COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Northern Ireland Ombudsman’s Report on a Complaint against
Belfast City Hospital
18 September 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill
Ms Sue Ramsey
Witnesses:
Mr William McKee ) Belfast Health and Social Care Trust
Dr Tony Stevens )
The Chairperson (Mrs I Robinson):
This evidence session concerns the Northern Ireland Ombudsman’s report on a complaint against Belfast City Hospital. The ombudsman found that there were major failings in the treatment provided for the lady in question. The Committee noted the report before the summer recess and agreed to ask the trust to brief it on what action had been taken as a result of the investigation. Members can refer to the relevant extract from the ombudsman’s report.
I welcome William McKee, chief executive of the Belfast Health and Social Care Trust, and Tony Stevens, medical director of the same trust. The Committee realises that the issue is serious and invites you to make a brief presentation. I will then invite questions from members.
Mr William McKee ( Belfast Health and Social Care Trust):
It is appropriate for me to begin by repeating the full and complete apology that I gave to the family of Mrs Maguire a few weeks ago. Although the incident occurred before the establishment of the Belfast Health and Social Care Trust, it inherits the assets and liabilities of the six organisations that came together, and it takes full responsibility for what happened previously in the Belfast City Hospital Trust. There are several key lessons to be learned. However, it will be helpful to summarise how the trust views what happened and to set out some of the failings. I will then ask my colleague Dr Tony Stevens to set out some of the measures that have been put in place since the incident and since the establishment of the Belfast Health and Social Care Trust to try to prevent such an occurrence happening again.
I am a little on the back foot, Chairperson, because my glasses have broken since I arrived in Parliament Buildings. However, I will do my best.
Mrs Maguire presented with pain in her left leg, weight loss, fatigue and loss of appetite at the Erne Hospital and was diagnosed as having a deep vein thrombosis and an elevated marker called CA 125, which is usually seen as a marker for an underlying malignancy — perhaps gynaecological or pancreatic cancer. As a result of that diagnosis, she was referred to an outpatient clinic at Belfast City Hospital on 12 December 2001. However, her son, wishing to do the very best for his mother, brought her to Belfast City Hospital on Friday 7 December, where she was admitted under the care of a gynaecologist who was away that weekend. At that stage, the hospital did not have consultant cover at weekends on its gynaecological wards.
Mrs Maguire subsequently discharged herself on Monday 10 December 2001; she had previously discharged herself from the Erne Hospital. Mrs Maguire then came back to Belfast City Hospital on 15 December and was seen at accident and emergency by a senior house officer. Her care was discussed with a vascular registrar, but she was not admitted and had to be driven back to Fermanagh. The following day, Sunday 16 December, Mrs Maguire once again attended the accident and emergency department at Belfast City Hospital; she was seen by the vascular team and admitted that day. On 21 December, an attempt was made to unblock the vein mechanically, and she subsequently went into cardiac arrest. She was admitted to the intensive care unit and died on 23 December 2001.
Even that brief summary of Mrs Maguire’s experiences does not make for happy reading. I will pick out some of the issues as I see them, which are separate from the ombudsman’s issues. It will be more helpful if we say how we view the matter. There is some overlap with the trust’s views and those of the ombudsman. However, the trust completely accepts the ombudsman’s report. It was not helpful that we lost a portion of Mrs Maguire’s nursing notes.
In hindsight, the quality of the notes was not as good as one would have hoped for by today’s standards. It was not a good situation for a patient to have been admitted to a gynaecology ward at a weekend without a consultant being on duty, although Mrs Maguire received good care from the junior medical staff on the ward. She did discharge herself, but more determined efforts should have been made to explain to Mrs Maguire and her family how ill the lady was and that discharging herself two days after admission was not a good idea. More determined efforts could have been made by the clinical staff to prevent her discharging herself.
Differing clinical views may be taken about whether she should have been admitted at her first attendance at accident and emergency. However, it can be powerfully argued that it probably was not the cleverest course of action not to admit a frail person who had travelled 70 miles to attend an accident and emergency department and send her back another 70 miles.
When Mrs Maguire was admitted to a medical ward for a second time, the consultant was on holiday. Again, good care was provided by the junior team. There was a delay in her being seen by the specialist vascular team about her deep vein thrombosis. With hindsight, it would have been better if a post-mortem had been carried out, and we might have pressed the family a little harder to obtain permission for a post-mortem. That decision was not under the jurisdiction of the coroner.
The trust’s medical director, Tony Stevens, has met the patient’s son, and I have issued an apology. Belfast Health and Social Care Trust carried out an internal review. Before the ombudsman’s review, the Western Health and Social Services Board, in whose jurisdiction Mrs Maguire lived, carried out an investigation, and the trust responded to that.
My intention is not to provide a comprehensive presentation but to provide a flavour of how, with hindsight, we did not do very well.
Dr Tony Stevens ( Belfast Health and Social Care Trust):
I will reflect on some of the actions that we have taken, and which we are taking. Since Mrs Maguire’s death in 2001, much time has passed. Belfast City Hospital is now part of the Belfast Health and Social Care Trust, so a different management system is in place, and there has been much change in those years.
One of the report’s key criticisms is that the gynaecology unit had no standard consultant ward round at the weekends or on bank holidays. The unit does not expect to, and does not normally, admit acutely ill patients. A ward round by consultants has now been established on Saturdays and Sundays. That was the key outcome as a consequence of Mrs Maguire’s death.
The trust conducted an internal review, and we reflected on the actions of the individual doctors. Six or seven years later, it is difficult to gain a full understanding of that. Not all those doctors continue to work for the trust; indeed, not all of them still work in Northern Ireland or GB. I do not think that any one doctor made a catastrophic error of judgement or showed a huge level of incompetence.
The junior doctor and the senior house officer from the accident and emergency department are most heavily criticised in the report, but the senior house officer no longer works under our jurisdiction; indeed, he no longer works in the UK. We feel that the system played the biggest role in letting down the family, particularly Mrs Maguire. At specific points, individual doctors might have contributed to that. It is important that those doctors fully understand the implications of what happened. I have ensured that, despite the passage of years, everyone has had the opportunity to reflect on the ombudsman’s report and the issues that arise from it.
We are introducing specific policies and procedures, particularly concerning the handover of care between consultants. The medical professor who was responsible for Mrs Maguire’s care when she was admitted to the medical ward was criticised because, although an informal handover had taken place, there was no formal handover. We are addressing that point so that all consultants are clear that a formal handover is required. We are also working on our policies, and training, on the reporting of death certification.
There have been many circulars and much information, unrelated to this case, requiring the trust to be more vigorous in scrutinising the way in which deaths are reported and recorded; that is happening and training is ongoing, not least because of hospital-associated infections. Mrs Maguire’s case proves that it is imperative for us to improve communication with the coroner. That is also happening through policy development and training, particularly training for junior doctors, so that they fully understand their relationship with the coroner and the issues associated with obtaining proper consent for post-mortems.
Since 2001, one of the greatest changes is the way in which we investigate incidents or adverse events. There is now a very robust incident reporting system, where serious adverse events are reported to the Department. We carry out our own investigations on cause analysis as soon as we know that something significant has happened. As far as I am concerned, it is unlikely that, in seven years’ time, I would have to appear before a Health Committee to discuss such an incident; indeed, I would be very disappointed if that were the case. We have concertinaed the process to ensure that when something, even relatively moderate, goes wrong, we have a means of learning and can put the necessary steps in place. That is one of the biggest changes since 2001.
There have been other changes. We have a much more robust governance arrangement: all doctors must take part in clinical governance procedures through appraisals, revalidation with the General Medical Council and audits. A huge raft of issues has toughened up the accountability arrangements in the healthcare sector in general, and certainly in Belfast. Much has changed since 2001, and some of those changes came about specifically in response to this case. Other changes will help to ensure that such a situation is managed much better in the future.
Mr McKee:
As a consequence of the ombudsman’s report, the General Medical Council has indicated that it will conduct a preliminary investigation into the actions of all the doctors who were involved, and we have co-operated fully.
The Chairperson:
Is there a follow-up procedure that will examine the failures of those doctors, who are identified only by their initials in the ombudsman’s report? We have to bear in mind that we are talking about a human being — a mother and probably a grandmother. I do not know the full details of the lady’s case, but I remind everyone to be circumspect in how we treat the issue. Family members may be listening or will want to read the transcript of the Committee’s discussion. I want to place on record the Committee’s condolences to the family, who suffered such trauma because of these issues. The ombudsman’s report is damning.
William, how many serious complaints such as this one have there been since you were appointed as the trust’s chief executive? How many cases are pending concerning this type of complaint, which involves a death?
Mr McKee:
I am not sure that I can answer that question, Chairperson, without notice, but I will send you that information through the Committee Clerk. It is very rare for the ombudsman to make such a criticism of an incident. I served in my previous post for 10 years without having a formal complaint from the ombudsman. Such complaints are rare, and rightly so.
Like all trusts, the Belfast Health and Social Care Trust has a complaints subcommittee that is chaired by a non-executive director; reviews of the complaints received are brought to the board of directors through its assurance committee. Therefore, the complaint is discussed at board level, and a profile of the complaint, together with any lessons learned, is compiled. Many of those complaints are relatively minor and centre on poor communication or perceived poor communication. The committee of the board of directors focuses carefully on the more serious complaints, but a complaint from the ombudsman is quite exceptional.
The Chairperson:
I am interested only in complaints that concern someone dying in the trust’s care, and where the family believe that there has been negligence on the part of the doctor. I am not interested in complaints about communication, and so forth.
Ms S Ramsey:
The Committee should receive that information. I am aware that the complaints procedure in the Belfast Trust has improved. As a Belfast MLA, I am in touch with the trust regularly, and I am aware that procedures and the standard of communication have improved. Therefore, credit should be given where it is due.
William, you said that the issues such as the one under discussion are rare. However, that does not seem to be the case. Indeed, in the past year, the Committee has learned of incidents in other hospitals. Therefore, it might be useful if we compare some of the issues that the Committee has previously discussed. For example, last week, the Committee heard about the death of a mother in another hospital. The rise in those incidents could be because they are being reported more often, but the general public [Inaudible.]
You also said that there are lessons to be learned from the ombudsman’s report. Can I then ask you [Inaudible due to mobile phone interference.]
How does the Committee reprimand the system? If it is the system that has let the family down rather than individuals — some of whom have left this jurisdiction — we need to reassure the public that the system will be changed. The fact that a family, which were coping with the loss of their mother, have had to wait seven years for their complaint to be reviewed is an indictment on us. Therefore, we need to change the system.
I accept that the complaints procedure for minor cases has improved, but we also need to send out a clear message that the system is changing. If staff move on, is the General Medical Council still informed of the complaint? If it is not, those staff members could move on for a year and subsequently return without a blemish on their records. We must ensure that the council is aware of those complaints.
The key issue is post-mortems. An individual who has recently lost a family member and who is asked for permission to carry out a post-mortem on that family member automatically thinks of all the bad things that are associated with post-mortems. How do we square that circle? How do we ensure that we are protecting individuals and families while ensuring that they are being treated humanely?
You spoke about different management strategies, the weekly ward rounds and the attitudes of doctors in the internal review. It would be interesting for the Committee to receive a copy of those results so that it could analyse how matters have changed since the ombudsman’s report.
You have come to the Committee today and have admitted that something went wrong, even though you were not chief executive of the trust at that time. That is to be commended. However, we still need to convince the public that, although something did go wrong seven years ago, it will not happen again. We must also convince the public that the system will not fail again. The public must be made aware that the issue of post-mortems and the confusion concerning admittance will be addressed by the trust. Will you tell the Committee how that will be done?
Mr McKee:
Ms Ramsey raised several important issues. I will try to take them in sequence.
I wanted to convey the fact that an ombudsman’s report such as this one is rare. Nearly 3,000 deaths a year occur in Belfast Health and Social Care Trust facilities; those deaths are inevitable, given the nature of the care that we provide. Therefore, I agree with Ms Ramsey that there are always other situations in which family members are unhappy about the circumstances surrounding a relative’s death. I meant only to say that an ombudsman’s report such as this is rare.
I welcome your positive comments about the trust’s complaints procedure. Dr Stevens is responsible for that. We both believe that we have a long way to go. We have struggled to bring together six separate complaints procedures in order to make the process coherent, responsive to the complainant and capable of providing senior staff with information that enables us to learn from our mistakes. We hope to make more substantial progress in the next six months.
It is worth focusing on the seven-year delay. The current standard expects trusts to make a substantive reply — that is, a genuine attempt at a full reply — within 20 days in 70% of cases. That means that, in seven out of 10 cases, we should have given a substantive reply within 20 days of receiving a complaint. The process includes an acknowledgement of the initial complaint — whether by phone call, letter or email — within two working days. I cannot recall whether those standards were set in 2001.
The trust is not overly concerned about the number of complaints it receives. If an organisation has several million engagements with citizens, patients, clients, family members and staff every year, the proportionate level of complaint is very small. Dr Stevens will prompt me with a figure for the annual number of complaints that we receive.
Dr Stevens:
It is around 1,000.
Mr McKee:
That is against, potentially, several million opportunities for people to feel dissatisfied with the trust’s performance every year. In fact, many tens of millions of contacts take place that could result in unhappiness or dissatisfaction.
In fact, we would prefer to hear more complaints, because those that we receive are only a small sample of the level of dissatisfaction that people have with the trust’s services. We can demonstrate 97% satisfaction rates with our services. Even if that were accurate, 3% of all the contacts constitutes more than 1,000 complaints a year.
We are interested in how many complaints that we manage to resolve. The final paragraph of each letter from the trust in response to a complaint explains that, if complainants are unhappy with the response, they are free to take the issue to the relevant area health and social services board. `
Mrs Maguire’s family went to their local board, the Western Health and Social Services Board. That board has a formal procedure in which an investigation is led by a non-executive board member, who brings in someone from outside the board. A report is drawn up, to which we reply. That may require the Belfast Health and Social Care Trust to issue a second apology or to take further action. If the family remain unhappy, they can make a further complaint to the Northern Ireland Commissioner for Complaints. I accept that seven years is a long time. I am fairly confident that the Belfast City Hospital Trust responded reasonably promptly in the first instance. The standard that I have described was introduced after 2001.
Plans for restructuring health and social care are accompanied by an associated proposal that the second stage of any complaint should go straight to the Northern Ireland Commissioner for Complaints. There are benefits and disbenefits to that proposal, but that is a matter for politicians and their advisers. We will follow whatever new guidance is given.
The General Medical Council will investigate all doctors, regardless of their place of employment, who are on its register of medical practitioners. The council will not investigate doctors who no longer work in the United Kingdom and who are no longer registered, because its responsibilities extend only to those who wish to remain on the register.
Ms S Ramsey:
What is to prevent a doctor who wants to avoid investigation from working outside the United Kingdom for one year and then returning?
Mr McKee:
Normally, the General Medical Council maintains its register. From the early long list of doctors that the trust has been asked to name and refer to the council, only one doctor is no longer within its jurisdiction. He now works in south Asia
The issue of post-mortems is sensitive. Procedures have changed quite markedly since 2001. Under changes to the coroner’s rules, a coroner and his agents will be much more likely to conduct an investigation to decide whether a coronial post-mortem is appropriate. New rules were created to tighten up procedures following the Dr Shipman case. If that happened now, it would be more likely that the coroner and his advisers would decide whether a post-mortem should be carried out rather than the doctors at the trust.
At that time, staff were not provided, to any great extent, with training to deal with the sensitive issue of asking permission to conduct a post-mortem. Although some of the nursing notes were missing — which leaves us open to substantial criticism — there is a suggestion that some nursing staff had raised the issue but that the family were under no obligation to consent.
However, since the scandal surrounding the retention of human organs surfaced around seven years ago, a considerable amount of training in the sensitive handling of that issue has been undertaken. Each trust has experts who are able to deal with those matters and to provide training for staff. Health Service staff would now handle the issue of asking permission to conduct a post-mortem very differently than they might have been done six and a half or seven years ago.
We are happy to make available the policies to which we referred as evidence that we are doing what any reasonable trust could be expected to do to prevent such an incident from happening again.
The Chairperson:
If you forward that to our Committee Clerk, we can supply the members with copies.
Mr Gallagher:
I knew Mrs Maguire. She, like me, lived in County Fermanagh. The ombudsman’s report contains some very disturbing findings, which you acknowledged. I am sure that we all appreciate how harrowing and distressing that has been for the family.
What stage is the General Medical Council’s investigation at, and when is its outcome expected? Everyone accepts that there were some failings on the part of the professionals who were involved in Mrs Maguire’s care. You mentioned that new procedures have been put in place, which is good. You also acknowledged how important it is to continue to improve and review procedures, and that is fair enough.
However, as one who lives in a rural area, I want to focus on a point on behalf of everyone who lives in such areas. A sentence in the ombudsman’s report states:
“it was obvious that she was exceptionally weak and not fit to travel the some 90 miles back to her home in Fermanagh.”
An issue arises here, and I want to know whether your procedures take account of it. A 90-mile journey is very long and demanding, even for someone in good health. Was that ever a consideration? It should be a consideration across all the trusts. Everyone is entitled to proper treatment. Had this woman been from an urban area, she would also have been entitled to be cared for and treated properly, with all standards adhered to and procedures followed. However, there is a particular difference when someone must make a journey of 80, 90 or 100 miles on leaving hospital. The ongoing centralisation of services means that very ill people are being taken from right across rural Northern Ireland to Belfast. That is a serious situation. I do not see in any of the procedures an appreciation of the distance travelled when decisions are taken on whether people should be discharged, either on a whim or at their own request.
If a patient who lives in Belfast asks to be discharged from hospital, and is, he or she is not too far away to be readmitted to hospital if ill. However, if a patient is 80 miles or more from home, and may need have to be readmitted, that is a serious consideration. I mean to be reasonable.
Has that consideration been built into your procedures for all the hospitals in Belfast? It is a good thing to have them all under one trust. What do you think about the issue of people coming from rural areas to be treated in larger hospitals?
Mr McKee:
Tommy has asked two separate groups of questions. I will answer on the issue of rurality, and my colleague will update the Committee on where we are with the General Medical Council, and what we anticipate to be its next steps.
For Tony Stevens, one of the most distressing aspects of the case is that it was not a transfer from the Erne Hospital to the Belfast City Hospital. Rather, the family wished to do the very best for their frail, ill mother. They came to Belfast expecting a higher level of specialist treatment, and we failed them. There is a certain irony — I do not wish to make light of it — in the fact that the family made that extra effort, not to wait for an outpatient appointment, but to take their mother to Belfast City Hospital. She was admitted and was then allowed to discharge herself, which should not have happened. She came up from Fermanagh to A&E a few days later and was sent home. She then came up again. It is clear that the family thought they were doing the very best for their mother in seeking a higher level of treatment, and they did not get that.
I have to be honest with you, Tommy. We must place decisions on whether someone is admitted to hospital in the wider context — primarily their clinical condition — and then such issues as their family circumstances, and how far they have travelled, might be taken into account. It would not be appropriate to impose a blanket rule to the effect that, if one has travelled from Fermanagh, or from somewhere else west of the Bann, or from wherever, one will be admitted. Someone could be living in Fermanagh but working in the Belfast area. Therefore, if a person presented at A&E with a trivial ailment, it would not be appropriate for that person to be admitted.
However, your point is well made: when doctors make decisions about the pathway of treatment, they should take into account all the family circumstances. I cannot confirm from the notes in front of me, but I suspect that the doctor who made the decision not to admit Mrs Maguire on the first occasion is the same doctor who is not from the European Union. I may be making excuses, but he may not have been aware of the geography of the place, for example.
Dr Stevens:
Mrs Maguire was a terribly ill lady, and I am not sure that she or her family fully appreciated that fact. She had a life-limiting illness. The tragedy is that we failed to make the final period of her life as comfortable as possible, not necessarily that anything that we could have done would have changed that.
I must preface what my remarks about the GMC by saying that, because the severity of Mrs Maguire’s underlying problem, and the inevitability of what was likely to happen, did not necessarily come out in the ombudsman’s report. In a way, the tragedy for us is that, during that period of great distress for her family, we were not able to take a completely person- and family-centred approach. The system did not respond in the humane way in which we would have wanted it to.
An awful lot of doctors from the Belfast Health and Social Care Trust, or the then Belfast City Hospital, was involved in Mrs Maguire’s care, and all their names were sent to the GMC. However, there has not been a referral to the GMC. The GMC is aware of the case through the ombudsman’s report, and it made a direct enquiry to me about the case, and I provided the names of all the doctors involved.
A significant number of the doctors’ performance and behaviour is exemplary in this case. Therefore, we are not talking about every doctor who is mentioned in the report as having failed. One or two doctors made decisions that we now regret at critical points, and those are the decisions that led to the family’s distress.
The GMC is carrying out a preliminary review. It received all the information, and asked for the report and all the names. I provided all that, and the GMC is reviewing the entire case and every doctor’s part played in it, with a view to deciding whether, in any individual cases, it needs to conduct a full investigation. The GMC is not expected to investigate fully every doctor involved in the case, because I think that it will be satisfied from the evidence that the vast majority of doctors behaved in a good or exemplary way.
The Chairperson:
I disagree with you on one point: you say that the family were not aware of how seriously ill their mother was. They obviously were, because they bypassed their local hospital in order to travel 90 miles two or three times. Therefore, I question that particular point.
Dr Deeny:
Thank you, gentlemen, for explaining this very sad case. If I were this lady’s GP, I would be very upset, and if I were her son, I would be extremely upset. My sympathy goes out to the family.
The case raises a number of issues, and you say, Dr Stevens, that some of them have been addressed. I worked in a hospital way before 2001 — indeed, in the early 1980s, I worked as a junior doctor. When a person was admitted, no matter what his or her condition, it was always essential that a consultant see that patient as soon as possible.
It is inexcusable for a very ill lady to be driven that distance and not be seen by a consultant over a weekend. William, a point that you made twice raises the question of whether there are enough consultants in Northern Ireland. In 2001, there were not enough, because there was no consultant cover over weekends. A lack of consultant cover for holidays was also mentioned, and that is very worrying. In this case, the patient was brought to hospital by her family, but she had been referred urgently, and I am sure that that referral included a great deal of clinical detail. As an experienced GP, if I refer a patient to hospital, I expect a consultant to see him or her very quickly.
The case also calls communication among hospitals into question, and that is an issue that I have been preaching about for years. When a patient arrives at a hospital from another in a different trust, one would think that the two hospitals were in different jurisdictions — staff do not know what happened to patients in the hospital from which they have come. The Committee discussed a case in which there was dreadful communication between two psychiatric hospitals — one was in Belfast and the other was Gransha Hospital. If a patient is transferred between hospitals — for example, from one in the Western Trust to one in the Southern Trust or Belfast Trust — there must be immediate communication. Although the family brought the patient to hospital in the case that we are discussing, I am sure that a referral letter had arrived at the hospital to explain how ill she was. That letter should have been acted on.
You mentioned consultants. Not so long ago, I referred a patient with a mental-health problem. I was very concerned about him. Last month, I discovered that, after 11 weeks, he had still not seen a consultant. I rang the hospital and said that I would raise the issue with the Department, and he was seen days later. Again, junior doctors are making decisions, and a patient that I referred to a consultant psychiatrist was not seen. Thankfully, he is recovering.
Earlier, the Committee held an informal lunchtime meeting with senior representatives from the Royal College of Psychiatrists. Those representatives spoke of their concern that there is 100% bed occupancy for mental-health patients. The same situation is occurring with beds for patients with physical-health conditions. I am concerned that the two hospitals that I refer patients to are sending patients home from A&E. Many of my GP colleagues share that concern. A few weeks ago, one of my young patients was sent home from A&E at Craigavon Area Hospital. The child’s parents were told to bring the child back if its condition did not improve. The child was ill and had to be brought back to the hospital. On two occasions in the Western Trust, GPs received letters asking them to try not to admit patients to Altnagelvin Area Hospital, because it was full to capacity. The situation is serious if the two hospitals with which I work — Craigavon Hospital and Altnagelvin Hospital — are bursting at the seams. My view, and that of my colleagues, is that there is always 95% to 100% bed occupancy in those hospitals. What is the rate of bed occupancy in the Belfast Trust? On 15 December 2001, Mrs M should have been admitted to hospital, but that is a matter for the GMC.
I am trying not to defend doctors, but many of our junior doctors are being put under pressure to keep people out of hospital when senior GPs think that those people should be in hospital. A balance is required, and there must be a maximum of 85% to 90% bed occupancy, because beds are required for people who become very ill. Pressure is being put on junior staff to keep people out of hospital.
In recent years, the trend in hospitals has been to reduce the number of beds available to patients with mental- and physical-health problems. That is worrying, and GPs have compared it to trying to get a patient into a five-star hotel. Nowadays, patients must be practically dying on their feet to be admitted to hospital in Northern Ireland. That is a widespread problem, which does not apply to the Belfast trust alone.
Mr McKee:
Dr Deeny mentioned the transfer — it was not strictly a transfer from the Erne Hospital to the City Hospital. An outpatient appointment was booked, but the family, who wanted to do the best for their mother, took her to the City Hospital, where the gynaecology consultant admitted her. If she had attended an outpatient appointment, it would have been more than likely — or there would have been a reasonable chance — that she would have been subsequently admitted to a gynaecology ward. At the time, there was no duty roster for consultants to do ward rounds at the weekend. That has changed — what happened then would not happen now.
I cannot comment on whether there are too many or too few consultants compared with our other resources. It is arguable that, up to a reasonably infinitesimal amount, there is no such thing as too many consultants. The trouble with resourcing health and social care is that it is necessary to make choices about how best to balance resources. There are considerable variations in consultant numbers here, especially compared with elsewhere on these islands. Furthermore, our choice to have a richer pattern of individual hospital sites in Northern Ireland adds greater pressure. However, I am not an expert — there are people in the Department whose job it is to understand medical workforce issues in great depth.
By and large, occupancy rates in acute general hospitals are much higher than one would expect in an efficiently run ward or hospital. Moreover, rates are much higher than the occupancy rate for which we had planned. Therefore, in an attempt to address that problem, when new hospitals are built, we plan at an occupancy rate that is much lower than reality. In the Belfast Trust, occupancy rates are, on average, around 80%. Given the profile of services, particularly in central Belfast, that is high. However, the rate varies from between 75% and 80% to 100% and over. That may not make sense, but, according to our counting method, the occupancy rate in some hospitals is greater than 100%. That puts us under pressure, but we have limited resources to meet unlimited demand. In order to ease that pressure, we probably run hospitals at too high an occupancy rate. However, given the resource envelope that we must work with, no easy alternative exists.
Dr Deeny:
Many GPs agree with my view that the number of beds in acute hospitals — in both the physical- and mental-health sectors — has been reduced to such an extent that many patients are not admitted when necessary or are sent home too early. In that event, the burden returns to GPs, or else something disastrous occurs.
Mr McKee:
The Department of Finance and Personnel’s view — based on one aspect of the Appleby Report — is that productivity of staff in Northern Ireland’s hospitals is much lower than in Great Britain drives much of the downward financial pressure on trusts. Therefore, part of the drive with the existing staff complement is to increase the number of patients whom we treat.
The comprehensive spending review (CSR) that set our health budget requires us to treat the same number of patients with fewer staff over the next three years. We will have to manage bed occupancy carefully, and take other measures, in order to ensure that we do that. We are being driven by a wider agenda to seek even greater efficiencies, which will probably mean that, although modest investment will be made in community care, we will have to rely on fewer hospital beds in future to treat the same number of patients.
Mr Easton:
One of the major issues that has been raised is that of the doctor who came here from abroad. Measures are in place to ensure that doctors who come to the UK are vetted and properly qualified. Bearing in mind the mistakes that occurred, should stricter vetting procedures be adopted?
Dr Stevens:
Very strict arrangements are already in place. In fact, some of the national reforms that have taken place have made it much more difficult for people to come here to practise, from the Indian subcontinent in particular. EU rules, however, make it slightly more difficult to be selective when it comes to doctors coming here from European countries. We must accept specialist accreditation from all countries, irrespective of whether that accreditation matches our needs. The picture is mixed — the criteria for people coming here from outside the European Union are already very strict.
The case under discussion concerned a young doctor who almost certainly made some mistakes, but he was not the only doctor who made errors of judgement. I do not want the blame to be attached to one overseas doctor who is no longer in the UK to defend himself. Errors of judgement were also made elsewhere.
Mrs Hanna:
My sympathy goes out to that lady’s family. I do not know the circumstances in which she discharged herself from hospital. There are issues of confidentiality, but I know that her family were not aware that she had discharged herself. Is that the case?
Dr Stevens:
This is a really important issue. Mrs Maguire made a decision to discharge herself from hospital. She had made a similar decision previously at Erne Hospital. Our medical staff chose to accept that decision. They did not discuss it with the family but worked on the principle that she was capable of making her own decision. In fairness, that is strictly correct. Our staff had no right to go behind Mrs Maguire’s back to discuss the matter.
William McKee and I have hinted at how we feel about the situation. For me, the underlying story is one of a failure of communication at key moments. There was clearly a failure to provide Mrs Maguire with the relief that she required at a very difficult time in her life. However, there was equally a failure of communication. Opportunities were missed to bring the family informally into the decision-making process. If I were being strict, I would say that Mrs Maguire was perfectly capable of making her own decisions. She made those decisions, and the trust obliged and let her go home.
If I were to take a slightly more humane approach, I would say that we missed a trick. An opportunity arose to engage the family and perhaps help the decision-making process. Again, it comes back to my earlier point. I do not necessarily think that Mrs Maguire was completely aware of the seriousness of her situation. That was possibly a situation that she, and, indeed, her family might have wished for, because Mrs Maguire’s underlying medical condition presented a bleak prospect for her.
We were dealing with a very difficult situation. There was a lack of communication, and we did not get it right. That is not a strict interpretation — I can make a defence.
Mrs Hanna:
I appreciate that a tough call was made. However, Mrs Maguire was very ill when her son brought her to the City Hospital; therefore, he had a right to know that she had discharged herself. I appreciate that there are confidentiality issues around the case, but her family were obviously very concerned about her.
Mr McKee:
We accept that point.
Mrs Hanna:
There was a lack of communication and poor record keeping in the hospital. That cannot happen any more. I realise that medical staff are busy and that it is difficult to maintain records, but it is essential to keep them.
Finally, will the GMC’s preliminary report come into the public domain?
Dr Stevens:
It will come to me and, as far as I know, it will also appear in the public domain. If a formal investigation is carried out on a doctor, the information comes into the public domain. However, at this stage, the process is informal, and I do not know how much information the GMC will publish. If a decision is made to carry out a more formal investigation, it will come into the public domain.
The Chairperson:
I would have assumed that the family would be insistent that the information be made public.
Mrs McGill:
I, too, offer sympathy to Mrs Maguire’s family. The incident occurred in 2001, which someone said was some time ago, but I disagree. I am sure that it does not seem like such a long time ago to the family.
The ombudsman’s report makes for frightening reading. What makes it such is that people who should act professionally and ethically made a sequence of blatant failures.
The Chairperson:
We all agree with that sentiment. William and Tony, I would be grateful if you could forward the information on procedures to the Committee Clerk. Thank you for your attendance today.