We Need To Talk About NHS Managers.

The story in The Times today about whistle-blowing doctors being punished ( https://www.thetimes.co.uk/article/nhs-bosses-use-dirty-tricks-to-force-out-whistleblowing-doctors-89j6nxg5b) for calling out bad clinical practice in others is not new. Whistleblowers have been pariahs in the NHS for decades, even before Dr Stephen Bolsin, a consultant anaesthetist, was driven from his job and to Australia by systemic bullying after drawing attention to very real high mortality figures at the Bristol Royal Infirmary paediatric cardiac surgery unit (http://news.bbc.co.uk/1/hi/health/532006.stm).

In the story in The Times today, several consultants describe being suspended, sacked, or taken to court on trumped-up charges simply because they cared about clinical standards at their place of work. Dr Salam Al-Sam, a consultant histopathologist and whistle-blower,  has brought together 140 such doctors under the monicker Justice For Doctors. No sooner has a doctor spoken out about failings in care than an internal investigation is launched not into those alleged of malpractice but into the whistleblower themselves. They are then usually suspended or sacked under spurious claims. Pointing out shortcomings, which have harmed patients is labelled ‘bullying of colleagues’, and the outspoken doctor is forced out. Many have been driven to sell their homes in order to pay to defend themselves in court. Some have been driven to suicide. There are clear parallels with the Post Office Horizon scandal.

The situation is made even more egregious by the fact that the managers wielding power often have little or no clinical experience. Many are officious box-tickers brought in to save money. I still recall the consultant surgeon who told me that a manager had asked why some of his ruptured aortic aneurysm patients stayed in hospital for over a week while others were discharged on the same day.

‘Can’t they all be discharged the same day?’ asked the hapless Rottweiler. My consultant friend had to patiently explain that rupture of aortic aneurysm requires lengthy surgery which has a long recovery time and can cause many complications because many blood products have to be given, and circulation to vital organs may be interrupted by the rupture.  Patients require so much opioid for the massive incision that they usually go to the intensive care unit and are ventilated overnight at least before being transferred to the surgical ward to recover.

‘

So what of the patients who went home the same day?’ probed the tenacious manager.

‘They died’, my friend replied drily.

As someone who used to be a consultant anaesthetist, and who before that worked as a physician and intensivist, racking up the postgrad exams required to specialise as both a consultant physician (MRCP) and a consultant anaesthetist (FRCA), I can see how genuine mistakes arise in medicine. Doctors who work diligently and try their best but make one terrible error should be dealt with with sensitivity while their fitness to work is assessed. Those who are lazy or sloppy, who don’t bother to do their own ward rounds and always dump on their registrars, or who run away to do private when they are rostered for NHS work should be dealt with firmly while also being assessed. Referral to the GMC is sometimes made by a complainant (patient or patient’s relative) or by other concerned clinicians. Every serious mistake should be fully investigated. Decades ago I suggested a national, and, in time, international, online log of all mistakes in clinical medicine, surgery, anaesthesia and nursing. It would be easiest to hold all this information in one place, and part of teaching juniors and consultants could consist of looking at the mistakes made in your particular field. It’s knowledge of possible complications that spur an exhausted doctor to check before important procedures. It’s because patients have died because the wrong patient’s blood has been given to them that doctors are so careful when writing names and DOB on blood samples for transfusion. It’s because the wrong kidney has been taken out that surgeons draw an arrow on the relevant side, and numerous nurses ask the patient which side is being operated on.

I understand the fatigue of clinical workers, especially doctors. In my day, as juniors, we worked 130 hour weeks - Monday, Monday all night, Tuesday to 6pm, Wednesday, all Wednesday night, Thursday to 6pm, then Friday, Saturday and Sunday 24 hours each day before showing up at 8am on Monday again, rumpled, dishevelled and knackered. Those were the worst weeks, when we worked a 1 in 2 on call rota. In theory, it sounds as if doctors’ hours have improved hugely, with the 82 hour weekend shift an anachronism. Junior doctors now usually work 12 hour shifts. But satisfaction among junior doctors has not improved as much as you might expect. Because we lived on the ward, we felt a part of the team. Our patients were ours, we knew everything about them down to every important electrolyte. We saw them through the admission from entry to discharge. We built up relationships with them, and with the nurses and other ward staff. We also learnt a lot clinically. But junior doctors nowadays working 12 hour shifts don’t see the same patients every day, and even if they do, they miss 12 hour chunks of their care so they can’t be on top of everything and know every detail about their investigations. They don’t build up the same rapport with other ward staff because more of them cover each ward for much shorter shifts.

And although being exhausted from working 130 hours a week did make us more likely to potentially sleepwalk into a terrible error, research showed that mistakes were generally not made when doctors were fatigued because they were hyper-alert, recognising their own lapses of concentration. No, mistakes were more often made when sailing smoothly and juggling lots of tasks at once, where it was much easier to go on autopilot - with potentially catastrophic mistakes.

All this is to say that I understand why doctors make mistakes, and acknowledge that they should be dealt with with kindness as well as firm determination to uncover the cause. Medicine is a hugely stressful job, and consultants generally work around 70 hours a week including on-call. And it’s also easy to see how, after 5 years of medical school and 6 - 9 years as a junior doctor, consultants might not be keen to come rushing in at night as well as working every weekday and some weekends.

But now I’m going to change tack. Now I’m going to tackle the problem from the point of view of the patient, because that is what I am nowadays. I took early retirement from being a consultant, because of severe ill health, back in 2002, after losing my fingers, thumb, toe tip, and large bowel to gangrene. A leg amputation, kidney obstruction, lung disease, frequent aspiration pneumonias, frequent obstructions of the gut due to fibrous adhesions from many abdominal surgeries, frequent bleeds from the small bowel causing dangerous anaemia, and cardiac failure have followed, as well as a smashed tibia and fibula which has kept me confined to my second floor flat for 15 months. Wonderful paramedics (well - 99% of them) carry me down my stairs for my frequent hospital admissions and appointments.

The first thing to say is, I’m grateful. I’m so, so, so grateful for all the hundreds of wonderful doctors and nurses and carers and paramedics and porters and radiologists and radiographers and so on who have kept me alive. 90% of them have been amazing. To the point where it seems churlish to point out mistakes. But since mistakes have almost killed me, and could easily kill someone else, especially someone without my medical knowledge, I feel I have to point them out, and, even more importantly, the failure of managers to whom I’ve written about some of these mistakes.

I didn’t report the brusque, patronising nurse who brought me a pot full of alien-looking tablets and insisted they were mine. I wrote about that experience elsewhere in this blog. Basically, I pointed out at least three times that they were not my drugs, and she told me I was ‘confused’ and must have ‘forgotten’ to take them the previous night. All the while, she was looking shifty, because she had brought the drugs in at that moment, and I found out later, she was in a panic because they had been sitting out all night on the nursing station, because  she had forgotten to give them to the relevant patient the previous night. Hence the lie about ‘ You must have forgotten to take them last night.’ It was only when I lifted my head from the pillow, and boomed (as much as one can on high flow oxygen) ‘ I’m a consultant anaesthetist and I want to speak to the nurse in charge’ that she scarpered. The lovely Ward sister explained the mistake to me. I didn’t pursue it, but I was more worried by the original nurse’s response to my pointing out the mistake - lying to save face, patronising me - than I was by the dangerous mistake of giving drugs to the wrong patient.

I did, however, write to managers to complain when an arrogant registrar did nothing as I lost half my blood volume in 13 hours overnight on an orthopaedics ward last September. 16 nails had been placed through my skin into my broken bones, and when I re-started my blood thinner as instructed that evening, several of the pin sites started gushing and would not stop.

I pleaded with the cocky but inexperienced registrar for blood, telling him I also suffered from long-term bleeding from my gut, and that I had had a heart attack when my haemoglobin had previously dropped to 7 g/dL. He refused. I begged him to call a senior and he refused. I tried to phone a senior myself, and he shouted at me. (And the senior on call hung up on me.) He was threatened by me being a consultant. He told me I didn’t need blood, and that on that ward, they only ever did one blood test every 24 hours maximum. The floor was being mopped every five minutes by an orderly. When the registrar came into my room, he asked the nurse how much blood she thought I had lost. I piped up with my estimate, since I am a consultant anaesthetist, and he poo poohed me as overestimating the blood loss. In fact, I had lost that much and went on to lose much, much more.

 

If it hadn’t been for the amazing registrar who came on 13 hours later at 8:30 am, I would not be here. By contrast with the night reg, this one called to the juniors to fetch sutures and chemical cautery and stopped the bleeding in half an hour. Sadly, he then had to go elsewhere to work, leaving me to the inexperienced juniors who gave me only one unit of blood, despite me telling them I had chronic long term gastrointestinal bleeding as well. I asked for more but was told my slight temperature showed ‘a transfusion reaction.’  I told them, I always had a slight temperature when I received blood, but they ignored me. I asked them to please ask a senior, but they didn’t. I was discharged with a haemoglobin of 8 g/dL, despite being a known massive leader from my gut.

I was readmitted almost moribund with anaemia a week later, thankfully under a different team. Never drop your haemoglobin from 12.5g/dl to 6.5g/dl on an orthopaedic ward at night.

I was left with a degree of PTSD after that experience, but I simply got on with my life, reading, writing, spending time at home with family and friends. I wrote a letter of complaint, and received the most odious angry, defensive response from a consultant had previously thought of as a friend. No one has even bothered to talk to the incompetent registrar. The consultant simply defended him. Which reflects badly on the consultant, if he thinks that massive haemorrhage of half the blood volume should be dealt with without any iv, no fluid, no blood cross matching, and no attempt to stop the bleeding. The consultant informed me that after I myself tried to phone the consultant, he ordered switchboard to cut off any calls I made via them. Thus I couldn’t even call for help from intensive care. I had kept telling the registrar overnight that I had a heart attack when my haemoglobin dropped to 7 g/dL. He didn’t care, he didn’t give me any fluids or blood. Even though my haemoglobin dropped lower than that.

Another time I complained was when my prosthetic leg was so loose that it came off when I was in Amsterdam on a three day break with my husband, causing me to fall to the ground and smash my tibia and fibula in the other leg. I was in hospital in Amsterdam for almost 3 weeks. I was deemed not fit to fly home in a commercial aircraft, so I had to pay for an air ambulance and land ambulances at either end to take me to hospital in Glasgow. We also had to pay for my husband to stay in a hotel for three weeks in Amsterdam. As well as sustenance for both of us. My beautiful Facebook friends raised £8000, which helped, but the total bill was around £30,000. When I complained to the Hospital Trust about the loose prosthetic leg, they hired an unpleasant lawyer to belittle all my claims. I even made video evidence on the orthopaedic ward as soon as I arrived of my stump with the prosthetic leg, being placed on it, showing how loose it was, and how it fell off if I raised my leg above the ground. But somehow, I was deemed to have magicked that up. Even though I volunteered to show them the leg to demonstrate. A kind prosthetist has subsequently made the leg safe with a valve and rubber oversleeve to keep it on, but why weren’t they done in the first place? Of course the hospital, trust insists that they were offered to me and that I refused them. Of course I did. I really wanted to have crippling pain for 15 months, be confined to two rooms for that time and longer (it still hasn’t healed) and waste £30K.

My last complaint was when a crown was knocked out and broken at endoscopy. I thought this would be simple. But it took three weeks for apathetic junior doctors to get hold of the trust dentist, even though I was told by the dentist that if they had filled in an online referral form, they would have come the same day. And then the dentist told me that the NHS no longer pays for lower crowns. So I wrote, quite reasonably, I thought, asking for the trust to pay for me to have the crown replaced elsewhere. This time their response was almost funny - they claimed that my husband had told them not to worry because the crown had fallen out the previous week when I ate an apple. Never mind, the fact that I haven’t been able to visit a dentist for 15 months because paramedics will not take you down the stairs in order for you to go to the dentist, only hospital, and there is no way that I could have replaced my crown myself, leave alone fixed the fracture in it. I asked them to speak to my dentist to find out if I had been in in the last 15 months.  I haven’t even been able to eat apples for years because they cause obstruction. When I replied, telling them that I would hire a lawyer, I was passed on to a more disapproving manager who told me I had shown ‘threatening behaviour’ and that this was ‘unacceptable behaviour.’

So my opinion of NHS managers - including the nurse manager, who bossily told me that I couldn’t have my heater in my room, even though my medical notes clearly state that I need to be in a very warm environment, otherwise I lose digits and other organs to gangrene - is low. Never mind that you are allowed to plug in all sorts of fraudulent apple iphone chargers which might burst into flame at any time, my small, new heater under guarantee was verboten.

Verboten is the word. There is something of the harsh Germanic disciplinarian in the way both patients and whistle-blowing doctors are treated. The senior managers seem to be mired in an ethos of the worst institutions half a century ago, with no respect for truth or honour, despite numerous GMC releases about governance and honesty with patients. Or the ethics of Russia and China, where complaint is seen as outrageous and the complainant dealt with severely and silenced. Even as they embark on their nth pious and uselessaudit, they care more about numbers admitted and discharged, like farmers at a cattle market. Patients are just bodies to be passed through the conveyor belt. Woe betide them if they question anything, even the most obvious mishap. Two years ago, I made the mistake of asking the Royal Free in London whether they would replace my suitcase, since it had become surrounded by filthy toilet water, which had erupted from the toilet in the ensuite of my four bedded ward. It took them a year to write back to me and inform me that the nurses had stated that the toilet water had not reached my bed space. Luckily, for me, I had photographs of my suitcase, surrounded by the dingy toilet water, and I sent one of these to them. There was initial silence, and then they wrote to ask me if I had any more photos of the ‘damage to my suitcase’. No, actually, because I thought a photo of my suitcase surrounded by shitty water from your toilet might be enough. Of course, I should have gone home and reused the faecal suitcase. Especially with my numerous ulcers and open wounds. I didn’t say any of this, but I felt like it,

Radio silence from them since

Human beings - and probably all mammals - require holistic care which includes treating physical disease and offering comfort, a quiet environment to rest (ho, ho), and decent nourishing food (ha), and dealing with them with respect. If a jumped-up clipboard warrior thinks they can cover up patient deaths and other serious problems by lying their two-faced, faux polite face off, they are mistaken. They may have got away with it in the past, but the future is another country. Their time will come.