Shocking hospital mistakes led to our daughter’s death
theguardian.com
theguardian.com
When I was in my late 20s, I had my vision go black for a short period. A concerned doctor had a full MRI workup done on me with review by a neurology team. They confirmed from the tests, as was 99.99% likely to be the case in an otherwise healthy 20-something, that it was an ocular migraine - alarming, but harmless. Problem is, what if it was the miniscule chance of being a stroke. The original doc could've sent me home with an aspirin, but could have also caused my death or severe disability if she was wrong.
And that is why this tragedy happened. The outcomes here are terrible but exactly what you'd expect and what the NHS's critics have been saying for decades. Talk to people who used to live in the Soviet Union and you'll hear stories indistinguishable from this one. There are people and equipment there, in theory the ingredients for success are available, but nobody seems to care about the results. So the system steadily degrades into ever more dysfunctional states, the problems are obvious to everyone who interacts with the system and yet it cannot/will not improve.
This is exactly the reason communism failed and now the NHS is failing in the exact same way, for the exact same reasons. It's not even a new set of problems, it's just that the state of collapse is now so bad that even the most ideological people (e.g. Guardian editors) are starting to open up about it.
Sadly this poor woman is still a long way from being able to understand what happened to her family. Her conclusion at the end of the article is "don't blindly trust doctors, research things on the internet and speak out". Yeah, and then what? She was already doing those things and the doctors/nurses were ignoring her. Patients in the NHS are totally disempowered. It's not like a private sector system where you have options and could go to a competitor. If the doctors aren't diagnosing your child's problem properly because they're WFH then, well, you're just screwed: the child is going to die and the resulting investigation will be a whitewash in which the doctors who messed up the worst get promoted. That's what happens when you have one state run system for everyone.
Before you say just find a new job. I'm tired of looking for a new job because the insurance started getting worse at a company.
It doesn't matter which doctor I see it won't change what insurance decides.
Fuck private healthcare.
Your insurance company may sometimes refuse to pay for tests recommended by your doctor because neither you nor your doctor are directly paying for tests so the insurers are the only parties whose job is to push back on over-testing. The USA is famously considered an over-tested and over-medicalized society in general so arguably they could do a lot more of such pushbacks. If you do some research and think that in your case they're overshooting, then you need a different health plan. The fact that you can't get one due to the job tie is indeed a really broken aspect of US healthcare, and the fix is to fix the tax code so there's no benefit to having employers pay the premiums.
That's not how the English NHS works. The hospitals are run by NHS trusts. This particular hospital is run by King's College Hospital NHS Foundation Trust.
An NHS Foundation Trust is a "public benefit corporation". This means it's a business, with a chief executive, a chair, and a unitary board of executive and non-executive directors. The organisation is primarily accountable to their local population.
I know the NHS is complex, but when you say stuff like this it just shows that you haven't got a clue what you're talking about.
> In this case however the family weren't private clients so the whole thing was state run end to end.
No, this is nonsense. It's clearer to see in cancer services, but a lot of stuff is provided via MacMillan charitable funding.
I mean your whole post seems confused about what the private sector actually is. A government department doesn't become private sector because it gets money from charities!
As for accountable, read the full article and see what NHS accountability looks like. It looks like nothing. "Lessons must be learned", indeed!
What? Of course it is. This hospital trust has its own budget, it has a board of directors, they're not controlled by local government, they're not controlled by central government, they're not controlled by civil servants, they're accountable to their local population before central government. Here's their annual report from 2020/2021. https://www.kch.nhs.uk/Doc/corp%20-%20684.7%20-%20annual%20r...
What's the difference between the chief executive of an NHS Foundation Trust and the chief executive of any other corporation?
You seem to think this hospital is controlled directly by the Department for Health and Social Care, and that's simply incorrect.
"On 2 April 2020, the Department of Health and Social Care (DHSC) and NHS England and NHS Improvement announced reforms to the NHS cash regime for the 2020/21 financial year. During 2020/21 existing DHSC interim revenue and capital loans as at 31 March 2020 of £735m were extinguished and replaced with the issue of Public Dividend Capital (PDC)"
The NHS is a government department as are all aspects of it. These organizations rely near totally on taxpayer funding, therefore, they are a part of the government. The fact that they claim to be independent is meaningless obfuscation and frankly the prevalence of this practice throughout the UK government is an indictment of the public sector culture there.
The idea they are independent of central government is especially bizarre. Read the report:
"Following a financially challenging 2017/18, the Trust was placed in Financial Special Measures on 11 December 2017 for breach of its NHS Provider Licence, having been in enhanced oversight for some years before that. Enforcement undertakings were issued in February 2018 and updated in August 2018."
They were placed (by the government) in "special measures" because they aren't a real company and therefore cannot just go bankrupt like a real company would, this happened because they breached their (government issued) NHS license, and therefore enforcement undertakings were issued (by the government).
These are government controlled bureaucracies being held to account by other parts of the government. They are certainly not independent of that government at any level, nor are they in any way directly accountable to the people using their hospitals.
Given your familiarity with NHS jargon I have to wonder if you work for the NHS, or at least very closely with it. If so, is this belief that the NHS somehow isn't the government widespread?
This belief that the NHS is not run by the government isn't a belief, it's fact, as you'd know if you'd read the legislation.
Your comments about putting a trust into special measures - not allowing it to go bankrupt - has nothing to do with it being run by the government or not, it's about protecting patients. There are plenty of providers of NHS services that do go bankrupt.
It's okay that you don't understand the NHS - it's a complex tangle of organisations. It's less okay that you insist that your poor understanding is The Truth. Genuinely weird that you accept that I know more about the NHS than you, but on this one point I must be wrong.
https://www.oecd-ilibrary.org//sites/3b4fdbf2-en/index.html?...
What we need are better staffing ratios and a proper process for designing out error. The Healthcare Safety Investigation Branch[0] has set out to do for hospitals what the Air Accidents Investigation Branch and NTSB do for aviation safety. Let's hope it helps.
1. Find it easier to promote based on skill rather than tenure.
2. Can give bonuses or fire bad employees.
3. Are incentivized to avoid horrible outcomes like this for PR/financial reasons alone beyond just the ethical issues.
4. Are also incentivized to avoid it due to liability lawsuits.
None of these incentives or systems really apply to the NHS.
In this case the problems seemed to be more like general management and staff dysfunction rather than a need to reward "going beyond". Constant rotation of doctors instead of assigning the patient to a single doctor, some of whom were in training, over confidence, refusal to make backup plans, apparent inability to recognize sepsis even in the most extreme stages and consequent refusal to escalate to ICU, keeping the parents and patients out of the loop, working from home despite being on call, apparent inability to preserve records, promoting a doctor just weeks after he made critical mistakes etc.
In other words - rampant and systemic incompetence.
The problems here were seriously compounded by a dysfunctional aspect of British culture in which the NHS is practically worshipped, and treating it cynically is deemed a severe moral failing (I'm British, I've seen this first hand). The article dwells on this near the start. Several times the mother correctly diagnose the fact that there are serious problems with their child's care and each time is basically told to shut up and Trust The NHS, which she then meekly does. It's easy to imagine American parents at this point starting to threaten lawsuits, switch hospitals, remind doctors that they're the 'customer' or take other concrete actions to express their displeasure but none of this is available to Brits.
This is the problem with all the anti-NHS posts on HN -- none of them have a clue how the NHS works, so they always miss the point.
The point here is "Why doesn't the 'chain of accountability' work?" Where were the governors, where were the NEDs, where was the FTSU guardian, where was the assurance about complaints? The point is absolutely not "state run organisations can't fire workers".
It's genuinely baffling that there are so many things actually wrong with the NHS that could be spoken about, but anti-NHS posters are unaware of those things and invent stuff instead.
It's not that different, no. At the scale of large institutions these two things blur together significantly. They "can" fire staff for incompetence in theory but if they actually do that more than once in a blue moon then the unions will revolt, so they develop a culture of never actually doing so because that's easier than trying to figure out if this time it won't cause a backlash.
The source of disagreement here isn't actually different levels of knowledge of the NHS's inner workings, it's that we're zoomed in to different scales. I'm looking at the forest, you're looking at the trees.
For example, you cite a bunch of different NHS-specific accountability mechanisms and say, why didn't each one specifically work? Elsewhere you argue the NHS isn't actually a government department because the different subdivisions claim to be independent and use names and concepts borrowed from the private sector like "corporation" and "board". To me this seems bizarre. It's like the author asking why everyone was repeatedly ignoring BPEWS and other warning systems. They didn't work because of they operate in the context of a massive Soviet-style state run bureaucracy. The primary constituents to which such bureaucracies are accountable is always themselves, so ability to self correct in such orgs is always a mirage regardless of how many titles and acronyms are invented. Dysfunction compounds and the system degrades. Asking why these mechanisms didn't work is like asking why the Soviet Parliament didn't do anything to correct human rights abuses of its citizens - it was because despite using names taken from democratic systems the resemblance was only superficial and skin deep.
The USSR collapsed and the capitalist west didn't because capitalism is a set of evolved mechanisms that were patched together slowly, over time, aligned with the natural way people actually think and work. Just like people's bodies - like any evolved system - it isn't perfect and sometimes goes wrong. The mistake is to react to that by saying, oh, this looks easy. We can do it better! Let's just start with a blank slate and get the smart people in the government to work out the details. The results are poor because everything they created was just a shallow imitation of the evolved mechanisms that they were trying to beat, but by then they're in too deep and can't admit that the system is failing.
The story this Guardian editor recounts is one of deep, systemic malaise and corruption at every level. As the girl was literally dying, the on-call doctor was working from home and refused to come in! How often had they been doing that before this story happened? From the general collapse in GPs actually seeing patients we can infer that this is a widespread culture. Asking "where is the NED" isn't going to fix this because they were probably WFH too, and the NED is far more concerned with being liked by their colleagues than their patients.
In recent weeks Gorbachev died. He became a hero to many for admitting what was obvious to others right from the start - the USSR wasn't working and couldn't be fixed via incremental reforms. It was rotten from the core and unfixable by design. He let it collapse rather than prolong the disaster by yet more decades. The UK needs a Gorbachev who will square with its people because the NHS is literally collapsing:
https://www.theguardian.com/society/2022/aug/14/ministers-ad...
... and it can't be repaired by adding a few more forms or yet another accountability officer. It will never work as well as a non-state system can.
Very many people are fired for poor performance each year. This is because no hospital wants the liability of poor staff; it's also because they have a legal "duty of candour" so they have to explain to patients when something goes wrong that they knew this healthcare professional was deficient; it's also because they have legal duties to report substandard healthcare to their regulators, and also report substandard care to the regulators of the HCP. You saying "they don't fire staff" is just a fucking enormous red flag that you don't have the first clue what you're talking about, and that you're arguing in bad faith from an ideological position.
You keep repeating the same thing - that the NHS is one big organisation, run by the goverment. Neither is true. Until you can break this misconception you're going to come up with stuff ("they can't fire workers because unions") that's so wrong it makes any convo impossible.
- failure to use a sepsis severity scoring system to determine need for higher level of care
- failure to order an unnamed test to determine severity of infection (I assume lactic acid?)
- failure to move to a higher level of care (ICU) earlier in the course of care
It appears that the patient was on (unspecified) antibiotics from a fairly early point in the course of care. I may have missed it being spelled out more explicitly, but it sounds like the patient died from traumatic pancreatitis -> necrotizing pancreatitis.
EDIT: Markdown fixes, autocorrect error
I wish the author had included names and pictures of the doctors and consultants that failed in their duties. Their future patients (not that they should have any) and their colleagues deserve to know.
Edit: I'll also add that if you are ever in a hospital ER or similar situation I recommend stopping everyone that comes in to the room to see the patient (your family member) before they start talking and get their name and position at the hospital before they continue. Then repeat what they said back to them and if it sounds fucked up ask them to elaborate.
But the mechanism of harm is known: disruption of the “electron transport chain” in the mitochondria.
Prenatal Tylenol is now well-associated with autism. I have a friend who I talked out of using Tylenol daily - she’s doing much better.
Edit: spelling (comment below)
"pa-ruh-SEE-tuh-mol", with the "pa" being like the "ma" in "marriage".
Tylenol does NOT have anti-inflammatory properties. Ibuprofen is a better in many different ways.
However, surely this dosage would be radically different between different people: a 40kg woman is not like a 100kg man.
And finally, if this drug is SO dangerous if you have a little too much of it, I have zero confidence that it's at all safe at ANY normal dosage (esp. since the dangerous dosage is very close to the normal prescribed dosage; it's not like you have to down a whole bottle at once to have a big problem). I simply don't see how this drug should even be legal for OTC use, or why it should be used at all in most situations when there's better and safer alternatives: aspirin, ibuprofen, etc. Personally, I'm simply not going to take the risk. Why bother?
The mechanism of action for Tylenol is mostly known and regardless it is not uncommon to have medicines with an unknown mechanism approved (e.g. gabapentin).
Furthermore, the mechanism of harm you quote is not, in fact, a known one. Frankly, I can’t tell where you pulled that from. The primary mechanism of harm is liver damage from prolonged use.
Finally, the association with autism is still under debate and I see several possible confounding effects in the current research.
Your post is incredibly misinformative and you should not be talking about anything medical science related if you know this little. You could get people hurt if they listen to you.
Hardly taboo. For one thing this person got her story printed in national news media, and other media also covered it. And there are several national newspapers who run anti-NHS stories every day.