By
Jane Feinmann
Last updated at 11:58 PM on 6th February 2012
Doreen Williams had a chest infection — it wasn’t serious but her GP thought it best to admit the 71-year-old to hospital so that she could have stronger, intravenous antibiotics.
Seven days later, Mrs Williams was dead as a result of a pulmonary embolism — a blood clot on the lungs which had developed while she was in hospital.
Her death was entirely needless, says her daughter Karen Rutland.
Karen Rutland’s mother Doreen Williams was admitted to hospital for a chest infection. Neither the doctors nor nurses intervened to save her life
‘My mother was a busy retired teacher who had visited Wales and Cornwall in the two months before her death,’ she explains.
‘She had chronic obstructive pulmonary disease, a long-term lung condition, but it never seriously affected her daily life.
‘It just meant she had to be careful to get proper treatment for chest infections.’
Mrs Rutland, 56, has no doubt what was to blame for her mother’s untimely death.
‘She was not given the intravenous antibiotics or standard blood tests until five days after she was admitted to hospital.
‘And although she was at high risk of a blood clot because of her age and her lung condition, she was never given the blood-thinning medication that would have prevented it.’
The doctor in charge also issued a ‘do not resuscitate’ order — without discussing it with the family.
So, as Mrs Williams lay dying, neither the doctors nor nurses intervened to save her life.
Shocked and distressed by this betrayal of her mother, Mrs Rutland, a former management consultant from Cornwall, did what most people would do. She tried to complain. She got nowhere.
The doctor denied any responsibility for her mother’s death. And Luton and Dunstable Hospital Trust, where Mrs Williams spent her last days, refused to accept any wrongdoing.
There were 7,000 complaints to the General Medical Council (GMC) last year. Only 17 per cent of those by patients were investigated
Perhaps most frustrating, however, was the response of the General Medical Council.
This is the only medical regulatory body in the UK with the power to suspend or strike off doctors in the interests of patient safety.
Initially, the GMC’s senior investigating team recommended the doctor in charge of Mrs Williams’s care should face a Fitness to Practise hearing.
But the hearing was cancelled — twice — because the GMC’s medical advisors said there was ‘an insufficient case to answer’.
However, the coroner who later examined the case said he found it ‘inconceivable that vital steps were not taken to follow up’ particular warning signs that something was seriously wrong.
‘There was every reason to believe that after a short stay in hospital, Mrs Williams should have been well enough to return home,’ he said.
So why didn’t the GMC take action? It is a question being asked in an increasing number of cases of alleged medical negligence.
The concern is that the GMC, which is funded by the doctors it regulates, is biased in their favour and shields those it is supposed to discipline.
Furthermore, it is accused of treating whistleblowers who try to expose malpractice as pariahs.
Five years ago Sir Liam Donaldson, who was then the government’s Chief Medical Officer, described the GMC as ‘secretive, tolerant of sub-standard practice and dominated by professional interest rather than that of the patient’.
It’s a criticism that won’t go away.
Last year, the Parliamentary Health Select Committee described the GMC in a highly critical report as ‘overly lenient’ to doctors — while just a few months ago, the chair of the Patients’ Association, Dr Mike Smith, accused the organisation of ‘clearly under-investigating complaints submitted by patients’.
The statistics speak for themselves. There were 7,000 complaints to the GMC last year. Only 17 per cent of those by patients were investigated — with only 11 doctors struck off as a result of these patient complaints. It is worth noting that once the GMC makes a decision, there is no right of appeal from the complainant.
Even when decisions do go against doctors, the criticism is that the disciplinary process takes far too long, allowing incompetent doctors to continue putting the public at risk.
It took 12 years after the first complaints were made about Dr Jane Barton for the GMC to initiate the investigation
In January 2010, Dr Jane Barton was found guilty of serious misconduct after a GMC investigation found she’d given painkillers at six times the recommended dose to 12 elderly patients, causing their death at two wards she ran at the Gosport War Memorial Hospital in Hampshire.
Yet it took 12 years after the first complaints were made for the GMC to initiate the investigation.
‘If Dr Barton had been suspended by the GMC in 1998 when her actions were first questioned, then many of these patients would have been saved, including my mother,’ says Ann Reeves, 57, whose mother Elsie Devine died aged 88 of a ‘substantial overdose’ of opiates administered by Dr Barton in 1999.
Incredibly, despite finally finding Dr Barton guilty of serious misconduct, a Fitness to Practise panel — who are appointed by the GMC — still allowed her to continue working as a GP (she has since retired).
Indeed, in 2010, 39 other doctors were permitted by panels to remain on the medical register even though the GMC’s own investigators recommended they be struck off.
One of these was general surgeon Gideon Lauffer, who was found guilty of serious misconduct after a series of botched operations that caused the death of two patients and injured 18 more.
Yet a Fitness to Practise panel ignored the advice and imposed a six-month suspension allowing him to return to work ‘under supervision’. By November 2011, he was back at work.
Karen Rutland had little idea of the failings of the GMC when she decided to complain to the organisation about her mother’s death in 2006. While Doreen Williams was in hospital, her husband Ralph had become increasingly worried.
Mrs Rutland recalls: ‘He told me the consultant in charge of my mother, Dr Tariq Mirza Rehman, hadn’t started her on the intravenous antibiotics.’
So, the next day, the concerned father and daughter spoke to Dr Rehman. ‘He told us in a reassuring voice how very seriously he was taking our mother’s care.’
But after her mother’s death, Mrs Rutland learned that from the moment Mrs Williams was admitted, Dr Rehman was responsible for a series of glaring omissions in her care. The full extent of neglect was revealed at an inquest in January 2011 — five years after Mrs Williams’s death.
The inquest heard that not only did Dr Rehman fail to prescribe Mrs Williams antibiotics, but he didn’t give her medication routinely prescribed to hospital patients of her age and health background to prevent the blood clot.
There were other more serious failings too. The level of oxygen in Mrs Williams’s blood dropped — a warning sign of a pulmonary embolism — and fell further on the day of her death, which should have resulted in her emergency transfer to intensive care.
At 3pm on Mrs Williams’s final day, Dr Rehman issued a ‘do not resuscitate’ order, a step that is supposed to be taken by doctors at the end of a terminally ill person’s life to stop resuscitation in the event of a cardiac arrest — thereby preventing unnecessary suffering.
Such a step was ‘entirely inappropriate and unwarranted’, according to Dr Vincent Mak, a respiratory medicine and intensive care consultant at Central Middlesex Hospital, North West London, and an independent expert witness at the inquest.
He noted Mrs Williams’s health prior to admission was ‘of reasonable quality’, adding that ‘she had recently had an echocardiogram that showed her heart was working well’.
By issuing the ‘do not resuscitate’ order, Dr Rehman breached two sets of legally binding guidelines, including failing to record the reason for taking this drastic step — which is mandatory.
Nor did he consult with Mrs Williams, later insisting that she did not have mental capacity — another claim denounced as untrue by the coroner.
It is also mandatory for doctors to notify a coroner if a death is unexpected —Dr Rehman did not do this. Instead, he allowed Mrs Williams’s death certificate to carry the cause of death as septicaemia and pneumonia.
Dr Mak said Dr Rehman presided over a regime of ‘suboptimal care that led to (Mrs Williams’s) death’.
The coroner summed up his concerns as Dr Rehman stood in the witness box as: ‘You failed to pay attention and treat the patient in front of you’.
Despite these findings, the hospital trust supported Dr Rehman and denied any wrongdoing.
So Mrs Rutland turned to the GMC for help.
‘We saw it as our duty to ensure no other family would suffer as we have,’ she says.
Dr Kim Holt was suspended by Great Ormond Street Hospital after blowing the whistle on staff shortages and a ‘chaotic’ appointment system at the clinic
Yet in 2008, the Fitness to Practise panel, a group of medical and non-medical volunteers, appointed to investigate Dr Rehman’s behaviour, was cancelled — because an independent medical expert claimed ‘none of the points in respect of medical management reflect either incompetence or malpractice’.
Astonishingly, the same thing happened a year later when a second hearing was set up following a complaint from the Rutlands.
Despite the coroner’s unusually critical verdict last January, the GMC insists its own rules prevent it from ‘reviewing a decision to cancel a hearing’.
Chief executive Niall Dickson recently defended the organisation’s record, claiming problems often lie with flawed perceptions of the GMC’s responsibilities.
‘Our job is not to punish doctors but to protect patients by taking action against a failing doctor,’ he said.
‘We look closely at every complaint to see if the doctor’s fitness to practise could be impaired but will only take a case forward if the complaint indicates serious concerns about the doctor. In the majority of cases where a doctor has made a single mistake, this is not indicative of a bad doctor, however catastrophic the consequences.’
So what exactly does a doctor have to do in order to provoke ‘serious concerns’ by the GMC? The worrying answer may be to tell the truth — there is growing concern that doctors who try to blow the whistle on unsafe practice could can end up facing disciplinary action themselves.
Two weeks ago, the GMC issued new guidance reminding doctors they have a duty to raise concerns about poor patient care.
Yet it’s an empty warning for Dr Kim Holt, a consultant community paediatrician at Haringey Primary Care Trust.
In 2006, Dr Holt was suspended by Great Ormond Street Hospital, the trust that then employed her, after blowing the whistle on staff shortages and a ‘chaotic’ appointment system at the clinic where, months later, Baby P (Peter Connelly) was treated days before his death.
‘It didn’t ever get to the stage of a complaint to the GMC. But there was an attempt to discredit me, to force me out of medicine as a damage limitation exercise,’ she recalls.
‘I was lucky in that I’ve now been reinstated in my job. But I’ve met several doctors who have been reported to the GMC by their trusts after they became whistleblowers, and a handful who have even been struck off the medical register.
‘Hospitals use threats of referral and actual referral to the GMC as a means of ensuring silence from medical staff.’
Brian Jarman, professor of primary health care at Imperial College, London, agrees changes are needed.
‘There is precious little evidence the GMC supports doctors who speak out when they see failing practice. Why doesn’t the GMC have a confidential helpline for people who see problems at their hospitals? That would be a start.’
Later this year, the GMC will supervise the launch of a revalidation scheme under which doctors’ performances will be evaluated every five years.
Katherine Murphy, of The Patients’ Association, is not impressed.
‘Unfortunately the GMC’s record on managing complaints makes you wonder how revalidation will work — and whether it’s going to be friends revalidating friends,’ she says.
‘We have many experiences of good care and unsung heroes in the NHS,’ adds Mrs Rutland.
‘But there has to be a way of taking action against the bad ones — otherwise standards slipping and people dying unnecessarily becomes acceptable.’
Luton and Dunstable Hospital Trust was unable to provide a comment.
Share this article:
Here’s what other readers have said. Why not add your thoughts,
or debate this issue live on our message boards.
The comments below have not been moderated.
-
Newest -
Oldest -
Best rated -
Worst rated
we are not only soft on doctors, we are soft on all those who are paid out of public purse.
Report abuse
“Karen Williams tried to complain to the General Medical Council after her mother Doreen Williams died (pictured left with her daughter) in hospital ‘needlessly’ got nowhere.”================ Does this make any sense to anyone? DM, you’re writing about a woman who has died; the least you could do is to write it in English, surely?
Report abuse
7000 complaints in a business which makes about a BiILLION decisions a year….many which can be with vague symtoms………yes strike off the obviously dodgy ones but accept that there are honest, well-meaning good doctors who cannot be expected to always get it right.
Report abuse
Dodgy doctors are protected by “the old boys club”.
Report abuse
Doctors mistakes get buried.
Report abuse
Try complaining about the lousy treatment of the elderly in York Hospital and you are either totally ignored, patronised or insulted back. The majority of Drs are great but the GMC is a joke and there needs to be an external complaints agency for them. Look at the way the osteopaths and chiropractors are policed – the same should be applied to the medics.
Report abuse
The GMC is the doctors trade union.
Why on earth would ANYONE expect fair treatment from the GMC when it exists to protect the medical profession.
Change is needed…
Report abuse
The views expressed in the contents above are those of our users and do not necessarily reflect the views of MailOnline.
Related posts:
Views: 0