Blackburn widower to sue hospital for ‘negligence’ after wife’s death

 A widower is to sue Royal Blackburn Hospital following the death of his wife.

Maureen McDonald waited hours to see a hospital doctor after she fell ill during chemotherapy treatment.

Her husband Alan said: “I’m suing the hospital for medical negligence. Cancer patients can’t go through this.”

He said that she had needed antibioltics urgently.

“They have a one hour window to survive. It’s the pits.”

Mrs McDonald’s death prompted a serious untoward incident review at Royal Blackburn Hospital after her husband Alan raised concerns about her care.

The report produced by the hospital trust found: 

• Two nurses had failed to recognise how ill she was.
• The Medical Assessment Unit, which had been expecting her, was not told she had been taken to the A&E department instead.
• She only saw a doctor after a delay of almost three hours when Mr McDonald called the chemotherapy unit himself.
• She was given penicillin when she was allergic to the drug.

The trust which runs the hospital said a number of actions had been implemented following the review to recognise similar patients.

Mr McDonald said he was speaking out after two other cancer patients had also suffered from miscommunication problems when taken for treatment at the hospital.

Mrs McDonald, 59, of Honeyhole, Blackburn, had been diagnosed with brain and lung cancer last December.

Just weeks later, after starting chemotherapy, she complained of sickness and chest pain and an ambulance was booked to take her to the Medical Assessment Unit at the hospital.

The report said when paramedics arrived they decided her symptoms were so serious she should be taken to A&E.

However staff in the emergency department failed to make cancer specialists at the hospital aware that Mrs McDonald had been admitted, and because the seriousness of her condition had not been recognised, there was a delay in prescribing her antibiotics, the report added.

Mr McDonald said: “They kept her in A&E for hours, in that time a senior staff nurse missed vital signs.

“She never received antibiotics or pain relief.

“I had to contact the cancer unit myself. The cancer nurse wanted to know why she was in A&E, not the medical assessment unit.

“The cancer specialist came rushing down and got her straight into resus.”

The report said that when the oncologist came down to A&E, the consultant in the emergency department did not have Mrs McDonald’s notes available, but the two consultants agreed that antibiotics should be prescribed.

Mrs McDonald was given Tazocin, but she had a penicillin allergy, and doctors did not check whether the drug would be suitable before administering it, the report said.

Mr McDonald said: “She had an allergy wristband on, but they never asked her what she was allergic to.”

Mrs McDonald was later transferred to the Medical Assessment Unit, but she passed away in the early hours of the following morning.

The report into her death has made several recommendations, including that feedback should be given to the triage nurse regarding the recognition of seriously unwell patients, and nurses should be made aware of the importance of early treatment.

It said: “It is unlikely that even if Mrs M had received antibiotics within one hour of her attendance at the emergency department that she would have survived however it is very difficult to know for sure.”

Mr McDonald, who is now taking legal action against the Trust, said he was very concerned that two other patients had died under similar circumstances since his wife’s death.

Blackburn Coroner’s Court has previously heard how retired milkman Roy Wildman, who lived in Lime Street, Nelson, died in May after it took two days for staff in A&E to inform cancer doctors of his arrival when it should have been done immediately.

Another inquest heard that Shirley Banks, 67, who lived in Constable Avenue, Burnley died within a few days of Mrs McDonald.

She had been diagnosed with cancer of the oesophagus and was undergoing chemotherapy when she was taken to hospital as an emergency admission. She died on New Year’s Eve.

Blackburn coroner Michael Singleton said he would be making a report to East Lancashire NHS Hospitals Trust relating to the triage of patients suffering from cancer, as he believed there remained a risk of further fatalities following an inquest into Mrs Banks’s death.

Mr McDonald said: “I was told this would never, ever happen again, because procedures are now in place.”

Chris Pearson, Chief Nurse at East Lancashire Hospitals NHS Trust said: “We are very sorry about Mr McDonald’s loss and our sympathies remain with him.

“We have met with Mr McDonald regarding the care his wife received at the Trust and the issues that he has raised with us are not the same as those he has indicated.

“A number of actions have and are being implemented to ensure the issues Mr McDonald raised with us do not happen again - this includes education and change of procedures within the Emergency Department so patients like Mrs McDonald are recognised and highlighted early for IV antibiotic treatment.”

This article is courtesy of the Lancashire Telegraph.

How much am I owed for my medical negligence case?

Every healthcare provider on the planet has a duty to fulfil. Whether performing a complex surgical procedure or a routine dental exam, they are expected to treat their patients with the best care possible in accordance to their own abilities and widely accepted medical practice standards. Failing to do so is a breach of duty known as medical (or clinical) negligence.

When medical negligence occurs, the patient is owed monetary compensation. However, before this is awarded, the following three factors must be demonstrated:

• Medical / clinical negligence
• Causation (i.e., a link between the negligence and the resulting complications)
• Damages

Assuming that medical negligence has, indeed, taken place, and that this can be linked to damages suffered on behalf of the plaintiff, then you may well have a bona fide medical negligence suit on your hands. Knowing that you have a case is one thing, but how does one go about determining how much they are owed?

The answer—as you might have guessed—is complicated. This is the territory of solicitors. They examine the case and come up with a figure that is based upon their own calculations and (perhaps more importantly) prior precedent. If courts have awarded a certain amount in the past for a similar case, then there’s reason to expect that a similar amount could be awarded again.

Of course, the defendant’s solicitors are aware of precedent as well. They also know that the number of medical negligence claims in the UK have risen by 80% since 2008. If this is a clear-cut case of medical negligence, then they’ll probably push to settle out of court—perhaps for slightly less than precedent dictates. If the defendant accepts, compensation changes hands and the case is settled without the rigmarole of a drawn-out court case.

Calculating medical negligence compensation

So let’s move on to the calculation. A typical medical negligence suit will take the following two types of damages into account to calculate the amount of compensation owed:

General damages

Operating Theatre (PD)General damages are the most tangible damages in a medical negligence case, but they’re also the most difficult to attach a price tag to. What is the market value of a limb? How much is a person’s wellbeing really worth? We’re naturally reluctant to set a price on an individual’s life or health—it seems petty. However, this is precisely what needs to happen if compensation is going to be determined.

Suffice it to say, the general damages calculated in a medical negligence suit are going to depend on the severity of the injury that was sustained as a result of the malpractice as well as the pain that accompanies it. In so many words, the general damages reflect the pain and suffering that the patient endured.

As mentioned earlier, the amount of compensation likely to be awarded depends to a large extent on legal precedent. If you would like an approximation of roughly how much you could expect to be awarded, the best thing you can do is review previous cases that are similar to your own. This is, at least, where your solicitor will begin. However, if they feel that there are extenuating circumstances or further complications in your case, then they may well push for a higher figure.

Special damages

The word ‘special’ brings the abstract to mind, and many people understandably assume that special damages are more difficult to nail down and calculate. As it turns out, the opposite is the case, and special damages (which are sometimes referred to as economic damages) can be calculated with relative ease.

This is the economic damages that the person endured as a result of the injury. Any extra money that they were forced to spend as a result of the clinical negligence is lumped into this category. With that in mind, special damages can include the following:

• Earnings lost because the person could not work during their extended recovery period.
• Potential earnings lost because the person is no longer capable of carrying out their former occupation.
• Travel expenses incurred travelling because of the injury or malpractice (e.g., travel to another hospital).

Putting it all together

If you can prove that medical negligence did occur, then you may well be entitled to compensation for damages as outlined above. However, as you can see, coming up with an exact figure is beyond complicated. That’s why it’s important to contact a solicitor that specialises in medical negligence cases as early in the process as possible.

This article is courtesy of Olivia Brean, writing on a freelance basis for Mintons UK, a law firm whose first priority is to ensure that clients understand how the law works and what they can expect when they look to make clinical negligence claims.

£6.7m award to boy whose life was ruined by ‘devastating’ errors at Portsmouth hospital

A young boy who received catastrophic brain damage due to mistakes made by a Portsmouth hospital has been given a settlement worth more than £6.7m.

At the age of four, the boy suffered devastating brain injuries after staff at St Mary’s Hospital in Milton failed to act quickly enough to spot that he had a serious medical condition.

As a result, he had a cardiac arrest which led to brain damage and left him with severe disabilities.

The child, now aged 12, and whose identity has been protected by a court order, has no independent movements, is reliant on carers 24 hours a day and can only communicate through eye moments and the use of specialist technology.

Lawyers from BL Claims Solicitors pursued a clinical negligence claim on his behalf, alleging there were delays in performing a chest x-ray to diagnose that the boy had a condition called congenital diaphragmatic hernia.

The condition is caused by the failure of the diaphragm to fuse properly while the child is developing in the womb, allowing organs to move from the abdomen up into the chest cavity.

It was also argued that there were delays in inserting a nasogastric tube to decompress the stomach and a delay in summoning specialists when he went into cardiac arrest.

On July 14 in the Royal Courts of Justice, His Honour Judge Moloney QC, sitting as a judge in the High Court, approved a settlement negotiated between the claimant and Portsmouth Hospitals NHS Trust, which runs St Mary’s.

The settlement, estimated to exceed £6.7m, is made up of a lump sum of £3.2m plus annual payments of £265,000 a year until the claimant is aged 18 and then £305,000 a year for the rest of his life.

The money will be used to pay for the specialist care the claimant needs.

Dr John White, of BL Claims Solicitors, acting for the family, said: ‘This significant settlement reflects the devastating consequences of the mistakes made at St Mary’s Hospital and the severity of the claimant’s injuries.

‘If the condition of congenital diaphragmatic hernia had been diagnosed more promptly and staff had acted more quickly to deal with its implications, the outcome would have been very different.

‘The claimant needs round-the-clock care for the rest of his life and this settlement will help to ensure that he receives that.’

The boy’s parents said in a statement: ‘The very tragic part is that if the doctors had listened or taken any notice of what we kept saying as parents then this event would have been easily avoided.

‘Instead our son’s life has been completely ruined. He will never go to his school prom, enjoy playing on the beach or have fun kicking a football around with his friends.

‘One message we would like give to all parents is please always trust your instincts when your child is unwell.

‘If you believe that something is wrong then insist that action is taken by the doctors.

‘Nothing will ever make up for the life that has been taken away from him.

‘Our son and his enormous daily battle are an inspiration to all that know or have met him. This is an absolute tragedy caused by mistakes that should never have happened.’

The claimant was seen at St Mary’s in the early hours of September 30, 2006 after developing pains in his stomach and admitted at around 7am.

Following an original diagnosis, he went into cardiac arrest and was transferred to Southampton General Hospital following being stabalised and underwent surgery to repair the defect in his diaphragm.

The case was initially defended by the trust and had been due to go to trial to decide on the issue of liability in the autumn of 2012.

Judgment was entered in the claimant’s favour in October 2012, and the hearing on July 14 approved the amount of the settlement negotiated between the parties.

This article is courtesy of Portsmouth News.

Clinical negligence claims up 18%

Clinical negligence claims went up almost 18% over the last year despite changes to the law banning no-win no-fee agreements , an NHS review has found.

The spike was due to new solicitors entering the market to chase lucrative no-win no-fee claims before new rules came into effect in April 2013, the NHS Litigation Authority said.

Its annual review found that the number of claims in England went up by 1,816 between March 2013 and March this year - from 10,129 to 11,945.

The body has set aside a provisional £10.5 billion to settle claims which have been notified to the NHS but are not yet resolved and claims that have been resolved over the last financial year.

A spokeswoman said: "A rise in clinical negligence claims by almost 18% over the last year is primarily due to new claimant solicitor firms entering the clinical negligence market and as a result of receiving significant numbers of claims funded by historic no-win no-fee agreements signed before April 1 2013.

"Until March 2013, these agreements allowed claimant solicitors to charge up to a 100% success fee on their costs if a claim was successful.

"Now, claimant solicitors can no longer double their fees. However, the NHS is still receiving claims funded under old style no-win no-fee agreements signed before the law changed."

The NHS Litigation Authority, which indemnifies NHS organisations in England against claims, said that almost half (44%) of clinical claims where care had not been negligent were settled without paying damages, saving the NHS over £1.3 billion.

It also boasted a further £75 million in savings over the last year achieved by "robustly challenging excessive costs" charged by claimant solicitors.

Chief executive Catherine Dixon said: "It is our priority to ensure that when a patient has been harmed by the NHS they are, to the extent we are able, compensated for the harm they suffer.

"However, we experienced a significant rise in the number of claims being brought against the NHS where the care provided was not negligent.

"We were able to resolve these claims without payment, saving the NHS more than £1.3 billion."

This article is courtesy of Yahoo! News.

Grandmother wins £250,000 after botched hip operation left her leg pointing in the wrong direction

A grandmother who was left with her foot pointing 90 degrees in the wrong direction after a surgeon botched her hip operation has won £250,000 in damages.

Brenda Gorst developed a life-threatening infection and her leg was left shorter following blunders by a consultant at Abergele Hospital in North Wales.

Since her surgery in October 2007, the 73-year-old has endured six major operations to try to correct the problem and faces further procedures to rebuild her femur, hip and pelvis.

Mrs Gorst began suffering aches and pains in her hips in her 60s, and was recommended for hip replacement surgery.

She said: 'When I woke up from the operation, my leg was black and I was in agony. It took some time to realise something had gone badly wrong.'

The pain and swelling in her leg did not subside, and a revision operation was proposed.

She said: 'After the second operation, it became obvious that my right foot had started to point east. They tried to put my foot straight using sandbags.'

During one of the operations, Mrs Gorst, who now lives in Newton-le-Willows in Merseyside but used to live in Rhos-on-Sea in Wales, contracted an infection.

She claims that when she was sent for a second opinion and an X-ray, the new consultant was visibly shocked at what he saw.

Mrs Gorst said: 'I was in acute pain, the bruising and swelling was terrible and my leg was twisted in entirely the wrong direction.

'At that point they thought I had a flesh-eating disease. They told me I could be dead in three days. It wasn’t a flesh-eating disease, but it was still a vicious infection.

'My leg is virtually useless. I’ve gone from someone who was active to someone who is unable to do many of the things I used to take for granted.'

The hip replacement has since been removed but her leg bone is now fused to the pelvis, shortening Mrs Gorst’s leg by four inches.

She won damages following a legal battle with the Betsi Cadwaladr University Health Board.

Her lawyer Daniel Lee, of Slater & Gordon, said: 'Her mobility and activity are dramatically reduced as a result of the operation which was meant to give her a new lease of life.'

Professor Matthew Makin, executive medical director at Betsi Cadwaladr University Health Board, apologised for the distress caused to Mrs Gorst.

He said: 'On behalf of the health board, I am sorry that the care Mrs Gorst received at the time fell short of the standards she deserved.

'We aim to provide excellent care and have looked carefully at this case to make sure mistakes are learned from and cannot be repeated.'

This article is courtesy of the Daily Mail.

Hospital apologises for failings after schoolboy died on his 13th birthday

Hospital bosses have apologised for their care of a talented young footballer who died of meningitis on his 13th birthday.

Thomas Smith, from Hednesford, near Cannock, was nicknamed Ronnie by friends who compared his soccer skills to those of Cristiano Ronaldo.

But he fell ill with meningitis during a family holiday to Wales – and died on May 29 last year after being given paracetemol instead of antibiotics.

A coroner yesterday condemned Prince Charles Hospital in Merthyr Tydfil over the error as the teenager’s inquest ended.

Christopher Woolley said: “The failure to administer antibiotics amounts to a gross failure of care.

“Antibiotics should have been given without delay. Where meningitis is suspected it’s essential antibiotics are given immediately. The need for basic medical attention in this form was obvious. The risk of giving unnecessary medication was outweighed by the risk of Thomas having bacterial meningitis.”

Mr Woolley said he was also concerned about “further deaths” at Prince Charles Hospital and ordered a report.

But he said it was not a case of “neglect” and, even if Thomas had been given antibiotics, he would probably have still died.

Mr Woolley recorded a conclusion of death by natural causes.

The inquest earlier heard Thomas complained of six tell-tale signs of meningitis, including a headache and a stiff neck.

But doctors failed to diagnose the illness and did not give him antibiotics for more than four hours.

He was seen by Dr Kwong-Tou Yip and consultant paediatrician Dr Ezzat Afifi, who both gave him paracetomal.

The inquest heard both Dr Yip and Dr Afifi had “failed in their duty of care” for Thomas.

After the hearing at Cardiff Coroner’s Court, Cwm Taf University Health Board – which runs the hospital – said it accepted it had failed the teenager.

Chief executive Allison Williams said: “I would like to extend my sincere apologies to the parents of Thomas George Smith for the loss of their son. This is an extremely sad case and we deeply regret there were failings in the care Thomas received at Prince Charles Hospital.

“As noted during the inquest, the Health Board undertook an investigation which identified lessons learned and recommendations to ensure this will never happen again. A number of changes have already been made to address the failings identified.

“Following the conclusion of the inquest, the Health Board will now consider the coroner’s findings and continue to implement the changes required to address any failings in service.”

This article is courtesy of the Birmingham Mail.

Care of the elderly – a medical negligence time bomb?

A report commissioned by Age UK and the Royal College of Surgeons, ‘Access all Ages’, which is a follow up to their initial one in 2012, reveals that many elderly people are being refused elective surgery despite such surgery being key to their quality of life. In another report, recent figures suggest that 30% of patients are responsible for 70% of NHS spending.
 
The majority are people with long term health issues, many of whom are elderly with multiple, chronic conditions. Both reports suggest that many of our elderly are caught in a downward spiral of health deterioration with the health and social care systems either unwilling or unable to help them. The management of chronic illness, in particular, presents both the NHS and the social care system with a dilemma – how to prevent the ‘revolving door’ syndrome where patients are admitted to hospital, stay beyond when is medically required, are discharged home where care is inadequate and then find themselves back in hospital.
 
NHS heading for crisis
 
The Health Select Committee (chaired by Dr Sarah Wollaston) has warned about the impending crisis facing people with long term conditions, many of whom are elderly, if NHS budget cuts start to bite before a proper community care programme is implemented. As medical improvements enable those with chronic conditions to live longer, including the elderly, there is an acknowledgement that the way in which their care is managed will have to change if the NHS is not to be overwhelmed. The statistics are alarming: 70% of NHS spending is taken up by approximately 30% of patients who represent around two thirds of outpatients and take up 77% of hospital beds.  In addition, if surgery is being refused on the basis of age then even more elderly patients will find themselves in hospital when they can no longer cope at home.
 
Budget cuts threaten community health care
 
Although the motivation behind the launch of the Better Care Fund next year is to improve the cooperation between the health and social care systems in order to deliver a more joined up service, with the intention of keeping individuals with long term conditions out of hospital, the debate about funding continues to rage. The Select Committee estimates that at least £4bn will need to be found by 2016 to cope with the rising tide of those with chronic conditions – which helps to give a sense of perspective to what the £3.8bn Better Care Fund will be under pressure to deliver. The social care system does not have adequate funds to cope with the number of elderly people relying on their services at the moment, let alone in the future, which is why so many are ending up unnecessarily in the health system.
 
More collaboration – and more funding
 
The general consensus is that greater collaboration is needed between GPs, community health services and specialists in deciding a care plan for each individual. This is encapsulated by NHS England initiative ‘The House of Care’ which is designed as a framework to enhance the quality of life for the elderly and those with long term health issues. At its core is the need to monitor and implement best practice so that the latest clinical improvements can be put into practice; and the implementation of individual care programmes so that patients and their carers learn to manage their own condition more effectively. However, as with all these initiatives, the devil is in the funding – with ongoing cut backs and shortfalls, all these ideas will struggle to take root.
 
This article is courtesy of Jeanette Whyman, a specialist medical negligence solicitor with Wright Hassall comments “Care of the elderly is reaching crisis point: there is much talk and a multitude of proposed initiatives – but all run up against the same problem – who’s going to pay for it? Improvements in how people are physically looked after in hospital are welcome but this doesn’t solve the issue of where to send them once they no longer need hospital treatment. The problem is only set to get worse: if greater longevity is not matched by a will to ensure that quality of life is maintained through surgery and proper back-up then the outlook, for those facing old age, is pretty miserable. The likelihood of the health service facing increased numbers of medical negligence claims from elderly people and their relatives is virtually guaranteed”

'Black box' tracks errors in Toronto operating room

A “black box” installed in a Toronto operating room earlier this year has found that surgical teams are making the vast majority of their errors during the same two steps surgery after surgery.

Now researchers are looking at how to reduce those mistakes and prevent similar slips in the future.

Dr. Teodor Grantcharov, who developed the operating room black box compares using the technology to learning how to golf.

“Usually we can’t appreciate our performance while we’re in the middle of the operation,” said Grantcharov, a surgeon at St. Michael’s Hospital. “You swing and you think you’ve done a great job and someone video records it and shows you how you’ve done and obviously there are so many things to improve.”

Three microphones and three cameras began recording all of Grantcharov’s surgeries at the end of April as part of the black box project. Two of the cameras film the operating room, while a third internal camera records what’s happening inside the patient’s body while the surgeon and his team perform minimally invasive surgeries. The video and audio collected is then analyzed by a team, who look at surgical techniques, the surgical team’s communication and how they work together, and what kind of hazards exist in the operating room.

An initial pilot recorded about 80 gastric bypass surgeries and found that 86 per cent of the errors were made during just two steps: suturing and grafting the bowel.

That information was very valuable, Grantcharov said, and a team is now working on creating educational tools based on the data.

“If we know where the errors happen, then we will know what to do to avoid them in the future.”

There are small errors in every surgery, but that doesn’t mean that a patient’s safety is compromised, Grantcharov said. An error could be something as simple as a surgeon losing sight for a split second of a needle while suturing.

“Error, for us, is minimal, the smallest deviation from the perfect course,” he explained. “In the vast majority of cases, it is nothing. The patient will recover perfectly and nobody will ever know that there has been an error.”

Traditionally, however, error hasn’t been discussed in surgical culture, Grantcharov said. He’s hoping having black boxes in operating rooms will help promote a safety culture similar to that of the aviation industry, where people can speak freely about mistakes and point out things they believe could be done better.

“I think it’s acceptable, it’s just human, that we make errors,” he said. “It’s not acceptable not to do anything about it.”

Reducing slips in the operating room will not only make surgery safer for patients, but it will help cut costs, too, said Grantcharov. If surgeons make fewer errors, they’ll be able to operate more quickly and do more surgeries in a given time period. Preventing errors will also cut back on adverse events — injuries that need to be fixed — which also saves money, he explained.

Currently St. Michael’s is the only hospital with the black box technology, but other hospitals have said they, too, want to try out the cameras and microphones. Grantcharov hopes black boxes will be installed in some European hospitals soon, and wants the technology to eventually spread to a wide variety of procedures in operating rooms around the world.

So far, surgical teams at St. Michael’s have been open to the black box project, and they see the potential learning and safety benefits, Grantcharov said. But there is potential for the technology to be used in less positive ways, such as recording evidence for use in malpractice lawsuits.

“If we choose to use it as a tool to place blame and to point fingers at surgeons for litigation, I think this will never take off,” Grantcharov said.

“It’s important that we use this constructively, that we use this to improve our selves, to become better surgeons and safer surgeons and improve the outcome for out patients. If we use it in this direction, I think this will change the way we practice.” 

This article is courtesy of the Brampton Guardian.

Cosmetic surgery compensation claims - Infographic

The original source of this information about cosmetic surgery compensation claims was Blackwater Law.

QMC error sees £8m payout for Nottingham boy

A seven-year-old boy who was left with "catastrophic" brain damage after his birth will receive £8m compensation.

The youngster, who cannot walk or speak, was left with "profound lifelong" cerebral palsy after doctors at Nottingham's Queen's Medical Centre mishandled attempts to resuscitate him.

London's High Court heard there were deficiencies in the way medics dealt with the boy's birth in November 2006.

The hospital trust publicly apologised and said changes had since been made.

Mr Justice Lewis said the boy, from Nottingham, had "suffered complications" following his birth after which hospital staff "failed to provide adequate treatment for him".

He said the settlement would meet the boy's lifetime needs.

Dedication commended
 
"There were deficiencies in the way the hospital dealt with the need to resuscitate him," the judge added.

He said the hospital had "since taken steps to correct what went wrong so other families won't be faced with the same difficulties".

Lawyers representing the boy's family said he has acute learning difficulties and needs a team of carers.

The case had reached the High Court after his parents sought approval for a compensation package to be met by the hospital's managers, the Nottingham University Hospitals NHS Trust, which admitted liability.

The trust's barrister, William Wraight, publicly apologised for the errors.

"There were deficiencies in the provision of resuscitation on that day but these problems have been identified and corrected," he said.

The trust's chief executive Peter Homa added: "Whilst no amount of money can compensate for, nor undo the harm and distress the family have experienced as a result of this tragic case, we hope this settlement provides the family with financial security for the future."

Mr Justice Lewis said he was satisfied the settlement was "just and appropriate" and commended the boy's parents and family for their dedication to his care.

This article is courtesy of BBC News.

USA Military Care, a pattern of errors but not scrutiny

Jessica Zeppa, five months pregnant, the wife of a soldier, showed up four times at Reynolds Army Community Hospital here in pain, weak, barely able to swallow and fighting a fever. The last time, she declared that she was not leaving until she could get warm.

Without reviewing her file, nurses sent her home anyway, with an appointment to see an oral surgeon to extract her wisdom teeth.

Mrs. Zeppa returned the next day, in an ambulance. She was airlifted to a civilian hospital, where despite relentless efforts to save her and her baby, she suffered a miscarriage and died on Oct. 22, 2010, of complications from severe sepsis, a bodywide infection. Medical experts hired by her family said later that because she was young and otherwise healthy, she most likely would have survived had the medical staff at Reynolds properly diagnosed and treated her.

“She was 21 years old,” her mother, Shelley Amonett, said. “They let this happen. This is what I want to know: Why did they let it slip? Why?”

The hospital doesn’t know, either.

Since 2001, the Defense Department has required military hospitals to conduct safety investigations when patients unexpectedly die or suffer severe injury. The object is to expose and fix systemic errors, often in the most routine procedures, that can have disastrous consequences for the quality of care. Yet there is no evidence of such an inquiry into Mrs. Zeppa’s death.

The Zeppa case is emblematic of persistent lapses in protecting patients that emerged from an examination by The New York Times of the nation’s military hospitals, the hub of a sprawling medical network — entirely separate from the scandal-plagued veterans system — that cares for the 1.6 million active-duty service members and their families.

Internal documents obtained by The Times depict a system in which scrutiny is sporadic and avoidable errors are chronic.

As in the Zeppa case, records indicate that the mandated safety investigations often go undone: From 2011 to 2013, medical workers reported 239 unexpected deaths, but only 100 inquiries were forwarded to the Pentagon’s patient-safety center, where analysts recommend how to improve care. Cases involving permanent harm often remained unexamined as well.

At the same time, by several measures considered crucial barometers of patient safety, the military system has consistently had higher than expected rates of harm and complications in two central parts of its business — maternity care and surgery.

More than 50,000 babies are born at military hospitals each year, and they are twice as likely to be injured during delivery as newborns nationwide, the most recent statistics show. And their mothers were more likely to hemorrhage after childbirth than mothers at civilian hospitals, according to a 2012 analysis conducted for the Pentagon.

In surgery, half of the system’s 16 largest hospitals had higher than expected rates of complications over a recent 12-month period, the American College of Surgeons found last year. Four of the busiest hospitals have performed poorly on that metric year after year.

Surgical Complications
 
Half of the military’s largest hospitals performed worse than established benchmarks in categories such as infections or improperly done procedures, according to a review from the American College of Surgeons. The college compared each hospital with an expected rate of complications based on the procedures it performed and what kinds of patients it served from July 2012 to June 2013.

Little known beyond the confines of the military community, the Pentagon’s medical system has recently been pushed into the spotlight. In late May, Defense Secretary Chuck Hagel ordered a review of all military hospitals, saying he wanted to determine if they had the same problems that have shaken the veterans system.

Mr. Hagel said the review would study not just access to treatment, the focus of investigations at the veterans hospitals, but also quality of care and patient safety — issues that The Times has been looking at, and asking the Pentagon about, for months.

Defense Department health officials say their hospitals deliver treatment that is as good as or better than civilian care, while giving military doctors and nurses the experience they may one day need on the battlefield. In interviews, they described their patient-safety system as evolving but robust, even if regulations are not always followed to the letter.

“We strive to be a perfect system, but we are not a perfect system, and we know it,” said Dr. Jonathan Woodson, assistant secretary of defense for health affairs. He added, “We must learn from our mistakes and take corrective actions to prevent them from reoccurring.”

The Times’s examination, based on Pentagon studies, court records, analyses of thousands of pages of data, and interviews with current and former military health officials and workers, indicates that the military lags behind many civilian hospital systems in protecting patients from harm. The reasons, military doctors and nurses said, are rooted in a compartmentalized system of leadership, a culture of interservice secrecy and an overall failure to make patient safety a top priority.

The investigations of unforeseen deaths or permanent harm, called root-cause analyses, are widely regarded as a centerpiece of efforts to make care safer. Asked about the military’s missing inquiries, Dr. James P. Bagian, director of the University of Michigan’s Center for Healthcare Engineering and Patient Safety, said, “If in fact unexpected deaths were reported and ignored, there would appear to be no good answer for that except that someone is sleeping at the switch.”

Avoidable errors can and do occur at the best of hospitals. But the military’s reports show a steady stream of the sort of mistakes that patient-safety programs are designed to prevent.

The most common errors are strikingly prosaic — the unread file, the unheeded distress call, the doctor on one floor not talking to the doctor on another. But there are also these, sprinkled through the Pentagon’s 2011 and 2012 patient-safety reports:

A viable fetus died after a surgeon operated on the wrong part of the mother’s body.

A 41-year-old woman’s healthy thyroid gland was removed because someone else’s biopsy result had been recorded on her chart.

A 54-year-old retired officer suffered acute kidney failure and permanent hearing loss after an incorrect dose of chemotherapy.

Such treatment failures are known as “never events,” because they are potentially so grave — and so preventable. They do not happen frequently. But a persistent rate of such mistakes can indicate broader patterns of slipshod care.

Malpractice suits can also be a rough indicator of risk. From 2006 to 2010, the government paid an annual average of more than $100 million in military malpractice claims from surgical, maternity and neonatal care, records show. It would be paying far more if not for one salient reality of military health care: Active-duty service members are required to use military hospitals and clinics, but unlike the other patients, they may not sue. If they could, the Congressional Budget Office estimated in 2010, the military’s paid claims would triple.

Experience in civilian hospitals, and in the veterans system, has shown that stricter procedures and more sophisticated surveillance can limit errors, sometimes markedly. Among some in the military network, concerns about patient safety are longstanding, if rarely acknowledged in public. But calls for change have consistently foundered in the convoluted bureaucracy.

The military health system is split into three major branches, with the Army, Navy and Air Force each controlling its own hospitals and clinics. The Pentagon’s Defense Health Agency also runs the Walter Reed National Military Medical Center and Fort Belvoir Community Hospital, both outside Washington. Any systemwide change involves a carefully calibrated consensus of three equally ranked surgeons general, as well as the Defense Health Agency. Dr. Woodson, who oversees the system, cannot order the surgeons general to act. He can only recommend.

Progress can be glacial: In 2007, for example, the military started rewriting regulations for handling events that harmed or endangered patients. It finished only last October. Several former Pentagon officials said embarrassing statistics were often filtered out, glossed over or buried amid larger data sets before they reached senior health leaders. Two measures used in major civilian hospitals to monitor quality of care — rates of death and readmission, adjusted for seriousness of illness — are simply not tracked.

“The patient-safety system is broken,” Dr. Mary Lopez, a former staff officer for health policy and services under the Army surgeon general, said in an interview.

“It has no teeth,” she added. “Reports are submitted, but patient-safety offices have no authority. People rarely talk to each other. It’s ‘I have my territory, and nobody is going to encroach on my territory.’ ”

In an internal report in 2011, the Pentagon’s patient-safety analysts offered this succinct conclusion about military health care: “Harm rate — unknown.”

Lethal Medical Errors
Katie Guill checked into the hospital at Fort Leonard Wood, Mo., on Christmas morning 2008, expecting to give birth to a healthy baby boy. She left with an infant so severely brain-damaged that at age 5, he cannot crawl, speak or swallow. He must be fed through a pump.

In the three hours before a doctor finally delivered their son, Justen, by cesarean section, the Guills said in a lawsuit, a monitor sounded 32 alerts that the baby’s heart rate had slowed. The suit also said the nurse had warned the doctor on duty four times that the baby was in distress before he arrived at Mrs. Guill’s bedside. The family’s lawyer, Laurie Higginbotham, said she believed the outcome might have been different had the nurse alerted the doctor’s superiors.

The government settled the case for $10 million, but Pentagon records give no indication that a safety investigation was conducted. Nor is there a record of any action taken against the doctors and nurses involved. A spokeswoman said the Defense Department was legally prohibited from discussing how any specific case had been handled.

“We don’t know what went wrong because no one has ever told us,” said Justen’s father, Jon Guill, a former Army mechanic who served 18 months in Iraq.

The Pentagon had promised to look harder at such mistakes.

In 1999, the Institute of Medicine estimated that medical errors killed between 44,000 and 98,000 patients at hospitals nationwide every year. Those numbers — which most experts now consider an undercount — stunned the medical community and kick-started an aggressive effort to protect patients from accidental harm.

Simply penalizing doctors and nurses for malpractice had failed, the institute concluded, because most mistakes arose from weak procedures, not reckless individuals. It called for new strategies, including mandating that medical workers report mistakes and hospitals investigate and correct the lapses that allowed them to occur.

The Pentagon embraced the report, requiring that military treatment facilities produce a written root-cause analysis within 45 days in all cases of unexpected serious injury or death. “Such events are called ‘sentinel’ because they signal the need for immediate investigation and response,” the regulations state. Military hospitals must also report sentinel events to the Joint Commission, an independent accreditation group. Specialists at the Pentagon’s patient-safety center, created in 2001, were told to review the analyses and recommend changes.

Certainly it is difficult to assess such a divided and diverse medical system, with 56 hospitals, domestic and overseas, ranging from the flagship, Walter Reed, to a hospital in the middle of the Mojave Desert with an average of three inpatients a day. They serve not only young, typically healthy active-duty families but also the longest-serving military retirees and their families. Even so, experts say safety reviews can reveal trouble spots as well as patterns of error across an entire system.

But annual patient-safety reports and other internal documents obtained by The Times show that, for years, the center’s analysts have often found themselves staring into darkness.

As early as 2003, a Pentagon audit noted that medical workers had reported 80 cases of severe harm or death in the preceding 12 months, but that only 32 root-cause analyses had been forwarded to the center. Five years later, another audit concluded, “Unfortunately, R.C.A.s are used relatively infrequently.”

The most recent safety reports paint a similar — and more detailed — picture.

In 2011, 50 unexpected deaths were identified but only 25 analyses submitted.

The next year, the center was informed of 110 deaths but received only 44 root-cause analyses.

And in 2013, the report documented 79 deaths and 31 root-cause analyses.

The safety audits also make clear that of the root-cause analyses that are done, the cases of clearest-cut blame — the “never events” — make up the largest group. Even so, the reports show, those mistakes have not subsided.

In 2010, the safety center had sounded a hopeful note. For the first time in nine years, it said, “all surgeries and procedures were performed on the right person.” But the next year, the center said surgeons were still performing the wrong procedure or operating on the wrong patient or part of the body at an “alarming” rate. It called for intensive hospital audits to lower it.

Last year, medical workers reported virtually the same number of errors. They also reported more cases in which medical devices were inadvertently left inside patients than they had four years earlier.

In a written response to questions from The Times, the Pentagon acknowledged that it had taken a decade before the reporting system was “operational and collecting data in a uniform manner.” Not until last October, for instance, were the Army, Navy and Air Force required to identify the facilities where patients were severely harmed or died.

Senior defense health officials say the missing investigations are not a true measure of attention paid to serious harm. “There are many mechanisms for reviewing significant adverse events,” the Pentagon said in a statement.

In an interview, Dr. Woodson said a different kind of inquiry that hospitals conduct — a risk-management investigation — might have gotten to the bottom of what went wrong. Those investigations focus on whether individual doctors or nurses provided substandard care for which the government could be liable.

“I feel confident that we capture and investigate the overwhelming majority of these adverse events,” Dr. Woodson said. “The key is having a robust system and that you pick all of them up and make the changes that are appropriate.”

But military regulations specifically require both types of inquiries, and for good reason, patient-safety experts say: Otherwise, even catastrophic errors — mistakes for which no one is specifically to blame, but that instead result from systemic lapses — can be easily swept under the rug.

Busy but Troubled Hospital

Womack Army Medical Center in Fort Bragg, N.C., is one of the system’s largest, busiest hospitals. Lately it has also been one of its more troubled.

For three years, it has had a higher-than-average rate of surgical complications, and in March it suspended all elective surgery for two days after inspectors found problems with surgical infection controls. Then last month, the Army ousted the hospital’s leadership after the unexpected deaths of two patients in their 20s: a mother of three who had undergone a low-risk surgical procedure and a soldier who had been sent home from the emergency room.

That same day, Defense Secretary Hagel ordered the systemwide review.

At Womack and elsewhere, some doctors and nurses complain that no one listens to their safety warnings. One staff member interviewed by The Times recalled filing roughly 50 reports of safety problems since 2007, each time providing contact information. Only once, the worker said, did a supervisor respond, and then only to express irritation at the fusillade of filings.

“It is an exercise in futility,” said the staff member, speaking on condition of anonymity for fear of job repercussions. “We can jump up and down and shake our fists, but nothing changes.”

Dr. Lopez, the former Army staff officer, said some hospital officials had told her that they felt pressure from superiors to focus on budget cutting and efficiency, while patient safety got a cursory nod.

Across the system, Pentagon officials cite some signs of progress. In 2008, for instance, the composite rate of 11 types of harm — like pressure ulcers and postoperative hemorrhages — was more than twice that of civilian hospitals with a similar patient mix. Last year, it was better than the civilian average, although the Pentagon’s own analysts warned results might be skewed by reporting problems.

Even so, the most recent patient-safety report complained of a general lack of headway in building a safer system. While the number of reports of harm has varied over the last decade, and “there are certainly pockets of excellence,” it noted, “The leading trends remain consistent.” What was needed was “enterprisewide change.”

The operating room has been one focus of concern.

The study by the American College of Surgeons found that in addition to Womack, three other major hospitals — Madigan Army Medical Center in Tacoma, Wash.; San Antonio Military Medical Center in Texas; and Portsmouth Naval Hospital in Virginia — have had high rates of surgical complications for two or three years in a row. Five of the eight cited last year had also been flagged repeatedly for high rates of infection related to surgery.

Dr. Brian Lein, the Army’s deputy surgeon general, said hospitals that fell below the benchmark “have dug deep into the data to find the actual issues and are addressing those issues.” The Navy echoed that response.

With so many young military families, the system’s maternity wards are among its busiest. Pentagon officials say maternity care is top notch, and on some leading measures of safe childbirth, the military hospitals indeed compare well with their civilian counterparts.

For example, their rate of infant mortality was equal to or lower than that of civilian hospitals in the most recent data analyzed by the National Perinatal Information Center, a private group with a Pentagon contract. In routine vaginal births, the rate of injury to the mother has consistently been below the national average.

On other measures, though, the military system lags.

In 40 percent of the military hospitals, mothers were significantly more likely to suffer hemorrhages after birth than at the civilian hospitals tracked by the perinatal center. The hemorrhages can lead to hysterectomies or even death. About 2,500 cases were recorded in military hospitals in 2012, roughly 760 more than if the military had met the civilian benchmark.

If doctors used instruments such as forceps to assist the delivery, mothers in military hospitals were about 15 percent more likely to be injured than mothers nationally, the most recent data shows.

One of the broadest measures of safe childbirth is the rate of injuries to babies, ranging from cerebral hemorrhages to small cuts on babies’ scalps. From 2009 to 2011, according to a Times analysis, the rate at military hospitals was twice the national average.

In 2011, nearly five in every 1,000 babies born at military hospitals suffered some kind of birth trauma. Had the military met the national average, 107 newborns would have been injured instead of 239.

Dr. Woodson said the military is looking “closely at areas where we are falling short” on maternity care and measuring its hospitals against civilian ones in order to improve.

Ordeal Giving Birth

When Stephanie King felt labor pains on Easter in 2004, she drove to Reynolds Army Community Hospital. She was 34, a kindergarten teacher and mother of two. Her husband, an Army artillery officer, was serving six months in Iraq, so her 12-year-old son accompanied her to the hospital.

Her contractions were coming every three to five minutes, court records show, but a resident on the maternity ward refused to admit her, saying her cervix was not sufficiently dilated. The attending physician agreed.

Mrs. King spent the next two hours in the hospital’s first-floor lobby, waiting room, cafeteria and bathroom. She wanted to seek care at the civilian hospital 15 minutes away, but her military insurance would not cover it. In the midst of her ordeal, her husband called from Baghdad to say he was being airlifted to Germany after an emergency appendectomy.

Finally, fearful that she would deliver on the bathroom floor, she took the elevator back to maternity. A nurse greeted her with what seemed to be a joke: " ‘Oh, Mrs. King, you are back,’ ” she recalled the nurse saying. " ‘You don’t look as good as you did when you first came in.’ ”

Any amusement vanished, however, when staff members realized not only that Mrs. King was about to give birth — but that her file showed she carried a common but symptomless strain of group B streptococcus bacteria. Women in labor must be given antibiotics at least an hour before delivering to avoid transmitting the infection to their newborns, hospital workers later testified.

Dawson King was born just 42 minutes after his mother was admitted. Doctors soon determined that he had contracted an infection, and warned Mrs. King that the only effective medication could cause deafness. Four months later, when Dawson did not turn his head when his parents walked into the room, it became clear that he was profoundly deaf.

Only three years later, after Mrs. King filed a malpractice claim, was the case discussed at Reynolds, court records indicate. The attending physician said a risk-management meeting was held to ensure that the standard of care was met. No report was written, and the doctors and the nurse emerged with spotless licenses.

That result that would appear to point to a lapse in hospital procedures. But both the resident and the nurse testified that they had never attended a meeting at Reynolds to discuss what had gone wrong.

“That’s the disturbing part,” Mrs. King said, while Dawson draped himself over the arm of his father’s chair, looking at photos of himself as a 1-year-old, his head swathed in bandages from surgery for cochlear implants. “Doesn’t the hospital want to know what happened?”

Mrs. King believes that she knows: Her file documented her history of strep B infection and the fact that her second child had been born after a 90-minute labor. And the resident testified that he could not recall if he had read her record before declining to admit her. “It boils down to they did not even read my records,” Mrs. King said.

The government settled the Kings’ case in 2009 for $300,000. Mrs. King describes her son, now an engaging, soccer-playing 10-year-old, as “a success story.” Still, she said, “it was devastating how easily it could have been prevented.”

The Kings’ malpractice payout was relatively modest. An examination of court records and Pentagon data from Reynolds and seven other hospitals turned up dozens of settlements, ranging from $30,000 to $10 million, but no record of a root-cause analysis.

Flying Blind on Safety

On Dec. 7, 2011, Dr. Woodson summoned senior health officials to a Pentagon conference room to discuss the safety of military hospitals and clinics. The deputy surgeons general of the Army, Navy and Air Force were present. So was Dr. Ronald Wyatt, then the director of the Pentagon’s patient-safety center.

According to accounts from several people familiar with the session, Dr. Wyatt suggested that the center was flying blind. Without knowing the facilities’ death and harm rates, as well as the rates of paid malpractice claims, he argued, his staff was unable to identify safety lapses — much less correct them.

And serious lapses did exist, he said, for “this system, like many systems throughout the country, hurts and kills people every day.” Angered, Dr. Richard A. Stone, then the Army’s deputy surgeon general, shot back: “I demand that you retract those statements.”

Dr. Warren Lockette, the deputy assistant secretary for clinical policy, stood by Dr. Wyatt. “What I am hearing is you are all satisfied with the status quo,” he said. Dr. Woodson tried to defuse the tension with a compromise: He would recommend that the services turn over the data.

Asked about the meeting, Dr. Stone said that data should be shared but that Dr. Wyatt’s statement was “inflammatory.”

The standoff was typical, former Defense Department officials say, of a continual tug-of-war between health care officials in the Pentagon and in the individual armed services that has crippled efforts to improve patient safety. In such a politicized system, data can be a weapon.

“Why should the Army safety system want to play with D.O.D., because then I have less control over my data, less control over my kingdom, and potentially D.O.D. is going to tell me what to do?” said Dr. Lopez, the former Army health policy officer.

To keep Pentagon overseers at bay, surgeons general have often relied on a provision in a 1986 law, known as 1102, that prohibits disclosure of medical quality assurance records. Originally adopted to ensure that medical personnel could be honestly evaluated without fear of publicity, former department officials say, it became a tool to withhold a broad range of data from the Pentagon itself.

And from the public. In response to Freedom of Information Act requests, the Pentagon provided The Times with thousands of pages of data. But much information was redacted and some reports were withheld as confidential, including all reports by the Navy’s inspector general on patient safety or quality of care. By contrast, the veterans system posts the reports on a public website.

While infighting held the military’s patient-safety programs in check, some civilian hospital systems cut death and harm rates. At Ascension Health and Kaiser Permanente, two of the nation’s biggest nonprofit systems, investigating workers’ reports was just a first step. The companies also analyze a vast array of data, including readmission and mortality rates.

The death rate is a broad measure that cannot pinpoint where care falls short. Nonetheless, “mortality is the mother of all outcomes,” said Ascension’s chief medical officer, Dr. Ziad Haydar. Measured over time, a death rate, adjusted for seriousness of illness, can show if a medical system is getting more or less safe.

Officials at Ascension and Kaiser say their hospitals have gotten safer. Ascension estimates that its safety measures have saved 1,500 lives in the last six years. Doug Bonacum, Kaiser’s vice president for quality, safety and resource management, said the mortality rate at Kaiser’s 38 hospitals had fallen more than 30 percent in the last four years.

The Pentagon does not routinely track the total number of deaths, and has no method yet to calculate adjusted rates. “Frankly it is not yet a helpful measure for assessing quality,” Dr. Woodson said.

As a result, why some military hospitals report many more deaths than others with similar numbers of patients is a mystery. The Army, Navy and Air Force each said that hospitals with above-average death rates treated older, sicker patients, but did not produce statistical evidence to verify that.

When it comes to gauging the frequency of errors, systems like the military’s that rely on workers to report harm have been shown invariably to undercount. Kaiser has long used another technique, called the Global Trigger Tool, that winnows out indicators of poor care from randomly selected patient files.

Using that technique, researchers concluded in 2010 that one-third of patients at three major civilian hospitals had suffered some kind of harm. A similar pilot study by the Pentagon last year found that nearly half the patients whose files were reviewed at a major military hospital had been harmed at least once. The study suggested 99 percent of harm at that hospital was not reported by medical workers.

Communiation Breakdowns

When patients die unexpectedly, medical workers often cite a breakdown in communications.

That appears to be the overriding explanation for the delay three and a half years ago in treating Jessica Zeppa, a case that ended with a $1.25 million malpractice settlement. But that is only conjecture. Her death was apparently never subjected to a patient-safety examination.

Mrs. Zeppa had been married and living at Fort Sill for only nine months when her husband, James, an air defense tactician, was deployed to the United Arab Emirates. She had their two dogs and a cat for company. And to her delight, she was pregnant. “She was just out of this world about it,” said her mother, Mrs. Amonett.

But five months into the pregnancy, Mrs. Zeppa became so weak that she struggled to climb stairs. She complained that it hurt to drink or swallow.

At Reynolds Army Community Hospital, she was initially treated in the obstetrics and gynecology unit, where an ear infection was diagnosed and she was prescribed antibiotics and ear drops, court records show. Three days later, she arrived at the emergency room at 4:51 a.m.; she was prescribed a painkiller for erupting wisdom teeth.

She returned that same evening and was found to have a fever, a fast pulse and an elevated white blood cell count — possible symptoms of serious infection. The emergency room physician, Dr. Raul Young-Rodriguez, treated her intravenously with fluids and a powerful antibiotic and sent her upstairs to the obstetrics and gynecology unit for possible admission.

No one called the obstetrician on duty to inform her of the patient’s condition, the Zeppas’ lawyers, Heather Mitchell and Steven Clark, said in court papers. Nor did the obstetrician, Dr. Debra A. Carson, call Dr. Young-Rodriguez.

As far as she knew, Dr. Carson later testified, Mrs. Zeppa was there for “obstetrical clearance.” She examined her and sent her home within 20 minutes. Mrs. Amonett said she protested but was told her daughter could not be admitted if the fetus was not in distress.

Dr. Carson testified that she had not checked the military’s electronic record system for Mrs. Zeppa’s history, because all too often she had found patient records missing. In Mrs. Zeppa’s case, lab results were posted less than an hour after she left. Had she seen them, Dr. Carson testified, “I would more than likely have admitted her.”

Two days later, Mrs. Zeppa returned to the obstetrics and gynecology unit, insisting that she would not leave until she got warm. A nurse midwife, Kelly West, treated her with intravenous fluids and again released her. Ms. West testified that she did not review Mrs. Zeppa’s records either.

The next afternoon, with Mrs. Zeppa struggling to breathe, her mother summoned an ambulance. Mrs. Zeppa was airlifted the following morning to a civilian hospital in Oklahoma City, where she miscarried 10 days later and died the next month.

Five months after that, facing a malpractice claim, Reynolds officials conducted a risk-management investigation. In an interview, Ms. West, the nurse, said she had been cleared of violating the standard of care. Nor is there any public indication that the two doctors were penalized. They did not respond to requests for comment.

Medical experts hired by the family’s lawyers said that had the Fort Sill doctors recognized that Mrs. Zeppa was suffering from septic shock and immediately hospitalized and aggressively treated her, she and the baby probably would have survived. The government’s experts disagreed, noting that civilian doctors had been unable to save Mrs. Zeppa in five weeks of treatment.

Justice Department lawyers called Mrs. Zeppa’s death a “unique and tragic case, but not a case of bad and actionable medicine.” Beyond the risk-management assessment, they said, they knew of no other inquiry. Ms. West also said she knew of none in the roughly eight months before she left Fort Sill.

That left any missteps that contributed to Mrs. Zeppa’s death unexplained.

“She was really pretty, and she had a really big heart,” James Zeppa, Mrs. Zeppa’s husband, said. Now, he said, he no longer trusts military medicine.

Mrs. Zeppa’s father, Mike Amonett, had one thing to say about the Fort Sill hospital: “I just want that place shut down.”

This article is courtesy of The New York Times.

Reducing medical mistakes

All the talk around patient safety is finally showing signs of translating into action as three different initiatives came together in the same week. On 24 June, Jeremy Hunt formally launched the ‘Sign up to Safety’ initiative, announced in March (blogs passim) which is a voluntary scheme designed to reduce medical mistakes by a third. At the same time, NHS Choices launched its new microsite wherein a range of data relating to patient safety has been published; and a review into the reporting culture of the NHS, led by Sir Robert Francis QC, was announced.  Since the Mid-Staffordshire scandal, patient safety has been top of the political agenda with promises to reform the system coming thick and fast; at last these pledges now seem to be bearing fruit.
 
1. Sign up to Safety
 
This campaign is being led by Sir David Dalton, Chief Executive of Salford Royal Hospital and, so far, 12 NHS Trusts have signed up, developing plans to show how they will reduce ‘avoidable’ harm such as infections caused by lack of cleanliness, medication errors and blood clots.  In other words, by looking after the small stuff, the big stuff has a better chance of looking after itself. This may seem like common sense but, as shown by the scandals following in the wake of Mid-Staffs, some hospitals have had to be reminded what they’re actually there to do and the proper environment in which to do it. So many medical negligence and NHS compensation cases that I see stem from a relatively minor cause or event which, had it been picked up and addressed early on, should not have caused the sort of harm that would lead to a claim. The fact that each ‘Sign up to Safety’ plan has to be reviewed and signed off by the NHS Litigation Authority - which then helps to finance the implementation of the plan - says it all.
 
2. Patient safety data
 
In the quest for openness, the NHS Choices microsite publishes a range of data enabling members of the public to assess their local hospital against seven criteria:  CQC standards; ‘open and honest’ patient safety reporting; safe staffing levels; infection control and cleanliness; assessment for risk of blood clots; responding to patient safety alerts; and, finally, whether staff would recommend their hospital to friends and family. Of course there is the small issue of data interpretation and missing data which skews the results for some hospitals but, overall, this must be a worthwhile project. The latest set of data to be added is that of actual staffing levels - down to ward level - along with planned staffing levels. Naturally this data does need to be viewed with a degree of caution while it beds in – for instance a fifth of NHS acute trusts are rated ‘poor’ for reporting on patient safety. Taken at face value, this sets alarms ringing but is it that patient welfare is seriously compromised in this number of hospitals or is it that they are behind the curve in data collection, management and interpretation? Publishing the data will be an excellent incentive for hospitals to get their acts together.
 
3. The latest Francis Review
 
Sir Robert Francis QC, who led the inquiry into the Stafford Hospital scandal, will be heading up in independent review: ‘An Independent Review into creating an open and honest reporting culture in the NHS’. His objective is to ensure that staff faced with a serious breach of patient safety do not feel prevented in any way from reporting their concerns or to feel that taking such action will compromise their employment.
 
4. Conclusion
 
Some hospitals have already discovered the benefits of gathering and interpreting data to help them improve on services delivered. University Hospitals Trust Birmingham has been using data to drive patient care for some time, helping to uncover trends and promoting best practice across disciplines. Hospitals are large, complex organisms and the level of specialisation means that departments can operate different sets of standards under the same roof. As I’ve said in the past, by being upfront, open and honest about shortcomings and medical mistakes, hospitals can avoid negligence claims being lodged and lay the foundations for future best practice.

This article is courtesy of Jeanette Whyman, a Medical Negligence Claims Solicitor with Wright Hassall; she has successfully secured NHS Compensation for many victims of medical negligence.

NHS Scotland's blunder payouts reach £186m as country's top doctor brands care crisis in hospitals a 'car crash'

The “disgraceful” total has increased sharply in the last two years, from £25.3million in 2011-12 to £35.5million in 2013-14.

Patients’ groups have slammed NHS Scotland for spending more than £186million on compensation claims and legal settlements in the last five years.

The “disgraceful” total has increased sharply in the last two years, from £25.3million in 2011-12 to £35.5million in 2013-14.

Claims from employees have also sky-rocketed – from £1.1million in 2009-10 to £3.4million last year.

This news comes as Scotland’s top doctor branded our crisis-hit NHS a “car crash” and blamed politicians for the disaster.

Dr Brian Keighley, head of the BMA in Scotland, warned that the future of the health service hangs in the balance because of unacceptable queues at A&E and delays in vital cancer treatments.

Dr Jean Turner, executive director of Scotland Patients Association, echoed his concerns and described the sharp rise in compensation payouts as “extremely worrying”.

She said: “These figures are disgraceful. It seems there are more and more people coming forward with complaints about the level of care they receive.

“It is a huge amount of money that could be better spent on drugs, treatment and patient care.

“There are problems with staffing and everyone working is under extreme pressure. This means they are much more liable to make mistakes.”

Scottish Labour’s health spokesman Neil Findlay accused Health Secretary Alex Neil of “jumping from one crisis to the next”.

He said: “Our NHS staff do a terrific job but we know there is huge concern about resources and staffing.

“If that is contributing to our negligence costs, then Alex Neil has to understand he has a problem. “

The Scottish Government said: “Scotland is recognised as having some of the safest hospitals in the world.

“However, it is absolutely essential that when clinical negligence claims do arise, NHS boards learn from these cases and put steps in place to ensure that there is no repeat in future.”

This article is courtesy of the Daily Record.

GPs who fail to spot cancer could be named

GPs with a poor record in spotting signs of cancer could be publicly named under new government plans.

Health Secretary Jeremy Hunt wants to expose doctors whose failure to spot cancer may delay sending patients for potentially life-saving scans.

Labour called the idea "desperate" and accused Mr Hunt of attacking doctors.

The Royal College of GPs said it would be a "crude" system and one that could lead to GPs sending people to specialists indiscriminately.

It warned this could result in flooding hospitals with healthy people.

The move is part of the health secretary's plans to make the NHS more transparent.

Ranking GP surgeries on how quickly they spot cases of cancer and refer patients for treatment is among proposals being considered.

The information could eventually be published on the NHS website.

This follows a survey for the NHS last year, which suggested that more than a quarter of people eventually diagnosed with cancer had seen their GP at least three times before being sent to a specialist.

"We need to do much better," the health secretary told the Mail on Sunday.

"Cancer diagnosis levels around the country vary significantly and we must do much more to improve both the level of diagnosis and to bring those GP practices with poor referral rates up to the standards of the best."

Doctors found to be missing too many cases of cancer or with patients who are forced to make repeated visits before being referred for tests would be marked with a red flag.

A patient's story
Susan has a sister with terminal cancer.

She told the BBC: "My sister was first told she had a prolapsed womb, then piles. "By the time she was seen by an oncologist, eight months had elapsed.

"She has terminal squamous cell anal cancer - completely curable if caught early enough. "She is 62, and now has a few months to live. "One of the classic mistakes the GP made was to diagnose anal bleeding as piles. It wasn't - it was the tumour.

"This doctor has condemned my sister to a year, so far, of terrible suffering and a death which is too dreadful to contemplate, when she could have been completely cured. 

"Prognosis is something like 96% complete cure if treated early." Susan believes her sister's GP should be "named and shamed" but thinks each case should be considered on an individual basis.

"As a retired teacher, I know what being continually maligned, judged, overlooked and overloaded can do to morale and performance," she added.

Those found with quick referral times for patients would be given a green rating.

Shadow health minister Jamie Reed said the government would not take responsibility for problems it had created in the NHS.

"David Cameron wasted billions on a re-organisation nobody wanted and left cancer patients waiting longer for tests and treatment. He should be ashamed of his own record - not attacking doctors," he said.

"This government has thrown away progress made on cancer care. It is proof of why the Tories can't be trusted with the NHS."

'Clog up clinics'
Dr Chaand Nagpaul, chair of the British Medical Association general practitioners committee, said to name and shame doctors would not help patients.

He said it was important to understand why there were delays in making referrals and to raise public awareness about the signs and symptoms of cancer.

"We need to look at the whole system and if you simply name and shame GPs, the tendency would be for us to refer everyone," he told the BBC.

"And that can be a disadvantage because if we clog up hospital outpatient clinics, we'll get patients who need to see their specialist actually having to wait longer."

Conservative MP Sarah Wollaston, a former GP who chairs the Commons health select committee, said the government needed to be careful not to wrongly label people as "poor doctors".

She too warned there was a danger of automatically referring everyone to a specialist and creating "impossibly long waiting lists", which could harm those needing to be seen urgently.

Rising demand
Dr Wollaston added that she could not see how GPs could maintain current levels of service amid rising demand without a funding injection.

"The NHS budget has been protected in line with background inflation but that does not keep pace with inflation in health costs from rising demand and demographic changes," she said.

"I don't want to see any reduction in services. I would like to see further improvements and that will require an increase in funding."

Dr Wollaston joined Conservative former health secretary Stephen Dorrell and Lib Dem former health minister Paul Burstow in calling for increased funding for the NHS.

Mr Burstow warned that the NHS was in danger of collapse within five years without extra spending. He said the health service needed an extra £15bn over that period in order to function properly.

Mr Dorrell said he would be ashamed if the government failed to increase NHS funding at a time when the economy was growing.

"I am in favour of the government not denying what 5,000 years of history tells us is true, which is that every time a society gets richer it spends a rising share of its income on looking after the sick and the vulnerable," he told The Observer.