Has a surgeon really "branded his initials on a patient's liver"?

Has a surgeon really "branded his initials on a patient's liver"? 

The media have reported that a Birmingham liver surgeon has been suspended for allegedly branding his initials on a patient's liver transplant. Of course they have all reported this as an allegation, not fact, but already people are expressing their disgust in a way that assumes that this allegation is fact, or at least credible. Is it?

If a surgeon were to do such a thing, he would have to secure the silence of his assisting surgeon(s) and scrub nurse. That seems extremely unlikely. What is the basis of this allegation? There may be professional rivalries behind this. And what's certain is that if (or more probably when) the investigation shows the allegation to be groundless, the media will not be reporting that. The story will live on however, and be used as proof of how arrogant surgeons are. 

The surgeon involved is well liked and respected for his surgical skills. It seems the reporting of this allegation owes more to the media's delight in sensational bad news about the NHS. The resemblance of this allegation to an incident in the crime novel "Remains Silent" seems remarkable.

In the two cases that might be considered similar, one surgeon puts his initials on the abdomen of his patient. The surgeon involved was argued to have Pick's disease, a type of dementia which often causes bizarre disinhibited behaviour. In another, a surgeon apparently branded his initials on an internal organ - but this was the organ he was removing, so although eccentric not harmful to the patient as such.

If this marking (not really branding, most likely argon beam cauterization) has occurred, then this could be viewed as a criminal assault - what specific offence is arguable, given that such an episode has not been prosecuted in the British courts hitherto. If the mark was inflicted prior to implantation, then arguably the patient has not been assaulted at all. It might be criminal damage. A more appropriate way to deal with the situation would be via the professional regulator, the General Medical Council. The mark would have a trivial effect on the liver, the main concern would be about the attitude of the surgeon concerned. 

The Care Quality Commission

The new Care Quality Commission 

The Care Quality Commission has had an overhaul. The current head, David Prior, is a former Conservative party deputy chairman. One of the members is a "whistle blower" on the CQC itself, threatened with the sack but tenure extended by the Conservative SOS for Health at the request of David Prior. Another is a member of the public who campaigned for an inquiry into his local hospital, again also granted by the SoS for Health, Jeremy Hunt. The "independent" CQC has weekly meetings with Jeremy Hunt. A recent inspection of GP practices resulted in highly misleading media reports of "maggots" in two practices. David Prior spoke of "millions" let down by the NHS.

Is the new CQC better than the old CQC? Is it simply mistaking being scathing for being rigorous and objective? Are there too many people with grudges in the CQC? Are there too many people with links to the Conservative party? Is the CQC now the cats paw of the DoH?

Employing whistle blowers sounds great in theory, but the problem comes with determining who is a genuine whistle blower.  Even if you can, the trials and tribulations of being a whistle blower may mean that person does not make a good regulator. 

"Failing" hospitals

"Failing" hospitals 

Hospitals are pronounced to be failing if they are failing to meet targets or running a deficit. This puzzles me as the Conservative party have been lambasting Labour for target-driven healthcare, and all NHS hospitals make no profit - they all run a deficit. A deficit means running over budget, which is subtly different.

So if a hospital is failing to meet targets, is it 

a) putting clinical priorities first

b) underfunded

c) poorly run?

If a hospital is running a deficit, is it

a) adequately funded but "unsustainable"*

b) adequately funded but poorly run

c) underfunded but putting patients first?

* the govt wants to cutback or privatize

Why do I ask these questions?

Because this puts the decisions of hospital boards in Mid Staffs in perspective.

We can be pretty certain that the current coalition government would not regard c) as a valid answer to the latter question. 

Reports of "forced Caesarean section" probably far short of the whole truth

Reports of "forced Caesarean section" probably far short of the whole truth

There have been reports in the Sunday Telegraph that an Italian national was forced to undergo a Caesarean section. The report states that Essex Social Services obtained an order without the woman's knowledge, who was sedated and woke up to find she had had a Caesarean section. 

The full facts are yet to come out, but this scenario seems far-fetched as it has been reported. The case law is quite clear that performing a Caesarean section without the consent of a competent woman is illegal, being an unacceptable breach of bodily integrity and autonomy. 

A mother who required Caesarean section because of a needle phobia appealed against a High Court that permitted this treatment without her consent in Re MB (An Adult: Medical Treatment). The Appeal Court agreed that this was in her best interests, because the harm to her from a birth accident outweighed the harm from the giving of the anaesthetic.

In St Georges's NHS Trust v S, the refusal of a woman with pre-eclampsia to consent to Caesarean section was held to be valid, and the order of the High Court illegal. However irrational or "morally repugnant" the refusal to give consent, the competent adult's wishes to refuse treatment must be obeyed. The situation of pregnancy changes nothing, legally - the unborn child has no legal personality. 

One sympathizes with the trial judge, who had to make a decision in the face of lives being at stake. Nonetheless, women can be reassured by the thrust of the case law. So it seems reasonable to believe that there are significant details about the current case that we have not been told about.

Update: A response from Essex County Council fills in some of the details not included in the Telegraph report: http://www.essex.gov.uk/News/Pages/Essex-County-Council-responses-to-interest-in-story-headlined-Essex-removes-baby-from-mother.aspx In particular they state:
"Mother applied to Italian Courts for order to return the child to Italy in May 2013. Those courts ruled that child should remain in England"
and 
"Historically, the mother has two other children which she is unable to care for due to orders made by the Italian authorities. 

In accordance with Essex County Council's Social Services practice social workers liaised extensively with the extended family before and after the birth of the baby, to establish if anyone  could care for the child."

Karoshi

Karoshi

The Japanese have a name for death through overwork, karoshi. The expression that "nobody ever died from hard work" is simply not true. The recent death of a Bank of America intern from an epileptic seizure could have been triggered by fatigue or sleep deprivation, Poplar's Coroner's Court heard:
 http://www.theguardian.com/business/2013/nov/22/bank-intern-moritz-erhardt-died-epileptic-seizure-shower 

There have been case reports of epileptic seizures triggered only by sleep deprivation. Sleep deprivation seems to have an effect on interictal epileptiform discharges (IEDs). Sleep deprivation will only trigger seizures in susceptible individuals, but those individuals will often have no reason to suspect that susceptibility.

Guinness World Records no longer accept record attempts for sleep deprivation over health concerns. The extreme sleep deprivation experiments in rats are marred by the methodology which imposed severe stress, which may well have been the cause of death. 

Severe stress from overwork can result in raised cortisol levels, raised blood pressure, heart attacks and strokes. The first reported case of Karoshi was a stroke in a 29 year old in 1969. It seems like it's not hard work as such that's the problem, but the associated stress, fatigue and sleep deprivation.

"Public interest journalism": when does reporting turn into advocacy?

"Public interest journalism": when does reporting turn into advocacy?

Shibley Rahman has written an excellent post about the wilful inattention of healthcare journalists to the smears surrounding the reporting of MidStaffs: http://t.co/UjSNBq1gIY

It seems clear that cub journalist Shaun Lintern who proudly proclaims that he "helped expose Mid Staffs scandal" and that he's "proud to have worked with Cure" is now attacking public health doctor Gabriel Scally because he is contradicting the smears and distortions of Cure and supporters. His career and success are intertwined with the success of Cure, and he seems to have crossed the line between reporter of the news and an advocate for the Cure campaign. The Health Service Journal is often considered by NHS staff to be a government mouthpiece, but surely even they would distance themselves from Tweets like this:

1. Shaun Lintern ‏@ShaunLintern40m

   Where is Labour's detailed response to #Francis? How can we make judgements without? I want and need more from my opposition.

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   12:31 PM - 24 Nov 13 · Details
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   Reply to @ShaunLintern 

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2. Max Davie ‏@maxdavie21m

   @ShaunLintern they're not opposing you, Shaun. Or are they.... Jeremy?

If Shaun Lintern's opposition is the Labour Party, how can he claim to not be party political?

Accountability and responsibility in the NHS (or any complex organisation)

Accountability and responsibility in the NHS (or any complex organisation) 

One repetitive meme of the Cure campaign and those affiliated to it (often the British equivalent of the US Tea Party who believe all public services are wasteful, incompetent and self-serving) is the notion that there is no accountability in the NHS. This necessitates the creation of new criminal offences because as Will Powell put it:

We need laws in the NHS that would deter neglect. It's because there is no accountability that some healthcare professionals are less caring.

Others state that the lack of sweeping sanctions and sackings "from ward to board to Whitehall" (to quote Deb Hazeldine) is down to a conspiracy to defeat justice by deflecting blame from any one individual.

All this would be very worrying if it were true, but thankfully it is not. The NHS like any complex organization has systems in place to avoid the entire responsibility resting on one person's shoulders except where absolutely necessary. The same is true for an airline, another complex organization where safety is critical but delivered by a number of people. The reason for this is that the inevitable human failure should not result in catastrophe - the system should involve sufficient checks that one person's error is picked up by somebody else. No conspiracy, just good risk management. More than one person checks which leg is to be amputated. Good practice, not an attempt to deflect blame.

So rare circumstances apart, like the transgressions of Beverley Allitt and Harold Shipman, when something goes wrong more than one person has failed. When a blood transfusion is given to the wrong patient, more than one person must have failed. Indeed Cure are implicitly acknowledging this with their call "from ward to Whitehall". How they reconcile these contradictions is frankly quite baffling.

They have been part of a smear campaign against Andy Burnham, even though he instigated an inquiry into Mid Staffs within a month of becoming Secretary of State for Health. The notion that the Minister for Health must fall on his sword if there are any failings in any hospital under his watch is utterly ridiculous, given the nature of healthcare in a structure like the NHS.

There are plenty of mechanisms for accountability in the NHS. Naturally, there is due process to consider. The existence of crime does not mean there is no accountability for criminals. The acquittal of some accused of crime does not mean that there is no accountability. The continued perpetration of crime doesn't necessarily mean that punishments aren't sufficiently draconian, unless you hold up states like Saudi Arabia as models of criminal justice.

So despite the continued protestations of Cure, accountability in their usage does mean "blame", and more than that "punishment". Retribution rather than correction. Looking backward rather than looking forward.