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Patient Safety

It is a pleasure to serve under your encouraging and benign chairmanship, Mr. Russell, and to follow the Chair of our Health Committee. I am pleased, too, that five of the really active members of our Committee are present in the Chamber. I am accused at home of doing this job as a hobby. If someone's hobby is something that really interests them and it is their job as well, it is marvellous. One of my hobbies for years and years has been to try to improve the national health service for the patient, and that is exactly what this report is about. I shall speak very briefly about a few of the recommendations and then concentrate on three of them. I will try not to overlap too much with our Chair. The first recommendation draws attention to the use of the words "safety" and "quality" in the Darzi review, and the second to the safer patients initiative, to which our Chairman referred and which we went to see in Luton and Dunstable. The Government welcomed both recommendations. Recommendations 5 and 41 reminded the Department of the value of random case note review. When I was a practising physician some years ago, we used to dread the visits of the royal colleges to examine our wards and our care because they would look in the note trolley and pick out any note, so we had to have all the notes written up without any gaps. The Committee wanted to emphasise the importance of such a review and, as part of the safer patients initiative, Luton and Dunstable had taken it on board. Recommendation 41 said:""We recommend the DH consider how to reinstate the best aspects of the Royal Colleges' inspections in the new system."" The Government's response stated:""The Government agrees that the new system of registration could usefully take account of previous experience in related fields, including the Royal Colleges' inspection of hospital training posts. We will draw this recommendation to the attention of the CQC."" That was excellent. Recommendations 9 to 11 talk about the NHS complaints process, which the Chairman also mentioned. The loss of the independent review of a complaint before it goes to the ombudsman is, as far as I am concerned, pretty much a disaster. If I am lucky enough to be back here in the next Parliament and back on this Committee, one of the things that I will be pushing for is an inquiry into the NHS complaints process, because it needs yet another review. Recommendation 24 emphasises the importance of training in non-technical skills, such as teamwork, communication and leadership, all of which are vital and should be taught. There are three areas that I want to cover at greater length: the electronic patient record in recommendation 32; human factors and error, which are covered by recommendations 34 and 35; and, inevitably, Staffordshire and whistleblowing, which the Chair of the Select Committee also mentioned. In recommendation 32, we deplored the delays in the electronic patient record and welcomed, of course, the marvellous success of the picture archiving and communication systems. We particularly deplored the delays in the summary care record, although the Government response said that""good progress is now being made in delivering the Summary Care Record."" The Committee heard about varying numbers of general practices that have the summary care records up and working. We asked for details of those practices to see whether any were in our home areas, so that we could visit them to see how they were getting on. I have been very surprised by the complaints that have come out recently, from the British Medical Association in particular, about confidentiality, because it is a matter that should have been sorted out ages ago. In France—I will not attempt to use a French accent here—the patient owns their summary care record and can therefore censor whatever is on it. If a person writes their own summary care record with their GP, they will only put on the things that are essential for safety in the middle of the night, and I see nothing wrong with that. We also saw the ideal summary care record in Canada. Called the patient lifetime record, it was designed by Infoway on a single computer screen. I have said many times that the Department of Health is making the summary care record too complex. On our visit to the US, concerns were expressed about the idea of trying to introduce a huge computer system with a big bang approach. Clinicians need to be involved in the design, and patients must be made to understand the huge advantages of having a summary care record, especially if they are taken unconscious into an accident and emergency department in the middle of the night. Moving on to recommendations 34 and 35, which cover human factors, it is quite obvious that patient safety should be in postgraduate training. Our Chairman went back several thousand years to "First, do no harm" or "primum non nocere", and I can go back to 500 BC to Aeschylus, who had a very reassuring quote:""Even he who is wiser than the wise may err."" That gives us all some encouragement. In 1690, in an essay concerning human understanding, John Locke said:""All men are liable to error"" and very worryingly, he added:""and men may be as positive in error as in truth."" Even now, we can see people trying to defend the indefensible. I shall come to that a bit later. Let me refer Members to a post note, written in June 2001, called "Managing Human Error". The overview is so good that I will have to read it.""Human error is inevitable. Reducing accidents and minimising the consequences of accidents that do occur is best achieved by learning from errors, rather than by attributing blame. Feeding information from accidents, errors and near misses into design solutions and management systems can drastically reduce the chances of future accidents. Hence, studying human error can be a very powerful tool for preventing disaster."" That is a very good summary. Let me broaden the debate and talk about medical errors because they are a bugbear to patient safety. I shall mention just four complaints that have come across my desk relatively recently. First, let me say that I am not perfect; I have admitted in this Chamber to a desperate mistake that I made as a junior houseman, and there were certainly other errors. However, I take encouragement from Aeschylus, who said that even the""wisest of the wise may err."" The four complaints that I want to draw attention to provide absolute lessons. The Minister will remember from her nurse's training that a patient losing their false teeth or glasses in hospital is an absolute disaster, because such things can never be found or replaced. In the first of my four cases, an elderly patient with mild dementia lost his false teeth. Despite his complaining of difficulty swallowing, it took three weeks and a request for an endoscopy for staff to discover that the false teeth were stuck within sight at the back of his throat. Nobody had done a proper examination or even looked down his throat, which is appalling. In another case, nobody recognised that a small boy was ill, purely because nobody had taken a proper history or done a proper physical examination. The defence—the case went to the Care Quality Commission, and we got a whitewash report—was that doctors do not examine the chest now. The hon. Member for Dartford (Dr. Stoate) will remember that we were taught that physical examination consists of inspection, palpation, percussion and auscultation.