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Patient Safety

I remember that one entirely; we were all told that. Inspection, palpation, percussion and auscultation are absolutely crucial, but nobody had listened to this kid's chest or tapped it, which is what Auenbrugg, the inventor of percussion, did on beer barrels. I am afraid that poor little kid died after several apparent examinations by the NHS. In the third case, there was a failure to recognise that a patient who could not stand up because his blood pressure fell every time he did so was actually having a gastrointestinal haemorrhage, which proved fatal. The failure to spot it was the result of total diagnostic incompetence, but so far it has been defended through a whitewash, and I am fighting for an external inquiry. The last case, which is very current and very sad, involves a girl of 15 with glandular fever who also had a fatal septicaemia that killed her. Nobody had sufficient experience to recognise that people do not die of glandular fever and that something else must have been going on. The attending doctors had inadequate experience, and nobody with experience intervened. That gives me a chance to mention a booklet called "Front Line Care", which is dear to the Minister. Its first recommendation is:""Nurses and midwives must renew their pledge to society and service users to tackle unacceptable variations in standards and deliver high quality, compassionate care."" It was a nurse who said that the girl who was dying could go home. Where are the good, old-fashioned matrons and ward sisters, who sail round in proper uniforms, know when people are ill and actually tell the doctors when they are missing something? Two of the cases that I mentioned in fact involved rare diagnoses, and I am not saying that everybody should be able to make a rare diagnosis. However, people must be able to spot whether somebody is ill. In a very good article in The Times on 15 March, Liam Donaldson drew attention to the poor awareness of rare diseases. Again, we are not all expected to make the best diagnosis in the world, although it is very exciting when we do, but doctors and nurses must have the basic ability to know when somebody is ill, and then jump up and down until something is done about it. Recommendations 44 and onwards are about Staffordshire and the inability of so many people there to spot what was going on. There has been a valuable spin-off from the Stafford disaster, in that great interest is now focused on patient safety. There are now open board meetings, board members are involved with safety and there is an awareness of the importance of whistleblowers and their problems. On 12 March, an article in The Times said:""The Toyota Way is famous…In reality, the Toyota Way is to ignore warnings from within the firm"." It was clear from the report that workers at Toyota had pointed out the deficiencies in quality control as long ago as 2006, but their whistleblowing had been completely ignored. Two things led me to use my opportunity to introduce a private Member's Bill to support whistleblowers. I wanted to call my Bill the "NHS Whistleblowers Support Bill", but I was not allowed to, because the word "whistleblower" is apparently non-parliamentary language. Instead, my Bill was called the National Health Service Public Interest Disclosure Support Bill, which is a mouthful. There were two reasons why I pushed for the Bill. The first was obviously Stafford. As our Chair said, there were whistleblowers there, but their whistleblowing was blocked before it got to board level, and they did not know what to do. The first thing, therefore, is to give them a system that allows them to go higher when they get blocked. My second reason for pushing for the Bill was that whistleblowers have come to me at home about the out-of-hours care service. They were frightened for their jobs, so they could not go through the normal channels. They came to me because they trusted me to keep their anonymity and to have the clout to do something, which I certainly did. The aims of my Bill were to publicise the Public Interest Disclosure Act 1998 and the work of Public Concern at Work, as well as to introduce support officers who would act as accessible and independent listeners, advisers and supporters. That is why I was pleased by the Committee's recommendation 56 and the Government's response. Our recommendation said:""We recommend that Annex 1 of the Health Service Circular…"The Public Interest Disclosure Act 1998—Whistleblowing in the NHS" be re-circulated to all Trusts for dissemination to all their staff as a matter of urgency."" The Government responded by saying:""We accept that proposals should be brought forward as recommended to improve protection for whistleblowers. We will consider the practicalities of establishing a model whereby whistleblowers can complain to an independent statutory body."" They are on exactly the same wavelength as my private Member's Bill, so perhaps it does not matter that it was filibustered out of existence a few days ago. Nurses have started really to push for quality. A little time ago, they produced a marvellous document called "Dignity in Care", and I have already referred to the little booklet called "Front Line Care". The Royal College of Physicians is also at work and has produced a booklet called "Leading for Quality", which says:""At the heart of quality rests safety. Many clinical errors could be avoided if the right information was shared at the right time."" However, errors and safety are not yet recognised widely enough. I dropped into the Library a few minutes ago and looked at the latest medical dictionary—the 41st edition of "Black's Medical Dictionary", which appeared in 2005. Look up "safety", and the only thing that it mentions is the safety of drugs. Look up "error" and the entries go straight from "eroticism" to "eructation". It does not even recognise that there could be errors. I leave the House with my four Cs for quality, and hence safety: care, compassion, communication and continuity.