In about October last year Mrs K had a heart attack at home. She was 40 years old and the mother of a young child. Paramedics arrived at her house and noted that she was not breathing. They attempted to ventilate her. There then followed a catalogue of errors. When she arrived at hospital it was discovered that the endotracheal tube was in the oesophagus. This meant that any oxygen was going into her abdomen and not into her lungs.
The shortage of oxygen caused her to suffer massive brain damage and she died a few days later. But for this mistake, she would probably have survived. An independent report found that wrong equipment had been used, no proper tests had been done to check that the oxygen was going to the lungs and that all but one of the paramedics, had not had clinical training for cardiac arrest management.
This was a tragic and avoidable death. I am currently dealing with the clinical negligence claim on behalf of the family. This is just one of many similar cases. It is almost two years since I posted my angriest blog of all, and the one which has had the most visits - by a mile.
A recent report from the Public and Health Service Ombudsman makes for disturbing reading. This document reported in today’s Guardian reviews 161 incidents between April and June 2014.
In one case a male patient died of a heart attack whilst on holiday. Doctors were aware that he was at high risk if he was to fly, but failed to warn him. In another case a mother gave birth at home after a junior midwife wrongly advised her that she was not in labour and sent her home from hospital. Perhaps the most tragic case concerns a new born baby who suffered brain damage after a nurse and two doctors failed to properly carry out a blood transfusion.
The Ombudsman, Dame Julia Mellor talks of the ‘devastating impact’ that these failures have on peoples’ lives – people like Mr K and his young family.
In its annual report, earlier this year the NHS Litigation Authority reported an 18% increase in Clinical Negligence Claims between 2013 and 2014. In time honoured fashion they laid the blame at the door of lawyers acting for victims and their families –
The NHSLA might wish to read the Ombudsman’s report, or speak to the families of victims. If the government wishes to see a reduction in claims, they should focus their
efforts on reducing the numbers of avoidable catastrophes. Ensuring resources are available for essential training seems to be a good staring point.
What is not acceptable is to blame the victims. Mr K has done nothing wrong. Why should he, and others, be made to think that the NHS is short of money because of him or his legal advisers?
I hope that the Ombudsman's comments will see the start of a shift from passing the blame to victims to addressing the true causes of a serious problem.