|
|
|
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
|
|
NHS Tayside - Uncovering the Cover-Up The description of events below is about the failure of basic care. Had it not been for the patient's daughter's persistence, the patient would have died.
The GP in question is no stranger to publicity: as a political animal he is frequently in the news. He is a BMA Doctors' representative. The following account is about how the authorities - NHS Tayside, Scottish Public Services Ombudsman and most importantly, the General Medical Council dealt with my complaint. The facts in this case, in the form of medical events, specific clinical issues and records speak for themselves. There is nothing here that has not already been available to the bodies dealing with my complaint. Those bodies seem to have been able to reach their conclusions only by suppressing or ignoring most of these specific clinical issues and records. That is why I believe it is in the public interest to reveal them here. The following narrative is based on a statement of events I provided first for the local NHS Complaints authority in February 2005. It was only in 2007, on the advice of my solicitor that I obtained the main, acute hospital records from Ninewells Hospital, Dundee - and felt that my suspicions about the investigations were fully justified. My father, whom I shall call Mr Y, had a long standing problem with fluid retention around the ankles (oedema), for which he had been prescribed Frusemide, a diuretic [or "water tablet"]. At 88 Mr Y was a physically active man - a retired teacher with a small pension, who managed his own affairs meticulously. We persuaded him to have some domestic help after my mother died. He had looked after her as she deteriorated with Parkinson's and arthritis, for ten years. In August 2004 my father's chiropodist (a highly qualified nursing sister) had asked me to go with him to his next appointment with his GP, Dr X. She had written to Dr X in advance detailing her concern. The appointment was also to discuss an ECG my father had had earlier. I later found this was abnormal. This is the chronology of events: 03 August 2004
Mr Y attended a consultation with Dr X . The clinical record reads "(With daughter) - problem is peripheral oedema - poor venous return. Discuss treatment options. 25 October 2004 Further consultation with Dr X. "Awaiting special compression stockings. Not tried Metolazone yet (?why). Further script as well as Frusemide 40mgs." [Mr Y had, in fact, taken the Metolazone immediately after it was prescribed, in my presence and that of his home help. He stopped when he thought it was making him unwell. He started again when Dr X told him to - with our encouragement.] 16 November 2004 House visit by Dr X.
"Unwell one week - neck/head 'pain but not exactly pain'. Tired.
06 December 2004 Further visit by Dr X. "Cataract surgery due Wednesday. Daughter concerned. Still vague concerns about head, memory. Probably cerebrovascular cause and age. Add Aspirin 75mgs per day." 30 December 2004 Patient is visited by the district nurse who records in her records - "19.30hrs eye drops to right eye as prescribed. Mr Y stated to me that for the last 2 weeks he has felt strange and tired. Something has "went" in his mind. He wants to be seen by GP. I reassured him that I would arrange this with doctor on duty in the morning. He has been reluctant to say before in case it was a bother. States he now needs more help on daily basis." 31 December 2004 Another district nurse notes in her record - "Re above. Dr X has already been informed and will deal with the matter." I phoned the surgery to make a telephone appointment to speak to Dr X and was reassured by reception that a telephone appointment had been made for the doctor to contact Mr Y. Neither appointment was kept. 4 January 2005 I rang NHS 24 for help, after Mr Y lost mobility and became very confused. Their summary: "Deterioration in mobility and mental alertness over past 8 weeks. Past 4 days has seen worsening of symptoms. Advised that condition best treated by own GP. Contact GP surgery within 36 hrs.May be suitable for an emergency appointment" This was received by Dr X and was signed by him. 5 January 2005 I made an urgent call to the surgery. Dr X writes later "I was in reception when the call came in." He could not have been unaware of the situation I described. The duty doctor Dr B attended. "On examination the patient himself could get around well and gave a reasonable account of things. BP 130/80. I issued another prescription for Aspirin 75mgs because he's not got them from 6.12.04." Dr B conveyed my annoyance about the missed appointments on 31st December to Dr X. Dr X later rang me and explained there had been a 'mix-up' 6 January 2005
Dr B's note: "Telephone call - Daughter is taking him up glen to be with her for a period. Wishes Zimmer. Ok. One ordered through physio also Lactulose given for bowels. Stop Senna." But my father was too weak now to leave his bed. 10 January 2005 Over the weekend my father had deteriorated further. On the Monday morning I rang the surgery expressing my extreme concern about his condition. I requested immediate attention. Five hours later Dr X, accompanied by a trainee, arrived. Dr X and his trainee observed my father. There were several glasses of water by the bed. He was urinating while they watched. He was barely conscious. Dr X phoned for an ambulance and Mr Y was admitted to the GP Unit in the cottage hospital. Dr X met his patient and attended to him personally. Dr X writes in the clinical records "Admitted from home, reduced eating for one week with reduced fluids, increased sleepiness. Recent concerns regarding memory not so good, ? TIA in early December. Past medical history - right cataract surgery in December. Peripheral oedema. Social history - widower, lives alone, daughter nearby. Drugs - Metolazone 5mg. Per day. Frusemide 40mg. Per day. Senna/Lactulose (for constipation), Aspirin 75 mg. per day. On examination dehydrated. Skin/facies reasonably bright. Pulse 60. Chest clear. Abdomen soft - NAD. No peripheral oedema. No evidence of cranial nerve or peripheral weakness. Plantars down going. Full blood count and biochemistry blood test, ECG. Plan - subcutaneous fluids tonight if not taking orally. Stop diuretics until U & Es available." The ECG revealed "Atrial fibrillation with premature ventricular or aberrantly conducted complexes. Left axis deviation. Septal infarct; age undetermined. Abnormal ECG." The patient is seen later by Dr C, another doctor of the same Practice who writes "I don't know this chap so can't compare his present condition with how he really is. There seems to be a lot of anxiety in the family about his condition. I have suggested ----- (indecipherable). Arranging chest x-ray and asking- to kindly cast an eye over him." 11 January 2005 A blood test reveals profound hyponatraemia (low blood sodium) i.e. an electrolyte imbalance in the blood Very abnormal electrolyte results phoned to the surgery at 16.08 hours. Sodium is markedly reduced at 117 (normal range 135 to 147). Potassium is reduced to 2 (normal range 3.5 to 5). Dr B is informed of these results and writes "see very deranged electrolytes - is off all diuretics now. Start Slow K 60mg. Three times a day. Check urea and electrolytes in one day". 12 January 2005 At midday I saw my father slumped in a chair in the ward, I was shocked at his appearance and I asked a nurse what was happening. She seemed very worried and said she would talk to me in a private room. I asked her to tell me what was wrong with him. She told me that Mr Y had lost essential salts because of the diuretics he had been taking. I demanded to see Dr X at the surgery. He was not there. Dr B came out. I ordered him to pick up the phone immediately and get my father admitted to Ninewells Hospital. Dr B records - "following discussion with his daughter transfer to Ninewells". The referral letter reads "Dear Doctor: Thanks for taking Mr Y as a transfer. Admitted here Monday with drowsiness/poor food and fluid intake. Had been on Metolazone 5mg. Per day and Frusemide for the past few months for apparently severe oedema. Electrolytes following admission very deranged, presumably due to diuretics which were discontinued on admission. Full blood count was normal. Mr Y isn't my patient but his daughter says he was very active until recently (would walk a half mile to town regularly)." The following are the nursing notes from Ninewells Hospital, Dundee Emergency Medical Ward on admission. 12/1/05 15.00 Via --- Cot Hospital
Started on Sando K - no effect.
13/1/05 01.00 Catheter inserted. Moved to rm2 for closer observation. HR still 42. 13.1.05 The Consultant Physician writes in the clinical records "I had a conversation with Mr Y's daughter who was correctly concerned about long-term prescribing of a loop diuretic and Metolazone together. She was also concerned that Mr Y had slowly been deteriorating for some time and she felt he was not being attended to appropriately by his GP. At present my opinion is that this man has become dangerously unwell as a result of over diuresis and loss of sodium and potassium. I am concerned that what was ostensibly a significant dependent oedema has not been adequately investigated or managed. I need more information regarding background to take management forward effectively." (Mr Y had arrived at Ninewells without notes and the Consultant had phoned me after I had spoken to the Ward this morning.) On 18th January, my sister (who had come over from the USA) and I, watched my father as he thrashed about in the bed. He seemed to be in a delirious state. A CT scan the next day showed a CVA. [The discharge notification on 24 January reads; "Principal Diagnosis: Stroke"] Mr Y was unable to use a knife and fork. I had to feed him and gradually accustom him to their use. He was unable to tell the time (this continued for several weeks), or to sign his own name. He gradually regained the use of his legs and began to walk again. When he returned to his own house in mid February, he was found sitting on the step calling for help. During his rehabilitation at the cottage hospital his new GP (he had been registered on 18th January) told me his kidneys might have been damaged - and asked me if I would want 'anything invasive' doing. The care he was now receiving ensured that kidney function returned and, though much weaker, with reduced mental capacity, he has survived reasonably well. On the 24th January '05, the day Mr Y was transferred back to the cottage hospital, he received the following letter from Dr X: Dear Mr Y, This is not an easy letter to write as I have been informed from my Practice Manager that you have terminated registration with ------ Medical Practice. I had been aware from Dr B and the Practice Manager, who had contact with your daughter that she was unhappy about some elements of your care although there has been no direct contact with myself. These situations are never easy particularly when, as in this case I believe there was a good doctor/patient relationship over four years, which also included looking after your own wife when she was at ---- (care home). ( I do, however, believe that however difficult it might be talking through the issues can often be of help in explaining why things happened the way they did. I am therefore extending an invitation to you and or your daughter should you wish to meet with myself and the Practice Manager, so that I may hear from you of your concerns. At that meeting Dr X admitted that he had not monitored my father's blood after prescribing the diuretics. I did not feel competent in asking any more questions and the doctor did not enlarge further. On the 8th February 2005, Dr X's medical practice held a Significant Event Analysis. I received a summary: There was a statement of the main clinical events from 3/8/04 until 10/1/5. Then Dr X adds: How do I feel? What would do differently? The Complaints Procedures In June 2005, the Complaints Department of the local NHS Trust decided not to allow an Independent Review of Dr X's treatment of my father. The reasons given by the Convener were that Dr X had admitted failing to monitor Mr Y's blood and to not considering an electrolyte imbalance as a cause for his symptoms in November or December. The Convener's medical adviser (who was a close colleague of Dr X) wrote that the "staff at Ninewells Hospital took a more aggressive approach to electrolyte imbalance therapy although this is not necessarily the best approach for all patients." She concluded that "since Mr Y had only been in the cottage hospital for a short time, it was not possible to say whether or not he was being treated appropriately." Scottish Public Services Ombudsman I received the SPSO Draft Report in September 2006. (case 200501485) Although this report came under the heading: "Health: GP; Clinical treatment", there was minimal information regarding my father's clinical condition. The clinical adviser to the SPSO (a GP) ends with this statement
The SPSO replied "------ At this point it may be helpful to explain that the subjects to be investigated are decided by this office rather than by complainants. This applies also to the evidence that is considered necessary for the investigation and to the details that are included in the report." Both my MSPs [ Scottish Parliament] read the draft report and met the SPSO to discuss it. I quote from their correspondence with me. "At the meeting, I raised with the SPSO a number of cases, including your own one, where a clear pattern has emerged. ------- in particular, I was concerned that there did not seem to be a basic investigation of the facts given rise to the complaint in your own particular case." My other MSP wanted to accompany me for a personal interview with Prof Alice Brown (the SPSO), but she refused to see me. He then wrote to the General Medical Council recommending a review of the case. My complaint to the SPSO was not upheld. In April 2007 my solicitor wrote to the Chief Executive of NHS Tayside in a final attempt at clarification. His reply states: "I must advise you that that Dr E's role as Director of Primary Care does not involve reviewing clinical care or management plans within General Practices. General Practitioners are independent contractors who hold a contract with NHS Boards to provide a service to patients. They are responsible for their own actions in exercising their clinical duties and for the administrative and organisational aspects of running their practices." My MSP (Scottish Parliament) also wrote to suggest a meeting with the doctors. This was 'declined.' The General Medical Council It would indeed be tedious to relate all the interminable delays and to-ing and fro-ing between me and the GMC, whom I first approached in November 2006. They effectively closed the case when they sent it back to NHS Tayside less than two weeks later. The GMC does not seem to understand even its own procedures, loses correspondence and generally causes maximum frustration and stress to the complainant. I had been advised by my solicitor in 2007 to obtain an Independent Expert GP Report. I was reluctant to spend the equivalent of my father's monthly income in getting what I was sure would be another whitewash. In the event, the report my solicitor obtained from a senior, highly experienced GP was cautious but fair. It dealt in a straight forward manner with the clinical issues contained in the documentation my solicitor provided. On the 26th March 2008 I sent this Report to the GMC and with it a copy of the SPSO Report for comparison. Six months later, I received a letter from the President of the GMC, Sir Graeme Catto, announcing that he was to undertake a President's Review under Rule 12 of the GMC (Fitness to Practise) Rules 2004 - (amended after the Shipman enquiry) - of the GMC's original decision to close the case. "... I do consider that the Independent Expert GP Report... comprises new evidence and information that makes a review necessary in the public interest." In August 2008 the President wrote again "... I have carefully considered all relevant material regarding this review, including the representations made by you and by Dr X, and have made my decision... The reports of Dr --- (my expert GP), which you provided to the GMC for its consideration, do, in my judgement, contain new information of potential significance. I am satisfied that the existence of these reports may make a difference to the outcome and that the matter should therefore be considered afresh by new Case Examiners." In March 2009, I received a copy of Dr X's last submission to the GMC. His solicitors wished to highlight that he had had "no involvement in the patient's care after arranging for his admission and early treatment at ------ Cottage Hospital on 10 January 2005" [The records (quoted earlier) suggest the other two doctors had no idea what was wrong with Mr Y.] Dr X gives as his reason for this "non-involvement" - "as the Complainant made arrangements for the patient to be removed from the Medical Practice list around the 12 January" To be quite clear: Dr X states that he ceased to care for my father on 10 January because I made arrangements for the patient to be moved from the Medical Practice list "around 12 January". It would also explain why I could not get information during those crucial two days at the cottage hospital. The GMC Case Examiners have made no comment. In May 2009 I received the long awaited decision from the Case Examiners. That decision was to conclude the complaint with no further action. Their comments take much the same line as the Scottish Public Services Ombudsman and they quote heavily from the SPSO report. (Possibly the Memorandum of Understanding between the GMC and the SPSO signed in July 2007 is relevant here). The GMC identified the following allegations from the evidence submitted: That Dr X failed: To monitor Mr Y's electrolyte levels: to make a home visit to Mr Y on 31 December as requested: to refer Mr Y to a general hospital rather than to the community hospital: to provide adequate care to Mr Y whilst a patient at that hospital. "The allegations against Dr X are serious and, if proven, would represent serious breaches of Good Medical Practice. The role of the Case Examiners is to consider the evidence relating to each allegation and decide whether there is a realistic prospect of showing that the doctor's fitness to practise is impaired. This is called the realistic prospect test." [Here, I quote from the "Guidance to the GMC's Fitness to Practise Rules 2004" which "aims to promote consistency and transparency"] "The Realistic Prospect Test will apply to the factual allegations and the question whether, if established, the facts would demonstrate that the practitioner's fitness to practise is impaired to a degree justifying action on registration. It will reflect not a probability but rather a genuine (not remote or fanciful) possibility. It is in no-one's interest for cases to be referred to a Fitness to Practise Panel when they are bound to fail. On the other hand, cases which raise a genuine issue of impaired Fitness to Practise justifying action on registration are for the FTP panel to decide" The Case Examiners concluded that the Realistic Prospect Test had not been met for any of the allegations which the GMC itself had identified from the documentary evidence and the new information regarded as "of potential significance" by the President of the GMC. On the first allegation the case examiners write: "----the complainant's expert notes that 'renal impairment will increase with age and it is widely accepted that the older the patient the more cautious one needs to be in monitoring electrolyte blood tests after the introduction of particularly strong diuretics.' He concludes that 'Dr X's failure to consider the possibility of electrolyte imbalance is ---- an indication of clinical negligence' "The GMC expert, Mr - opines that the care Mr Y received from Dr X was of a high standard but that Dr X made a mistake which he has both acknowledged and learnt from. ----- Dr X's standard of care did not fall below a minimum standard of reasonable professional competence" Having reviewed all the evidence, the Case Examiners are satisfied that this was a single clinical error. They note that Dr X has demonstrated insight about his error and its impact on a patient's health and taken steps to upgrade clinical protocols in the Practice." i.e. agreement by the practice GPs: *to be more cautious in the use of diuretics; The Independent Expert GP reporting for my solicitor writes in his Summary: "The side effects of Metolazone are widely recognised - and I would have expected a GP acting with ordinary skill to arrange monitoring of electrolytes following the introduction of this strong diuretic, particularly when co-prescribed with Frusemide in an elderly patient. Several opportunities to do a blood test were missed in the months following the introduction of this potent diuretic." On the second allegation, "The GMC's expert states that Dr X's failure to ring the complainant on 31 December was an error but accepts Dr X's explanation that his decision that the call could wait was a misunderstanding of the situation." On the last allegation (Dr X failed to provide adequate care to Mr Y whilst at the community hospital) the Case Examiners write: "Although the complainant's expert has conceded that 'admission to the Cottage Hospital was initially very appropriate,' he concludes that 'his remaining there was not appropriate, particularly when the electrolyte disturbance was discovered.' The GMC's expert has opined that 'although he (Mr Y) had significant fluid imbalance it would probably... have corrected itself at the cottage hospital; although it may have taken a little longer with oral fluids as he was beginning to drink on admission and his diuretics had been stopped'" I would here ask the reader to refer to the Chronology of events - January 11 & 12 and to the Ninewells hospital records that follow. Only by suppression of this clinical information is this GMC Expert able to "opine" as he does. Asked by my solicitor (as part of the Report) - "Would you regard these biochemical results (phoned directly to the Surgery on January 11) as indicating a medical emergency?" My Expert GP wrote: "Yes, I am of the opinion that on receipt of these very disturbed electrolyte results in an elderly patient an ordinarily competent general practitioner would immediately have sought further specialist advice." The reader will note that the GMC Expert does not challenge that opinion. He merely ignores it. It is difficult for anyone, expert clinician or not, to censure a GP's decision to send a patient to the local community hospital. But that decision was made by Dr X on January 10 knowing that his 89 year old patient had been untreated during months of unmonitored prescription of powerful diuretics. The Case Examiners "advise Dr X to review the elements of good clinical care outlined in paragraph 2 of Good Medical Practice" [GMP paragraph 2 - 'Clinical care must include: a) adequately assessing the patient's conditions, taking account of the history (including the symptoms, and psychological and social factors), the patient's views, and where necessary examining the patient; b) providing or arranging advice, investigations or treatment where necessary; c) referring a patient to another practitioner, when this is in the patient's best interests'.] Since my original complaint to NHS Tayside in 2005, some twenty thousand patients or their representatives have brought their stories of maltreatment by doctors to the GMC. The vast majority of these complaints are rejected. Most people are reluctant and afraid to complain about their GPs; only written communication is allowed and no help given to the complainant. It is a wonder therefore that those five thousand patients every year stay the course even for the first hurdle. The GMC Website trumpets: 'We are not here to protect the medical profession - their interests are protected by others. Our job is to protect patients.' A casual reader of this website might wonder how the notion of the GMC as protector of the medical profession could possibly have arisen. Those of us who have experienced not only the traumatic results of medical malpractice but also the whitewash and cover-up of the self-proclaimed 'independent regulator' know only too well. Related Links 1. Lothian Heart Failure Network 2. Patient.co.uk 3. BNF Entry for Metolazone 4. Side Effects of Metolazone as listed in the BNF 5. 1981 BMJ Note to the General Practitioner [by NHS Exposed]. Each doctor is aware of the impact of combination diuretics. Awareness happens from about the 2nd year of medical school when pharmacology is studied. Moreover, the management of basic peripheral oedema is known to a first year junior doctor. If you were not aware of the risks of prescribing dual diuretics then Pub Med, Medline or Best Practice/Evidence Based Guidance were all available to you. To blame the BNF is no defence at all. We note that no referral was made to NCAS regarding the assessment of your performance
|
|
|
|
|
[Home] [NHS Exposed] [Patients] [Health Workers] [NHS in Crisis] [Legal Issues] [Media] [Helpdesk] [Public Views] All copyright remains with original authors unless otherwise stated. |
In February 2005, I made a complaint to NHS Tayside about the treatment my father received from his General Practitioner. My father was aged 89 at the time.
Mr Y had had severe diarrhoea during the night. For the last few days he had eaten little but had drunk copiously. I spoke to a physiotherapist at the cottage hospital about his poor mobility. I wanted to take him home with me but he needed a Zimmer frame. I was advised that there must be an underlying cause for the immobility, not just "old age". I should phone my GP. This I did.
