Thursday, 5 March 2009

You get what you pay for, less training more mistakes

With kind permission from the author I have reproduced the following tale to show how quite simply less training leads to more mistakes and a lower quality of care:

"Not so long ago, in a land not far from here, a young boy awoke one morning with a painful tummy.

"Daddy!" he cried. "My tummy's hurting."

The father looked down at his dear son and said, "Don't worry, O son, for I know a Wise Woman who will be able to cure your pain. Let us go and visit her."

And so, the family made haste their travel to the local Walk-In Centre, where the friendly nurse greeted them with a warm smile. "Come in, and tell me all about it," she said. And the young boy proceeded to tell the Wise Woman of his painful tummy."This is nothing to worry about!" she declared in a very wise and motherly way. "Be gone, for your pain is due to a virus."

The Wise Woman did not need to examine the young boy, for she had been on a "couple of courses."

The family thanked the Wise Woman for her great wisdom and made good their journey home.2 days later, the post-mortem report concluded that the boy had died from a perforated appendix.

The morals of this story are that:

1: When you assess a patient, you often have to examine them.
2: If you do not know how to examine a patient, you should not be assessing them.
3: Sometimes it takes a few disasters before mistakes in policies are addressed.
4: Nurses, as with doctors, have a duty of care to their patients. If that duty is breached and harm results, then they are NEGLIGENT.
5: After a few civil cases, nurses in WICs will realise that they are on their own, in a failed policy.
6: The public should be fully informed when consenting to treatment: "You get what you pay for."

Wise words. I am not pretending doctors are perfect, far from it, however less training results in worse care, it's very very simple.

25 comments:

Lucien Sanchez said...

Funnily enough, I was having a natter with the missus the other night about protocol-driven assessment by the untrained and how it'll unfortunately take a few kids given viral advice and succumbing to perforated appendicitis or meningococcaemia before some of the suits realise the flaw in their crafty money-saving scheme.

Being right is a bittersweet sensation when dead kids are involved.

Henry North London said...

Hello Ferret Fancy doing a piece on how the GMC are being nasty?

-----Original Message-----
From: Gillian Needham
Sent: 19 July 2008 10:18
To: PAICE, Elisabeth
Subject: Re: FW: DNUK
Thanks Lis. Quite shocking.
I will discreetly pursue.
Thank you.
Gx
>>> "PAICE, Elisabeth" 19/07/08 09:08 >>>
Dear Gillian
I thought I should bring the letter below to your attention. It is a posting on DNUK from a doctor whose DNUK profile identifies him as xxxxxxx, an StR year 3 in general surgery. He signs off as 'from Inverness' so I imagine he is one of yours. I read the DNUK fora from time to time and came across his posting in the 'air your views to the media' forum, which clearly states it is open to journalists.It is therefore intended as a public statement of his views. I wrote to Sir Cyril Chantler, who is the chair of the DNUK board, as soon as I saw it. It has now been modified with all the scatological languiage removed. I have been assured that further steps will be taken to stop this kind of behaviour. I thought you should be aware, as you may feel that this posting, which was up for at least 5 days before it was altered, is evidence of unprofessional behaviour in one of your trainees. He may of course be unwell. I would be grateful if you would not circulate this further than absolutely necessary, as the fewer people read it the better.
Kind regards
Lis


This email is at the GMC headquarters

The bitch actually tried to libel him

the a&e charge nurse said...

A woman wants an investigation into a GP who she claims misdiagnosed her appendicitis as a stomach bug.
Christy Millar, 21, from Ellesmere Port, Cheshire, was given an injection and sent home by a doctor at the Urgent Care 24 clinic in Liverpool last May.

Her appendix burst 48 hours later, leaving her in a six-week coma.

Miss Millar's family has reported the doctor to the General Medical Council (GMC). The clinic says it will co-operate with any investigation.

Miss Millar now needs kidney dialysis three times a week and will eventually require a kidney transplant.

http://news.bbc.co.uk/1/hi/england/merseyside/6358273.stm

Garth Marenghi said...

AE CN,

the point is still there and no matter how much you ignore it, it will not go away!

the facts of the case you quote are not mentioned, the GP may well have examined the patient properly and may well have acted completely properly, these things sometimes happen,

he may have been negligent, doctors do make mistakes and some doctors are better than others, it's hardly rocket science!

the point is that people who are trained less, for example NPs who are trained to examine with a couple of weeks of crappy dumbed down examination courses, in comparison to years of proper training at medical school, are very unsafe to be let loose to practice medicine independently,

less training, more cock ups, it's simple, it's true, denial does no one no good

the a&e charge nurse said...

Ferret - doctors have been missing appendicitis (and meningitis) since I were a lad (see post above).

They will continue to do so until EVERY case of vague abdominal symptoms is admitted to hospital for observation.

As you know initial symptoms of appendicitis can be vague so even the most skilled clinician must rely on the patient being able to follow sensible discharge in some cases.

It is impossible to tell from your anecdote if the nurse is guilty of anything more than simply being a quack ?

the a&e charge nurse said...

Oops - should say ...... sensible discharge advice (in some cases).

jayann said...

Not only appendicitis, charge nurse. My father had to threaten a GP to make him get my mother admitted to hospital (severe abdominal pain, fever; she, who never took to her bed, could not rise). We thought it was appendicitis; the GP thought it wasn't worth bothering with... ; the hospital (yes, the threat worked) admitted her from A & E, and operated. (Inflamed abdominal cyst.)

Rachel said...

A&E charge nurse - you've missed the point entirely.
This child was NOT EXAMINED!!
Anyone - be they doctor, nurse, or janitor - who puts themself in a position to make diagnostic decisions about patients should know you can't exclude appendicitis without touching the tummy. Children with painful bellies get examined, this is basic stuff.
Getting it wrong when you've done all you can and all you should is unfortunately just the way the cookie crumbles, fucking up because you didn't look for the problem is negligent.

the a&e charge nurse said...

Rachel - isn't the point of the post to highlight how nurse-quacks (who have done a couple of courses) are now killing children ?

Anyway, Jayann's experience (above) illustrates perfectly how the intuition of relatives is often the most significant factor in a consultation - I hope your Mum recovered, satisfactorily, Jayann.

Incidentally, Rachel, do you have a view on the paediatric consultant who failed to detect a spinal fracture amongst many other injuries in the Baby P case (allegedly due to lack of examination).

Garth Marenghi said...

denial.

less training more mistakes.

the child was not even examined.

jayann said...

charge nurse, she was fine, thank you, eventually. (That was a long time ago -- nearly fifty years ago.) But how she'd have been if she hadn't been taken to hospital then, I dread to think. Thank goodness for fathers who'd get Zero Toleranced today... .


(Intuitions of relatives; yes, well, a failure to see that relatives may know the patient so well as to have valid insight into their condition, remains.)

Garth, my mother wasn't examined. The GP failed to examine her *and* took no note of our concerns.

I agree that "less training = more mistakes" absent an understanding by the less trained of what their limits are. But I am most unhappy about the use of this little parable as a stick to attack nurses. It is a vague anecdote par excellence and we all know what smartarse doctors say about anecdotes and data...

the a&e charge nurse said...

Ferret - the formula you seem to be expounding is:
One rubbish = ALL rubbish
(providing they are not doctors).

Actually, I AGREE with you that nurse quacks should not be seeing sick children (unless it's part of a multi-disciplinary process, including medics).

Having said that, many doctors seem to become rather reticent when it is one of their own who screw up, for example, I do not recall you gloating in quite the same way about the paediatric consultant who failed to exam Baby P (allegedly).

Before slagging nurses off you should get your own house in order - look at this.

"A GP who failed to examine a patient adequately hours before he died of heart failure was found guilty of serious professional misconduct yesterday.
Dr Herbert Montague-Brown acted in an "inappropriate and irresponsible" way when he visited Richard Joiner at his home in the early hours of July 5 1998, the General Medical Council's professional conduct committee ruled.
Instead of checking his blood pressure and pulse, Dr Montague-Brown injected him with double the recommended dose of an anti-nausea drug to stop his vomiting and advised him to see his regular GP the next day.
Mr Joiner, 55, from Canvey Island, Essex, died several hours later from coronary artery thrombosis. Mary Clark-Glass, chairman of the GMC committee, told Dr Montague-Brown: "It was your responsibility to ensure that you had obtained an adequate medical history. You did not do so."
She said: "Nor did you perform an adequate physical examination or make an adequate record of your consultation. Your conduct . . . fell seriously short of the standards expected of doctors." Earlier Mr Joiner's wife, Marilyn, told the hearing that the GP ignored her concerns about her husband's excessive vomiting and low blood pressure".

http://www.telegraph.co.uk/news/uknews/1331676/Patient-died-after-GP-doing-two-jobs-did-not-test-heart.htm

Another one to be swept under the carpet, eh ?

Garth Marenghi said...

less trained more mistakes,

the same is true for the less experienced doctors coming through some of the dumbed down modern medical schools,

an insight into one's own limitations is very important and often the less trained one is, the more unaware of one's ignorance one is

the a&e charge nurse said...

Ferret - think of the provenance of these sayings:

August = the killing season
(referring to each fresh wave of newly qualified doctors).

Or, you're not truly a doctor, until you have killed a patient.

Or, the sickest cared for by the thickest
(a reference to the lack of medical seniority during night shifts or over bank-holidays).

Medical inexperience is an inescapable fact of life. Even the very best doctors have to learn their trade and to a greater or lesser extent this comes at a cost to some patients.

In my view, nurse quacks (with years of experience in a given specialty) can sort out certain types of cases safely and effectively.
This claim is supported by the research evidence.

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the a&e charge nurse said...

Lucien - do you think the GP and nurse worked at the same walk-in-centre ?

"A toddler suffering from meningitis was told by a doctor she had suffered a splinter and given a sticking plaster, her furious mother said today.

Kadi Bulloch almost lost her foot when septicaemia struck and needed five days of intensive care before beginning her recovery.

Stephanie Bulloch, from Middleton St George, County Durham, said she took her daughter to an NHS walk-in centre in Darlington after spotting a tell-tale pinprick on her hand on February 23.

Ms Bulloch said: 'I took her to the doctors and he said it was a splinter and put a plaster on it".

http://www.dailymail.co.uk/health/article-1161193/Meningitis-toddler-sent-home-plaster-doctor-said-splinter.html

jayann said...

this GP, too? -- a hospital doctor in this case, too...

http://www.dailymail.co.uk/news/article-1160894/Grow-stop-worrying-What-doctor-said-X-Factor-singer-months-killed-cancerous-tumours.html

Garth Marenghi said...

relying on the daily mail for your stories, oh dear oh dear

if you read the stories they are clearly spun out of all proportion,

the story I tell is of a child with abdominal pain who was not examined,

it doesn't even need sensationalising

less training and education, dumber service and more mistakes,

HCAs replace nurses, technicians replace paramedics, practitioners replace medical degrees, PCSOs replace police officers and on and on

maybe the message will get through the brick wall eventually

these short cuts are economically inefficient as well as being dangerous

the a&e charge nurse said...

Not just the Daily Mail, Ferret.

Allegations against doctors are being heard everyday by the GMC (fitness to practice hearings).
Interestingly the case against Dr Andrew Wakefield will be heard today (16th March).

See here
http://www.gmcpressoffice.org.uk/apps/news/events/index.php?key=0

As I say I agree with you about limiting the role of NPs - seeing children, for example, is fraught with danger, but irrespective of either of our opinions the nurse quacks are here to stay.

Darzi & Johno are converts, allegedly ;o)

jayann said...

Agree on Daily Mail; but there's no need to rely on it for that story. The coroner's narrative verdict has now been given. The story's been covered by the Telegraph, ITN, Sky News, The BBC, the local papers (Hull/Yorkshire) and so on.

It's a mistake to think that because the Mail is a right wing zenophobic right wing rag, everything it says is wrong. It's also a mistake (IMO) not to check papers (etc.) of more than one political persuasion, and to rely on broadsheets only.

the story I tell is of a child with abdominal pain who was not examined,

it doesn't even need sensationalising


right; it did not need to be twee and silly and sarcastic and juvenile ('wise woman' etc.); but presumably you could not resist that. Not only am I not a nurse, I've been known to criticise nurses heavily. But your little cautionary tale raised my hackles.

And it remains a story we cannot check; the story I gave most certainly can be checked.

We are all agreed on the basic point about training.

the a&e charge nurse said...

Yes, Ferret - supply us with the link, or is it an apophrycal tale from the secretive DNUK ?

Henry North London said...

Dont you mean apocryphal

At least dont show yourself up by not being able to spell

the a&e charge nurse said...

I'm sure you correct HNL, spelling was never my strong point - my main point still stands though, I think Ferret should share his source with us.

Anonymous said...

This is no different than the countless mothers who have been falsely accused of MSBP and their children have died.

Having spent years on the subject of MSBP none are of abuse but of NEGLIGENT treatment by doctors.

Yep, they all keep their jobs and woefully incompetent.

It is policy that needs to change.

Virus is very easy to diagnose - serious illness not but when they start messing up then the allegations come.

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