Annabel

Justice for Doctors is a not-for-profit organisation. Their aim is to provide support and guidance to doctors and other healthcare professionals who have experienced or are experiencing discrimination, harassment, and bullying, and feel targeted because of whistleblowing. On 16 May 2024, Justice For Doctors held a landmark conference about doctors speaking up for patient safety at the Royal Society of Medicine. This opinion piece by Dr Annabel Bentley is part of a series on “safe spaces”. In it she reflects on the conference and some of the experiences shared by the doctors, journalists and patients who attended.  The NHS depends crucially on its reputation which is too often protected above all. Doctors say that when they raise patient safety concerns, they are mistreated by powerful trusts who investigate them, rather than the safety issues. In some cases, individual Trust reactions to staff raising whistleblowing concerns have been likened to that of a cult, where reputation is protected above all, even patient safety. It is part of a much bigger picture - the exposure of the realities of the institution that is NHS. This week’s publication of the Infected Blood Inquiry is the biggest and most costly NHS scandal. But it is all part of the same thing - the institution being valued above those it serves. Justice For Doctors conference Last week I was at the landmark conference held by Justice For Doctors at the Royal Society of Medicine in London. The day was led by Dr Salam Al-Sam, consultant histopathologist. As founder of Justice For Doctors, he’s created a safe space for doctors to talk. The event was chaired by Professor Jane Somerville, an eminent professor of cardiology at Imperial College who was involved in Britain’s first heart transplant in 1968. The room was packed, and more joined online - around 100 doctors, plus journalists and patients. A pattern emerging We heard stories of how doctors were targeted when they spoke up about avoidable deaths and serious harm in NHS hospitals where they worked. Their tales of being persecuted for speaking up - as is their duty - began to show a familiar pattern. One doctor recounted how they were told to come to a meeting with Trust managers. The doctor asked if they could bring their trade union representative with them but was told it was a ‘routine’ meeting and therefore not necessary. However, when they went to the meeting alone, they felt ambushed as managers told them that concerns had been raised about them, to leave the hospital immediately, go off on sick leave, and not talk to anyone about why. Feelings of betrayal and bafflement were common themes. One doctor said: “I feel a bit of an imposter. I’m not a whistleblower, I was doing my duty as a doctor. I felt that if I didn’t stick up for my patients, then no one else would.” Doctors spoke about how trusts used bullying tactics to silence and isolate them when they raised safety concerns. There seemed to be a common tactic emerging. Instead of investigating the concern, the Trust investigates the doctor who raised the concern. If that, combined with harassing the doctor, doesn’t trigger them to resign, the Trust then launches multiple lines of attacks; retaliatory General Medical Council referrals, maintaining high performance standards (MHPS) investigations, notifying other parties and smearing their reputation. That creates multiple jeopardy for the doctor. Doctors say that where this pattern plays out, a culture of fear sweeps the Trust. Dr Azhar Ansari, said he felt he had no choice but to leave his job after he raised concerns about staffing and deaths. “They made false allegations, basically that I was a madman,” he said. “They went after me rather than the patient safety concerns I was raising”. He had raised concerns about a patient who died of starvation. Dr Ansari said: “The culture I worked in, the doctors did not want me to come and see the patient. I was prevented from attending the inquest as a witness, despite being the Trust’s lead for inflammatory bowel disease”. Regardless, the coroner found the death was ‘contributed to by neglect’. The coroner’s report describes the lack of feeding for over a month, from the end June to 10 July 2017; ‘omission’ of nasogastric tube feed which ‘contributed to malnutrition’. Then from 11 July to the beginning of August 2017 it states; ‘failed to feed’ with total parenteral nutrition. Another story was shared by Mr Martyn Pitman, an obstetrician, who said he was confronted with retaliatory allegations of bullying and harassment after raising concerns about safety in maternity care. He said his trade union representative told him that trusts “deliberately extend it because they want to break you. They want to absolutely destroy you”. The founder of Justice for Doctors Dr Salam Al-Sam, who’s brought more than 140 doctors together, is being compared by some to Alan Bates the Post Office campaigner. Dr Al-Sam told me: “We all want to keep patients safe. Managers - including doctors in managerial positions - are abusing taxpayers’ money by spending it on persecuting doctors rather than fixing the patient safety issues they raised.” Strength in numbers More doctors and patients are finding their voices to speak up for patient safety. What was a trickle of stories in the media seems to be increasing - see recent reports in Westminster Confidential, The Times and the Telegraph. The next wave of action will be patients’ voices combining with doctors. There is strength in numbers and solidarity from banding together. I joined the Justice for Doctors conference with Dorit Young, whose 25 year old daughter Gaia died in University College London Hospital in July 2021 of an unexplained brain condition. Patient stories joining forces with Justice for Doctors is important. As Dr Al-Sam says “Justice for doctors is justice for patients and vice versa”. Related reading Professor Jane Somerville: Supporting doctors who speak up for patient safety Still not safe to speak up: NHS Staff Survey Results 2022 (Patient Safety Learning blog) Treated with callous disrespect: A bereaved mother’s tale of institutional apathy from the Coroner Service Truth For Gaia campaign Share your insights What did you think of Annabel's blog? Have you got insights to share around patient safety and raising concerns as a member of staff, patient or carer? Comment below (sign up for free first) or contact the team at [email protected]

A story of a bereaved mother’s experience with the Coroner's Service in the aftermath of her previously well 25-year-old daughter Gaia’s unexpected and unexplained death and why she set up TruthForGaia.com in her search for the truth.  This case demonstrates systemic failings in the Coroner Service: the dismissive way that bereaved family members are treated through the inquest process and a lack of clinical curiosity to determine the primary cause of death.  This inconclusive inquest prompts wider questions about who speaks up for the dead. Just as we have Martha’s rule in life, should there be a Gaia’s rule in death to help families be heard about failed inquests? Gaia’s death and failed inquest are chilling reminders that this could happen to any one of us and our families. It was a beautiful sunny summer’s day. Twenty-five year old Gaia Young had been out for a gentle bike ride to do some shopping, came home and had an ice cream in the garden in north London that afternoon. Just hours later she was dead . Gaia, the only daughter of Dorit Young, died of an unexplained brain condition after an emergency admission to a London teaching hospital on a Saturday night in July 2021. I spoke to her mother Dorit about what happened and how she has had to embark on her own search for the truth. Dorit said: “Although her death sent shockwaves through the hospital, it remains unexplained despite hospital investigations and an inconclusive Coroner’s inquest. “I have had to do my own investigation. I set up TruthForGaia.com for medical crowdsourcing and in the hope it may contribute to wider learnings." The inquest was held in February 2022, six months after Gaia died. Dorit said: “I was treated with callous disrespect through the inquest process. “I was in no way treated in line with the stated goal of 'placing bereaved families at the heart of the Coroner Service' [1]. My experience was the very opposite – it has added to the pain of my grief. “What I experienced should not be allowed to happen to any bereaved family. There were a series of failings which show the Coroner Service for Inner North London is not fit for purpose.” Dorit added: “I rightfully published my daughter’s medical records and coronial documents on my website despite heavy resistance by the hospital Trust and the Coroner." The Times reported that the inquest was "uninformed and uninformative".[2] Dorit told me the facts of what happened: The court hearing lasted less than a day. She believes this is insufficient for the unexpected and unexplained death of a healthy 25-year-old woman in hospital with a brain condition. The inquest was about complex medical issues which she found emotionally draining. She gladly accepted the 10 minute break for lunch the coroner offered! Her questions to the Coroner's court in advance of the hearing were proportionate and relevant to finding out the cause of her daughter's death. She asked in advance of the hearing about a differential diagnosis of metabolic encephalopathy (brain condition), but her submission[3] was disregarded. There was also striking lack of curiosity by the hospital – the Trust includes the UK's leading neurology hospital – in the investigation of how Gaia died. There were no independent experts giving evidence other than the two pathologists; there were no independent clinicians to give evidence on the care provided. The hospital was permitted to investigate itself in an independent judicial process; there was no external scrutiny. The coroner and the hospital opposed her request for a neurologist and other experts to attend. See her submission.[3] Dorit’s questions at the inquest about fundoscopy and Gaia’s brain “coning” (being squeezed down) due to raised intracranial pressure (high pressure inside the skull) could not be answered properly because the witness chosen by the hospital was an Accident & Emergency (A&E) consultant, so not best able to answer her neurological questions. At the inquest itself, Dorit says the Coroner shut her down when she tried to ask questions. She felt she was shown little empathy and was stopped from telling her side of Gaia’s story. Dorit said the Coroner did not allow her to read out her personal statement. You can read for yourself how this happened in pages 31 –34 of the Coroner’s transcript.[4] If anyone reading this article knows a bereaved family who has had a poor experience with the Coroner Service, let them know they can share their story with the public inquiry into The Coroner Service: The Follow-Up. The window is open until 15 January and submissions will be published on the government website. Dorit has made her submission to the government inquiry and you can read it in full on her campaign website.[5] References UK Parliament. Justice Committee launches new inquiry into the Coroner Service to examine progress; 20 November 2023. Catherine Baksi and Jonathan Ames. Mother may win new hearing into headache death. The Times; 16 October 2023. Dorit’s investigation – memorandum submission January 2023. Approved transcript of Coroners Inquest 14 February 2022. House of Commons. Justice Committee inquiry. The Coroner Service: follow-up Submission of Dorit.

In the past, long before Covid, doctors used to openly discuss complex cases and unexpected deaths on an anonymous basis either in the doctors' mess or in medical grand rounds hosted by their hospital’s clinical education department. What's happened to these forums for learning? Are these clinical conversations alive and well, and helping doctors and nurses alike to learn from safety incidents? Or have medical grand rounds disappeared from practice? At the Safety for All conference held at the Royal College of Physicians in December, I heard a huge number of experts call for new ways to improve safety. The event was hosted by Patient Safety Learning, a charity leading the way to galvanise people to take action on safety. I was prompted to ask about medical grand rounds as a way to discuss medical errors and a safe place for safety discussions. These discussions may well have transformed into WhatsApp chats or video calls – but I hope the medical grand round with many different specialties joining in still takes place, even if it takes a virtual form for our new digital age. My interests when I was a junior doctor included medical evidence, how to communicate clinical risk and emerging threats to health. I was an active participant in medical grand rounds, which meant sitting in a lecture theatre in King's College Hospital. I caught up with one of my alumni from King's College Hospital, Dr Raza Malik, now Chief of Hepatology, Lahey Hospital & Medical Center, Massachusetts, and he said: “I loved medical grand rounds at King's College Hospital with giants in medicine inspiring me to maximise my potential as a physician to enhance clinical care and improve human health”. Dr Malik’s career has taken him to all corners of the globe, starting with the NHS in the UK, volunteering in Malaysia and Borneo through to Australia and finally landing in the USA as the Chief of Hepatology at one of the largest liver units in the world. He says this is “ironic because King's is where it all started and is itself the first and largest liver transplant unit in Europe.” Dr Malik believes grand rounds are crucial for education, saying they “provide an academic forum to critically evaluate complex cases in a multidisciplinary format that is unique in medicine and critical for clinical care and education.“ Can grand rounds be a useful forum for learning from medical errors? I heard from Dr Phil Batty, President of the Independent Doctors Federation, who said: “The most important aspect in learning from medical errors is the culture of the doctor and the team or organisation in which they work. Recognising mistakes is the first step. The vast majority of caring doctors will find mistakes painful because they care. Overcoming the dissonance of denial is the first step” Dr Batty said it works better when colleagues, family and a structure within an organisation support a learning environment. “Often mistakes are multifactorial and a safe learning environment facilitates learning for individuals and systems.” In the private sector, medical grand rounds are alive and well. Dr Batty says “doctors learn from auditing their work, patient feedback, morbidity and mortality meetings” and that “ideally we learn from others' mistakes, but inevitably we make mistakes ourselves. Doctors are humans and nobody is perfect”. Dr Batty is optimistic that sharing mistakes openly and transparently with colleagues is the most powerful learning tool, but a support network needs to be in place because it can be “challenging for the individuals concerned who need support.” Discussing medical errors and sharing learnings from mistakes is a longstanding part of continuing professional education, highlighted 20 years’ ago by Dr Richard Smith, former-editor of the BMJ who said in a blog: "All life is mistakes. The more mistakes you make, the better." Mistakes are great teachers, but they also allow us to get through the day. Try to spend a day without making a mistake, and you’ll do nothing. So I find it hard as I survey 52 years of mistakes to pick my biggest. I’m spoilt for choice..." The mistake Dr Smith chose to discuss was about deciding to not treat a patient and simply tucking him up in bed. "This was a mistake with wholly positive outcomes. The patient did well—and might not have done if we’d tried some heroic treatment. I learnt about the severe limitations of medicine and that I was a fool. Only unthinking fools could have decided to leave a man to die without learning more about him and talking directly to his relatives. I couldn’t claim now not to be a fool, but that mistake made me a wiser fool."[1] Doctors and clinicians need to be able to discuss cases and incidents for learnings openly. Medical grand rounds are a great way to bring a wide range of different specialists together to bring fresh perspectives to solve tricky cases. We need to encourage transparency and safe spaces for doctors and nurses to speak up. I hope that learning keeps evolving and grand rounds adapt for the digital age. References Smith R. Tell us your greatest mistake and what you learnt from it. BMJ 2004. Accessed on 11 December 2023. https://www.bmj.com/content/suppl/2004/11/11/329.7474.DC3. I'd love to hear from you. Do medical grand rounds still exist? What do you do in your organisation? Comment below. (You will need to be a member of the hub, and signed in. Membership is free and you can sign up here.)