Woman loses schizophrenia misdiagnosis claim

A 46-year-old woman’s damages action over allegedly having been misdiagnosed with schizophrenia, after she complained of being sexually abused by a sibling, has been dismissed.

High Court President Mr Justice Nicholas Kearns found that the claim by the woman, who cannot be identified for legal reasons, is statute-barred.

She claimed she spent 11 years in a 13-year span effectively locked up at a Dublin psychiatric hospital following an alleged misdiagnosis by a doctor attached to the facility. The woman was first admitted in the early 1980s, when she was in her mid-teens.

Mr Justice Kearns heard that while she was an in-patient at the facility, she claimed to have been sexually abused by a male trainee nurse and a religious brother she had grown to trust. That abuse was the subject of separate legal proceedings.

In the 1990s, the woman had come under the care of another doctor who told her she did not suffer from any mental illness. Arising out of the alleged misdiagnosis, she brought a negligence claim, seeking damages, against the hospital and the doctor.

The claims were denied and, in a pre-trial motion, the defendants argued her claim should be struck out because it was statute-barred. She had first known about the alleged misdiagnosis in the late 1990s, a solicitor instructed in 2002, but had not initiated her claim until 2009 — which the defendants said was outside the statutory-allowed time period of three years.

Mr Justice Kearns, in a written judgment, said that with great regret he was dismissing the woman’s case after finding it was statute-barred.

He said she was an honest and entirely reliable witness and had shown herself to be a remarkably resilient individual.

In her evidence, the woman claimed that from a young age she had been sexually abused on a continuous basis by an older brother. Judge Kearns said that, in her mid-teens, she reported the abuse to a neighbour but had not been believed. As a result, she attempted to take her own life and had been admitted to hospital.

She had eventually been taken to the psychiatric hospital where she met with the doctor who, she alleged, misdiagnosed her condition. 

This article is courtesy of the Irish Examiner.

Girl, 7, dies after hospital sends her away for third time following repeated misdiagnosis

A seven year-old girl died just two hours after being sent away from hospital for the third time following repeated misdiagnosis.

Little Evelyn Smith was rushed to A&E by her parents last September after falling ill suddenly, suffering from a soaring temperature and vomiting.

The youngster was misdiagnosed and sent away from hospital and her GP's surgery.

After her terrified mum Helen took her daughter to see a doctor for the third time in three days, just two hours after being sent away, Evelyn collapsed and died at her home in Warwick.

An inquest into her death discovered she had died from a rare bacterial infection - Bacterial trachetis - as a result of croup.

Even though a doctor had diagnosed Evelyn with viral croup, they failed to recognise the deadly bacterial complications she was suffering from - and a coroner has ruled that Evelyn's death could have been prevented if she had been diagnosed and treated correctly.

Devastated Helen said: "Losing Evelyn has been totally devastating for us.

"She deteriorated so rapidly, even a year on it doesn't seem real. She was such a happy girl - a real livewire, so happy and always smiling. She's left a huge hole in our family.

"We took her to hospital three times in three days - we repeatedly returned for medical help and that should have been a red flag to doctors and nurses.

"I don't want any other parent to go through what we have been through. Trust your instincts - if you think there's something seriously wrong, insist that it is looked at."

The inquest, at Warwick Coroner's Court, head that Evelyn had woken up with a mild headache on Wednesday, September 11, 2013 - but still went to school that day and her ballet class in the evening. But at 2am the next morning, she came bursting into her parents' bedroom shouting that she couldn't breathe.

Helen rushed her to Warwick Hospital Accident and Emergency department, where her temperature had rocketed to almost 40 degrees. She was examined by a doctor, and despite vomiting, discharged a couple of hours later, with advice on how to reduce her temperature.

But when her daughter was still burning up on Friday morning, Helen took Evelyn to her GP surgery, where she was examined by a nurse, who prescribed her penicillin for her inflamed tonsils.

That afternoon her temperature had risen again and Helen took her back to the GP. Their Dr Susan Martin diagnosed her with oxygen saturations and moderate croup and made an appointment for her to come back on Monday.

Tragically, Evelyn collapsed and died at home two hours later leaving Helen to desperately give CPR while she waited for an ambulance to arrive.

At the inquest assistant coroner for Warwickshire, Dr Richard Brittain said: "Evelyn Mary Smith died from the consequences of both a viral and bacterial infection of her upper respiratory tract.

"Her family sought medical attention three times in the days leading up to her death. There were missed opportunities to diagnose and treat Evelyn appropriately on each of these occasions. However, I am satisfied that none of these consultations were neglectful.

Based on the evidence heard, it is more likely than not that her death was preventable; although it has not been possible to conclude the causative impact of each missed opportunity."

Among those giving evidence at the inquest was Warwick Hospital doctor Emma Sexton, who first examined Evelyn on the day before she died. She said the child did not appear to be displaying signs of respiratory distress and her cough sounded like a viral croup, although she had looked for symptoms of other conditions as well.

Dr Sexton added: "Bacterial trachetis is a very rare condition that arises from these symptoms. I had not come across it prior to this case."

Haidee Vedy, head of medical negligence at Alsters Kelley LLP, who represented the family at the inquest said: "Evelyn's death was an absolutely tragedy and should never have happened.

"Her family put their trust in the hands of the hospital and their local GP surgery and it would appear from the evidence presented at the inquest that they were badly let down.

"We will now be investigating further to find out what more could have been done to prevent Evelyn's death."

But at the inquest, Helen Lancaster, the director of nursing, who had commissioned an independent report which highlighted missed opportunities, did accept its findings.

Dr John Omany, medical director for NHS England (Arden, Herefordshire and Worcestershire), who oversee GPs' surgeries, accepted "opportunities were missed" to identify the seriousness of Evelyn's condition.

Mr Omany added: "We have looked into the circumstances of this tragic case and our priority now is to ensure that GPs across our area are aware of the dangers of croup.

"We have also contacted all GP surgeries and all out-of-hours providers to highlight some of the difficulties in identifying seriously ill children, and encourage them to refer children for specialist care as a precaution as soon as they have any concerns.

Evelyn's parents Helen and Trevor are now trying to raise awareness about complications of croup and encouraging parents to trust their instincts.

Helen Smith said: "When she first showed signs of being unwell, it was just a mild headache and that's something that all parents encounter.

"But when she burst into our room at 2am saying 'I can't breathe', that was when we knew it was something serious so I took her straight to A&E.

"We feel bitterly disappointed in the trust for failing to acknowledge that changes in their practice needed to be made to reduce the risk of deaths in the future.

"This has added unnecessary distress to our family. This was compounded by a total absence of any aftercare once we had left the hospital after Evelyn died."

This article is courtesy of the Mirror.

Mother in £400,000 deep vein thrombosis compensation

A mother is to be awarded £400,000 in compensation for a hospital's failures around her developing a potentially fatal blood clot after giving birth.

The 41-year-old will receive the payout to settle her medical negligence case against South Eastern Health Trust.

She developed deep vein thrombosis in her leg after her first child was born at the Ulster Hospital in June 2009.

She had claimed that as a pregnant woman over the age of 35, she was not properly assessed as being at risk.

Further alleged negligence occurred when she first went to accident and emergency following the birth with symptoms of deep vein thrombosis.

“It's affected every aspect of my life, I just feel old before my time”

With women more likely to develop blood clots of this type during pregnancy, they can be fatal if they dislodge and travel to the lungs.

The woman, who has since had two more children, said she was told it was probably just her hormones.

Liability was admitted before the level of compensation was agreed.

Speaking after the case was settled at the High Court in Belfast, the civil servant said there had been an ongoing traumatic impact.

"It's affected every aspect of my life, I just feel old before my time," she said.

"I find walking for more than 10-15 minutes very hard to endure and stairs are incredibly difficult."

She had to undergo further operations following the births of her other two children due to associated issues.

"If it had clotted again I could have lost my leg," she added.

As well as her medication, the woman says she now has to wear tight stockings "the equivalent of a wetsuit".

This article is courtesy of BBC News.

Misdiagnosis: can it be remedied?

Misdiagnosis -- diagnosing a patient with the wrong disease, or with the correct one too late -- continues to be a big issue for healthcare providers. And despite continuing efforts to reduce it, the problem isn't going to go away any time soon.

The major areas of misdiagnosis -- commonly defined as "a diagnosis that is missed, wrong, or delayed, as detected by some subsequent definitive test or finding" -- have not changed much over the years, according to Mark Graber, MD, founder and president of the Society to Improve Diagnosis in Medicine (SIDM), who coined the definition in 2005.

For example, when looking at malpractice cases filed over the years involving diagnostic errors, "there is consistency: it's ... cancers; cardiovascular disease -- including strokes, heart attacks, and aortic dissections; and infections, things like sepsis and meningitis," he told MedPage Today.

Graber, a senior fellow at RTI International in Rockville, Md., and his colleagues who are interested in reducing misdiagnosis founded SIDM 3 years ago to draw more attention to the issue. They are hoping that the society's work -- plus an upcoming report on misdiagnosis from the Institute of Medicine -- will bring more interest from the medical community.

Autopsy Findings
In trying to better define the problem, autopsies are one place researchers turn to as a source of misdiagnosis data. In 2002, the Agency for Healthcare Research and Quality published an evidence report by Kaveh G. Shojania, MD, of the University of California San Francisco, and colleagues entitled "The Autopsy as an Outcome and Performance Measure."

"At the level of the individual clinician, the chance that autopsy will reveal important unsuspected diagnoses in a given case remains significant," the authors noted. "Moreover, clinicians do not seem able to predict the cases in which such findings are likely to occur."

Furthermore, they said, "While 'newer diseases' such as opportunistic infections have undoubtedly increased in recent decades and account for some of the misdiagnoses detected at autopsy, clinically missed diagnoses continue to include common diagnoses such as myocardial infarction, pulmonary embolism, bowel perforation, and other common conditions."

Another study, published in 2000 by Franco Salomon, MD, of the University of Zurich in Switzerland, and colleagues, looked at diagnosis errors found via autopsy in 1972, 1982, and 1992. The researchers looked at results from 100 autopsies done in each of the 3 years studied.

The authors found that the rate of diagnostic errors was halved over the course of the study (1972, 30%; 1982, 18%; 1992, 14%; P=0.007); however, the types of diagnoses missed continued to fall into the same categories: cardiovascular diseases, cancers, and infectious diseases, with the drop in error rate mainly due to improved detection of cardiovascular disease.

A third autopsy study, published in 2008 by Fabio Tavora, MD, of the University of Maryland in Baltimore, and colleagues, looked at autopsy results from three different institutions from 1999 through 2006. The investigators found that "the largest single category of unsuspected diagnoses was pulmonary embolism followed by undiagnosed infections, including cases of tuberculosis; cardiovascular disease, including undiagnosed coronary artery disease and ruptured aneurysms; and ... undiagnosed neoplasms."

That study found an overall rate of major discrepancy involving the cause of death was 17.2%. Although misdiagnosis rates in general are hard to quantify, "we think in general practice it's at least 10%," Graber said.

Many of the most common diagnosis errors haven't changed much in frequency over the years because "the symptoms are nonspecific, and too often the presentation is atypical," he continued. Besides, he added, "Diagnosis is hard!"

Physician-Reported Errors

Studies of physician-reported diagnosis errors are less common, though there are a few. A 2009 study by Gordon Schiff, MD, then of Cook County Hospital in Chicago, and colleagues, analyzed 583 physician-reported errors from hospitals nationwide and found that the five most common misdiagnoses were:

• Pulmonary embolism (4.5% of all misdiagnoses)
• Drug reaction or overdose (4.5%)
• Lung cancer (3.9%)
• Colorectal cancer (3.3%)
• Acute coronary syndrome (3.1%)

Breast cancer, stroke (including hemorrhage), congestive heart failure, fracture (various types), and abscess (various locations) rounded out the top 10 misdiagnoses.

Types of misdiagnosis are very specialty-dependent, noted Paul Epner, executive vice-president of SIDM. "If you ask emergency physicians for their top 10 list, it's different than if you ask pediatricians [about] their top 10 list," he said, adding that "many of the most common diagnoses are where we find the highest number of diagnostic errors."

In the emergency department (ED), "the common diagnoses we miss are heart attacks, acute coronary syndrome ... ruptured abdominal aneurysms, and appendicitis," said David Meyers, MD, an emergency physician at Sinai Hospital in Baltimore. "We also miss strokes."

For the most part, the most common ED misdiagnoses haven't changed much since the first monographs were published on them 30 years ago, Meyers told MedPage Today.

There are a few exceptions, however. "We're not missing as many ectopic pregnancies, because the ease of getting pregnancy tests has improved over the years," said Meyers. "Also, childhood meningitis is very rare now -- [malpractice] claims in that area have gone down significantly because kids get vaccinated against the bugs that cause that disease."

And some newer entries have crept up as well. "Sepsis and necrotizing fasciitis were very rare in previous eras, and, now, it's not that they're common, but they're much more common than they used to be," Meyers added. "Maybe by overprescribing antibiotics, we're allowing stronger bacteria to take over and become more prevalent. We're also able to keep sicker people alive longer with drugs that compromise their immune system."

Error Types Vary
In addition to specific diseases, misdiagnosis errors also vary by the type of error. For example, in the radiology department, there are two types of errors, Leonard Berlin, MD, of Skokie Hospital in Illinois, explained at an Aug. 7 meeting in Washington on diagnostic error in healthcare.

First, there are perceptual errors (not seeing what is on the film), which account for 70% of errors; and then there are cognitive errors (seeing what's on the film but attaching minimal significance to it), which make up the other 30%, Berlin said.

Perceptual errors come in several different types, he continued. One is called "satisfaction of search," meaning that once an abnormality is found on a radiology film, physicians become less likely to find additional abnormalities.

In one study involving 25 residents and staff members at an Ohio hospital, participants had a 75% chance of seeing one abnormality on a film that only contained one, and a 75% chance of seeing at least one abnormality on a film that contained multiple abnormalities, but the chance of seeing a second or third one dropped to around 40%.

Another type of error is known as an "alliterative" error, in which physicians who see a particular finding listed on previous radiology reports for a particular patient tend to make the same finding themselves, even when it is in error.

The overall rate of radiology errors is around 4% and has not changed greatly over the years, according to Berlin.

One barrier to improving misdiagnosis rates is that generally speaking, "physicians are lousy at reporting errors," Robert Trowbridge, MD, of the Maine Medical Center in Portland, said at the meeting, which was sponsored by the Institute of Medicine.

Part of the reason for that is the "blaming" culture of medicine, Michael Kanter, MD, medical director for quality and clinical analysis at Southern California Permanente Medical Group in Pasadena, Calif., said at the meeting.

Kanter is running a program to try to reduce missed follow-up opportunities at Kaiser facilities; his philosophy is that instead of focusing on who is to blame for a particular error, "you need to get the physicians engaged to fix that problem, so they need to feel comfortable in the process and cooperate."

Ideally, reducing misdiagnosis would start early in physicians' careers, Graber said. "We'd like to do things in medical education that will make doctors better diagnosticians. If they realize they make mistakes, they are less likely to make them."

To help achieve that goal the SIDM has established an education committee, and one of its major projects is to develop a consensus curriculum for medical students that will help them spot and reduce errors, he said.

This article is courtesy of Medpage Today.

Dad was not told his cancer had spread until day before he died

A patient was not told his cancer had spread until the day before he died, a new report reveals.

The case is one of three complaints about care delivered by Coventry and Warwickshire hospitals which have been probed by the Parliamentary and Health Service Ombudsman.

Yesterday, the ombudsman published a summary of its investigations for the first time to highlight cases concluded in February and March.

George Eliot Hospital in Nuneaton was investigated twice, and the trust in charge of University Hospital in Coventry once.

In one case bosses at George Eliot Hospital awarded compensation in relation to a male patient, referred to as Mr B, who had been diagnosed with prostate cancer.

The patient was admitted to the hospital when he became unwell and while there underwent a scan on his back.

The scan showed the prostate cancer had spread to his spine – but the patient was not told and Mr B was discharged home, growing more ill until he was eventually readmitted to hospital the following month.

It was only then that the patient and his family were informed that the cancer had spread.

Sadly Mr B died the next day.

His daughter later complained to the ombudsman about the lack of information, the fact her father’s pain was not managed properly in hospital and was not offered support to manage at home.

The ombudsman found in the daughter’s favour, ruling that the consultant in charge of Mr B’s care should have told him his cancer had spread before discharging him from hospital and that staff should have given the man better pain relief.

The ombudsman also found that Mr B should have been assessed for home care support.

The report says: “The fact that they did not do this meant Mr B was left without support when he needed it, which was distressing for his daughter to see. She now has to live with the fact that more should have been done for her father.”

The ombudsman also found the trust’s response to the complaint “inadequate”.

The trust has now acknowledged the failings in Mr B’s care and its handling of the complaint, paid the daughter £1,250 in compensation and drawn up an action plan for improvements.

In the second case, the ombudsman found doctors at George Eliot Hospital delayed acting on a patient’s low oxygen levels for as long as 12 days.

The patient, referred to as Mrs L, was admitted to the hospital at the end of 2011 for stroke rehabilitation and was discharged to a care home after a six-month stay.

She was readmitted to the hospital after five weeks and died a week later.

Her daughters complained the trust did not provide adequate care and that their mother was not in a fit state to be discharged, and complained that nurses did not administer oxygen properly.

The ombudsman found there was a 12-day delay in doctor’s taking action on Mrs L’s low oxygen levels, which the report says “fell so far below the applicable standards that it was a service failure”.

The ombudsman partly upheld the daughters’ complaint about doctors’ failure to treat Mrs L’s chest condition but found no other failings in the case of Mrs L.

Following the ombudsman’s final report, the trust wrote to the daughters to acknowledge the failing.

Kevin McGee, chief executive of George Eliot Hospital, said: “We welcome the publication of these complaints as we appreciate the need for transparency and to be held to account when mistakes are made.

“We have carried out thorough internal investigations and demonstrated to the Ombudsman that we have satisfactorily improved our procedures to avoid further similar problems."

The trust in charge of Coventry’s University Hospital has also been probed by the health service ombudsman.

The ombudsman found University Hospitals Coventry and Warwickshire NHS Trust, which also runs St Cross Hospital in Rugby, failed to properly assess a male patient before discharging him from hospital.

The man, referred to as Mr B, suffered heart failure along with other chronic illnesses and was left to go home in a taxi.

He was readmitted to hospital the same evening but sadly died the following day.

The patient’s son complained his father was too poorly to leave hospital. He believed this led to his father’s death.

The son was also unhappy that his father was left to get a taxi by himself and no-one contacted the family to let them know.

The ombudsman found medical records supported the trust’s response that Mr B was medically suitable for discharge.

But the report says “it found that the trust should have assessed Mr B’s social needs before he was sent home to make sure he could get home safely and had support in place.

“We upheld this aspect of the complaint,” it adds.

On the trust’s actions following the ombudsman’s findings, the report continues: “The trust agreed to acknowledge and apologise for not assessing Mr B’s social needs, and the distressing impact this had on his family.

“It also agreed to confirm what action it had taken to make sure that assessments were carried out in future.”

The Parliamentary and Health Service Ombudsman is the final step for people who want to complain about being treated unfairly or receiving poor service from the NHS in England, or a UK government department or agency. It investigated 2,199 cases in 2013/14 compared to 384 the previous financial year.

Andrew Hardy, chief executive officer at University Hospitals Coventry and Warwickshire NHS trust, said: “On this occasion the ombudsman agreed that the patient was suitable for discharge but that the trust should have assessed their social needs before being sent home.

“The trust has further apologised to the family and provided them with a copy of our action plan in line with the recommendations made by the ombudsman.”

This article is courtesy of the Coventry Telegraph.

The most devastating failures by public services revealed

A woman whose husband died hours after one of England’s biggest NHS hospitals missed several chances to diagnose his fatal condition was given just £2,000 in compensation, according to files published today, that highlight “devastating” failures by public services.

University Hospitals Birmingham NHS Foundation Trust mistakenly said the man was suffering from a blood clot when he actually had a tear in the blood vessel from his heart to his body, which resulted in his death. The case is one of 81 anonymised summaries of complaints - 58 healthcare and 23 Parliamentary cases – revealed by the Parliamentary and Health Service Ombudsman so “valuable lessons” can be learned.

It is the first time the public can search the watchdog’s website to see the range of complaints it deals with. The Ombudsman investigated 2,199 cases in 2013/14 compared to 384 the previous year.

A geographical breakdown of healthcare cases showed that the East of England had the highest number of complaints dealt with between February and March this year with a total of 15. West Midlands’ hospitals received 13 complaints, East Midlands had seven and London six. The North East and South West had the fewest complaints with just one each.

The report said that regarding Mr F’s case in Birmingham, his symptoms were not typical for his condition, which made it more difficult to diagnose. It concluded: “However, the Trust missed several chances to correctly diagnose Mr F, including taking account of his previous medical history and unusual symptoms, carrying out a chest X-ray and misreporting a scan. While we cannot say that Mr F’s death was avoidable (because his condition was very serious), it is clear that the Trust lost the chance to give him treatment that might have prevented or delayed his death.”

In another case two Trusts failed to communicate effectively when a woman suffering from bladder cancer had her wishes for surgery ignored leading the watchdog to describe the last six months of her life as “wasted just waiting”. It concluded an “unacceptable delay” had taken place as Bedford Hospital NHS Trust and Cambridge University Hospitals NHS Foundation Trust could not agree on the best course of treatment, although the Ombudsman concluded that due to Mrs C’s condition the delays did not affect her prognosis.

The Trusts paid £1,750 compensation to Mrs C’s family “for the upset and frustration they experienced as a result of the poor care given to their mother”.

The Home Office was among the Government departments criticised in the files after a teenage asylum seeker spent 10 years in the UK without legal status waiting for his case to be decided. The 17-year-old applied for permission to stay with his mother, who had fled from her home country, but was told he would need to reapply after he turned 18 and was left in administrative limbo.

Repeated requests from his MP were also ignored by the Home Office until a decade had passed. He eventually received an apology from the Home Office and £7,500 compensation for the “serious mistakes” that occurred.

Ombudsman Dame Julie Mellor said: “Our investigations highlight the devastating impact that failures in public services can have on the lives of individuals and their families. We are modernising the way we do things so we can help more people with their complaints and to help bodies in jurisdiction learn from mistakes other organisations have made to help them decide what action to improve their services.

“We will continue to work with others including consumer groups, public service regulators and Parliament, using the insight from our casework to help others make a real difference in public sector complaint handling and improve services.”

A Department of Health spokeswoman said: “Listening to patients is one of the best ways to improve standards and we welcome this increased transparency around complaints. Hospitals should make sure patients, their families and carers know how to complain - including displaying information on the complaints system in every ward.”

Other cases

A woman in her late 90s died on the toilet at home in her granddaughter’s arms after doctor discharged her without examining her abdomen. She had perforated diverticulitis. Miss T complained to East Kent Hospitals University NHS Foundation Trust and said that the Trust had failed to provide an adequate response regarding her grandmother’s death and had tried to ‘cover up’ its failings, but no evidence was found to support the claim. The Ombudsman recommended the Trust pay £500 in compensation for Miss T's distress.

Harrogate and District NHS Foundation Trust failed to spot signs of sepsis when Mr L arrived at hospital in the early hours of the morning from his care home. After being seen in A&E he was assessed as being safe for discharge back to his care home with some antibiotics, but died the following day. His wife complained to the Trust and said that if her husband had been admitted for treatment, he might have survived. The Ombudsman said because Mr L’s full diagnosis was not known, it could not say for certain whether his death was preventable. The Trust apologised and paid Mrs L compensation of £2,000.

A patient’s death from deep-vein thrombosis could have been avoided after a London GP practice failed to properly investigate her symptoms or refer her for further tests over two appointments.  At both appointments the GPs who saw Mrs G failed to follow the relevant medical guidelines on investigating a possible DVT. They also failed to investigate her symptoms properly. The practice provided Mrs G’s relatives with evidence of what they had learnt from the complaint and apologised to them.

This article is courtesy of the Independent.

The battle against misdiagnosis

Still, after years of taking a back seat to problems such as medication and treatment errors, misdiagnosis is getting attention. In 2011 my research colleague in projects on misdiagnosis Mark Graber founded the nonprofit Society to Improve Diagnosis in Medicine, which now holds an annual medical conference on diagnostic error. More recently, the Institute of Medicine, an influential branch of the National Academy of Sciences that advises Congress on health care, is preparing a comprehensive action plan and hosting its second major expert meeting on Thursday and Friday. In 2015 the IOM will issue a report on misdiagnosis.

Meantime, the U.S. health-care community can take steps to reduce the problem.

The first is to improve communication between physicians and patients. Patients tend to be the best source of information for making a diagnosis, but often essential doctor-patient interactions such as history and examination are rushed, leading to poor decisions. As new forms of diagnostic and information technologies are implemented, managing large amounts of data will become increasingly complex, and physicians could become more vulnerable to misdiagnosis.

This problem exists in large part because time pressures and paperwork often force physicians to spend more time struggling to get reimbursed than talking with patients. Extra hours spent pursuing a correct diagnosis are not compensated beyond the payment for the visit, an already small sum for primary-care physicians.

Patients can't solve this problem, but insurers can streamline administrative paperwork and re-examine the logic behind reimbursement policies. Hospital systems can help by providing high-tech decision support tools and encouraging physicians to collaborate on tough cases and learn from missed opportunities.

Metrics also need work. As the old business adage goes, you can't manage what you don't measure. Yet most health-care organizations aren't tracking misdiagnosis beyond malpractice claims. Doctors need mechanisms to provide and receive timely feedback on the quality and accuracy of our diagnoses, including better patient follow-up and test-result tracking systems.

Electronic health records will help eventually, but slow innovation in this area has frustrated many physicians. And most doctors still lack access to electronic patient data gathered by other physicians. Doctors can make a more informed diagnosis when they can see the disease progression or learn what other doctors have discovered about the patient.

Finally, patients must start keeping good records of each meeting with a doctor, bringing the information to subsequent medical appointments and following up with the physician if their condition doesn't improve. No news from the doctor is not necessarily good news.

There is much we don't understand about the burden, causes and prevention of misdiagnosis. The IOM report will spur progress, but health-care providers, patients, hospitals and payers can all help. The health outcomes of at least 12 million Americans each year depend on it.
 
This article is courtesy of The Wall Street Journal and was written by  Dr. Singh, Chief of Health Policy, Quality and Informatics at the Michael E. DeBakey VA Medical Center, and an associate professor at Baylor College of Medicine.

Mother spent two years preparing to die after she was misdiagnosed with cancer

A mother has spoken of the 'absolute hell' she endured after being wrongly told for two years she had terminal cancer.
 
Denise Clark, 34, arranged her own funeral and wrote heartbreaking goodbye letters to her sons after she was told the disease would claim her life.
 
After being given the prognosis at Aberdeen Royal Infirmary, she also spent £10,000 attending an alternative therapy clinic in Spain.
 
She hoped the treatment there would extend her life, giving her more time with her two young boys before she died.
 
But as the months passed and she continued to feel well, she became suspicious and eventually demanded another scan.
 
To her total shock, the results revealed the growth in her pelvis was not cancerous - but internal damage from previous cancer treatment she'd undergone.
 
Ms Clarke has now settled a claim for a high five-figure sum after she took action against NHS Grampian.
 
She said she hoped no-one else would ever endure the nightmare ordeal her family went through.
 
'I planned my funeral and wrote farewell notes to my boys. It was heartbreaking but I had to do it for my family. No one should have to do that if they don’t need to.
 
'Hearing them say it was a mistake was amazing  - but it doesn’t give us back the two years of our lives that were made absolute hell.'
 
Ms Clarke's ordeal began in 2009 when she suffered bleeding, nine weeks into her pregnancy with son Luca, now four.
 
When she finally got an appointment for tests nearly six months later, in January 2010,  she received the devastating news she had cervical cancer.
 
With the disease spreading, Luca was delivered at 33 weeks so Ms Clarke could start treatment as soon as possible.

She went on to beat the disease but in November 2011 she was told she had a huge, cancerous mass in her pelvis and there was nothing more doctors could do.
 
'They said I'd already had as much radiation as I could have in a lifetime,' she said.
 
'There was an option for some more chemo - which might buy me some time - but I wanted my boys to remember me how I was, and not rotting away on a couch.
 
'I was absolutely devastated. We just weren't expecting it at all.'
 
Desperate, she researched alternative treatments and booked herself into a special clinic in Spain to build her health up as much as she could.
 
She also began to plan for the future of her two sons, Harvey and Luca.

'I wrote them farewell letters to say how proud I was of them and told them not to be sad because of all the good times they had spent together.'
 
She even had family photographs taken to remind them of her.
 
'I wanted the boys to have fun times and lots of mum memories, like playing football together or having a barbecue. Nothing that cost a fortune.'
 
She added: 'I didn’t know if I was going to end up dying in a hospital, if I would be at home or how it would happen.'
 
Then after two years of agony, specialists revealed her recurring health problems were actually due to internal damage caused by high levels of radiation she'd received during her initial cancer treatment.
She said: 'The doctor was there with the test results and my mum burst out crying. I just started to laugh.
 
'Mum said "how can you laugh?", but it was out of relief,' says Ms Clarke, an oil firm operations manager.  

'I got home and said to my son: 'Harvey, the doctors made a mistake, they are wrong". His little face just lit up and he was hugging me the hardest he has ever hugged me. He said he never wanted to let me go.'
 
She added: 'It's a massive relief they made a mistake and I'm OK - but that's two years of my life I'm never getting back.'
 
She also worries the misdiagnosis had forced her eldest son Harvey, now 10, to grow up too quickly.
 
'Even now he's still got worries in his head, he says he doesn't want to be without me and tells me not to leave him,' she said.
 
The misdiagnosis also led to her running up huge debts paying for alternative treatments and her marriage broke down due to the strain of her poor health.
 
During treatment, high doses of chemotherapy left her needing a blood transfusion and she suffered acute renal failure after medics unnecessarily inserted stents to maintain her kidney function.
 
Despite this, Ms Clarke added she has nothing but praise for many of the medical staff at the Aberdeen Royal Infirmity  X-ray unit, but said she felt let down by NHS Grampian.

'It wasn't just one department that got it wrong, it was multiple departments. They made mistakes time and time again,' she added. Going through something like this gives you clarity on so much. All I want now is to see my boys grow up, and watch my babies become the men I know they will be.'
NHS Grampian refused to comment on the case, adding that it was a confidential matter.

This article is courtesy of the Daily Mail.

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.

£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.

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.

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.

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.