Abstract
A 3-year-old arrived in the A&E department after near-drowning in a water butt. He was breathing (just), cold and blue, despite oxygen being applied by paramedics. The first mistake could have occurred at the point of arrival if no paediatrically trained physician or anaesthetist were immediately present. The second could have been within seconds, if appropriate protocols for resuscitation were not followed. Within minutes, clinicians might have failed to obtain adequate intravenous access because the infant's peripheral circulation was closed down or because the Foundation Year doctor was inexperienced and the consultants hypermetropic (changes in visual acuity in late middle-age) or out of practice. Even with availability of immediate evidence-based literature searching on the registrar's palmtop, the decision on whether it was better to give normal saline or plasma could be erroneous either way. When, after 30 minutes, the laboratory reported an extraordinarily low serum sodium (because the child had absorbed so much water through its lungs and stomach) very few physicians would have knowledge or experience of using hypertonic saline solutions; because their use is so rare, nursing or pharmacy staff might have been tardy in locating an infusion pack or even been unable to find one at all. And so it might go on: during the 2 or 3 hours resuscitation in A&E, followed by ambulance transfer to a paediatric intensive care centre, each of dozens of binary decisions is prone to error. By the time the infant left intensive care a week later, that would have increased to hundreds, possibly thousands. Fortunately many errors carry little risk or might even cancel each other out – but the chances are high of a sequence of minor incorrect choices becoming cumulative in causing harm. As one recent review put it: ‘Nearly all critically ill patients in ICU will suffer a potentially life-threatening error at some time in their stay.’ 1 And that is without taking into account negligence or seriously poor performance.
Thus, patients are always in multiple jeopardy, both from their clinical problem and its management. Properly, that is a matter on which this journal concentrates. However, this month we are reminded that doctors, too, face multiple jeopardy. Alleged incompetence, insensitivity or unavailability may bring about disciplinary procedures from their employers; the NHS complaints process may grind into action; a disgruntled patient or relative may seek redress through the civil courts by an action for clinical negligence. They, or more usually a representative of a public or statutory body may report the doctor concerned to the General Medical Council (GMC), which will investigate to determine whether or not his or her fitness to practise is impaired. If the patient is unlucky enough to die, a criminal charge may be brought if negligence is considered to be gross; even in the absence of criminality the findings of a Coroner's inquisition may provoke subsequent civil or regulatory proceedings. In exceptional circumstances a public inquiry might be initiated, such as the current Inquiry into Deaths Related to Hyponatraemia in Northern Ireland. 2
This month sees three contributions relating to medical jeopardy. Andrew Bradley, HM Coroner for North East Hants Division explains doctors' duties in relation to death certification and when to alert the coroner. He outlines the purpose of inquests and reminds us that rule 42 of the Coroners Rules 1984 proscribes a verdict framed in such a way as to appear to determine any question of criminal liability on the part of a named person or civil liability. Nonetheless, a narrative verdict can get sufficiently close to falling foul of rule 42 such that clinical staff involved are placed in jeopardy.
John Hendy QC examines the new framework governing disciplinary procedures involving senior medical staff in the NHS. The previous procedure, known as HC(90)9 involved a due process which served to protect those accused of matters of professional conduct or competence (as opposed to personal misconduct). This appears to have been swept away by the abolition of HC(90)9, resulting in the loss of an independent panel with a legally qualified chair, the removal of the right to legal representation and the right to hear and cross-examining all witnesses. Mr Hendy fears the chance of ‘trumped up charges generated by personal malice or professional jealousy, or intended to neutralise an outspoken defender of patient services from the economic imperatives of management’.
The Medical Act 1983 gives the GMC the power to restrict a doctor's practice if his or her fitness to practise is impaired, among other reasons, by deficient professional performance. The GMC has adopted tests of competence and workplace assessment with peer-review as part of its procedures in investigating those alleged to be performing poorly. Co-authors from the division of medical education at University College London Medical School and the GMC detail the process by which the assessment has been developed according to educational theory. This includes how the standards are set and the material validated, the latter by calling upon volunteer doctors to undertake the knowledge test and objective structured clinical examination. As a final turn of the jeopardy screw the volunteers are warned, on recruitment, that if their results show overall evidence of poor performance they may be referred to the GMC!