also restates a basic tenet of medical practice: that any care is tailored to an individual's needs. It restates established medical practice. It is worth putting that on the record.

It may be helpful if I set out my understanding of the definitions that will inform the full meaning and implications of the amendment. "Sustenance" is defined in the Bill to mean the provision of nutrition and hydration, however delivered. That includes the range of methods by which sustenance can be provided, from simple oral nutrition and hydration to invasive intravenous and PEG methods.

The word "offer" in the amendment is not defined in the Bill, but the use of the word suggests that it refers to patients who are in a position to refuse. By inference, apart from that limitation, the amendment also implies that if, as the end of life is reached, it is not clinically and/or nutritionally appropriate to offer increasingly invasive methods of delivering sustenance, those caring for the patient do not have to make that offer. Where a person is not in a position to consent to treatment, or where they refuse an offer, the normal rules apply, and those providing care must act in the person's best interests. I offer that as the Government's view of the definitions.

In response to the noble Baroness, Lady Knight, we believe that the clause is aimed at all those caring for patients. It seems to include not only healthcare professionals but family and lay carers also.

Lord Alton of Liverpool: Earlier in the debate, the noble Baroness, Lady Andrews, said that she would hold the ring in maintaining her neutrality. She has done that extremely well in her response to the amendment. Perhaps she should hold the ring further by taking up the suggestion of my noble friend Lady Masham that the Government assist with ensuring that the draftsmanship of the amendments matches the definitions that have been described. That would be of valuable assistance both to my noble friend Lady Finlay, whose amendment I support, and to the noble Baroness, Lady Knight, who says that she accepts the spirit, if not the detail, of the amendment.

Much common ground can be made up before Report. I hope that it will be possible for the Government at least to provide neutral advice on ensuring that the draftsmanship is right so that any legislation we approve is valuable.

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Baroness Knight of Collingtree: I wish to express my gratitude and thanks to the noble Baroness, Lady Andrews. All noble Lords who have been engaged with the Bill so far are very pleased that she has been in charge on the Government Bench.

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