16 June 2000
As a gynaecologist who worked in the UK for 14 years after being struck off in Canada faced a General Medical Council disciplinary hearing, Health Secretary Alan Milburn said at least 850,000 adverse incidents occurred in hospitals each year, and these cost more than £2bn.
Doctors have been beset by a spate of incidents of alleged incompetence, which have damaged public confidence. New allegations emerged involving a retired pathologist working as a locum who is said to have missed positive cancer tests.
Milburn has asked the new standards watchdog, the Commission for Health Improvement, to investigate the doctor's work.
England's chief medical officer, Liam Donaldson, said a new register, to be implemented by the end of the year, would act as an early warning system. All failures, mistakes, errors and near-misses would be logged while a central database would be used to analyse the data and share its lessons. It will replace the current, patchily implemented adverse incidents reporting system.
Professor Donaldson said the NHS must adopt the approach used in the aviation and other industries to analyse mistakes and failures.
'The culture of the NHS must change from a closed, blame-centred culture, to an open, learning one. We must not only ask the question "who made the mistake?" but "what features of the health organisation created the conditions where mistakes were more likely?"'
The British Medical Association welcomed the new register. 'Such a system could well have stopped some of the problems that have recently come to light,' said Ian Bogle, the BMA's chairman.
'It will help strengthen patients' trust in their doctors not just by highlighting problems but by showing that, as Alan Milburn said at the weekend, Britain has some of the finest doctors in the world.'
In the latest case to emerge this week, the Commission for Health Improvement will be asked to assess the work of Dr James Stanley Elwood from July 1994 to January 2000 at Swindon and Marlborough, Mid Sussex, Frimley Park Hospital and the Royal United Bath Hospital trusts.
A review of more than 10,000 cases has revealed seven patients who were misdiagnosed and subsequently suffered serious consequences.
PFjun2000
