Dear Editor,
Please permit me to respond to an editorial by the Stabroek News titled `Death of three children’ in yesterday’s edition.
Stabroek News had this to say, “It is noteworthy that it took the GPHC more than six weeks to deliver a report on the deaths. That is completely unacceptable for what was a straightforward investigation.” Has Stabroek News ever investigated a Serious Untoward Incident (SUI) before? How do they know six weeks is too long? How do they know it’s a straightforward investigation? Please permit me to highlight the folly in that statement.
When there is an investigation into an unexpected death, firstly the Terms Of Reference (TOR) of the investigation needs to be formulated. The death did not occur in isolation. A sequence of events occurred which resulted in the deaths. That sequence of events needs to be identified and the most appropriate process needs to be determined to investigate that sequence of events. Also in formulating the TOR, appropriate witnesses need to be identified. This preliminary TOR is then shared with the parties involved for their comments and the comments and amendments of their representatives and lawyers. This process can take up to two weeks minimum. The fact is that this is a legal process and needs to be able to stand up to legal scrutiny. Once that TOR hurdle is overcome then statements are taken. Stabroek News may believe that statements are only taken from the two doctors involved. Wrong. The whole department should provide statements to give a complete picture of what happens on that ward daily. Was this unsupervised junior an isolated event? Were there near misses that were never investigated? This process may take up to six weeks for each death. The reason being is that healthcare professionals are busy. They cannot leave the other patients to die so that they can provide a statement. The investigators need to work around their schedules. Then the post-mortem. In a previous letter, I explained why they were inconclusive. So it was likely toxicology and body samples were taken. This can take up to eight weeks to be reported on. These toxicology tests are not done in Guyana hence are taken overseas. We can add another two weeks to that. Then the investigators read the statements, read the post-mortem reports and read the toxicology report before making a final report on the deaths. For each death, this can take a good week.
So in total, if done thoroughly investigations can take up to 25 weeks. If some investigations are run concurrently then this can be reduced but clearly not less than six weeks as Stabroek News is suggesting.
Secondly Stabroek News is suggesting that investigations of these deaths were straightforward. Wrong. You have that silly position and a below average defence attorney will destroy you on the witness stand. No death investigation is straightforward. It’s a legal process hence needs to be done thoroughly.
Stabroek News further had this to say, “The sequence of events shows clearly that GPHC has major problems with the quality and supervision of its staff.” Let me share these experiences with the readers. I had worked in Guyana for a little under two years after medical school. Most times as a junior doctor I was unsupervised. We were unsupervised. The senior doctors who should be supervising us were at their private practices or private hospitals despite being paid by GPHC. They were paid to be eight hours at GPHC but if they spent two hours they spent a lot.
The fact is, the evidence shows that most health care errors are down to system failures. That’s a fact. When a doctor makes an error that is just the symptom of a failing healthcare system. A well-functioning system supports doctors, ensures doctors are adequately trained and supervised, ensures that for doctors claiming to be specialists that their credentials are scrutinised, ensures that a medical council is fit for purpose etc. I know everyone would be calling for the head of the doctor who administered the drugs. I would suggest caution on this position. The junior clearly made a series of errors. The fact that it was repeated three times would suggest that there was a knowledge gap. He/she clearly did not know an error was being made. Where was the senior supervising doctor? Dereliction of duty.
As consultants in the UK when things go wrong we as the attending consultants take ultimate responsibility. We face the coroner’s court to explain what went wrong. We face the patient’s relative to explain what went wrong. It is irrelevant if we were not present when the error occurred. It is irrelevant if we had not known about the patient. We are the responsible consultants for those patients- The buck stops with us. I say this to highlight the fact that whoever was the senior doctor supervising that junior doctor has to take ultimate responsibility. The junior was undertaking a medical intervention on his/her behalf. It was his/her responsibility to ensure that the junior doctor was adequately trained and supervised. The junior doctor should be supported and not made a scapegoat.
I would hope that these deaths be a stimulus for a complete revamp of the healthcare system. Their deaths should not be in vain. Rename that paediatric oncology department after them. Let their voices drive the ministers to make those changes. Revamp the Medical Council. Doctors investigating doctors is completely shocking to the rational mind. Who is there for the patients? Revamp GPHC. Focus on the simple and forget about the tertiary centre complex services. GPHC is not a tertiary centre. It lacks the medical skills, expertise and investigatory tools among other things, as evident by this tragedy. Revamp and focus on the health centres. Preventive medicine is what third world countries should focus on. The health centres need adequate staff. Nurses, pharmacist etc. No junior doctor should be working at a health centre unsupervised. Have systems in place where doctors and nurses are appraised regularly. Empower patients to provide feedback on the care doctors and nurses have provided. Make it simple for patients to make complaints. Support them during the complaints process. Deficient doctors and nurses should be provided opportunities to develop their skills. Make medicine in Guyana, patient-centred and not healthcare professional-centred.
Yours faithfully,
Dr. Mark Devonish
MBBS MSc MRCP(UK)
FRCP(Edin)
Consultant Acute Medicine
Nottingham University Hospital
UK
