A man died after I didn’t speak up, and I still feel guilty about it, says DR SCURR. But second opinions aren’t enough to save lives – it’s the culture of hospitals that has to change

The tragic death of 13-year-old Martha Mills following poor, possibly negligent care at a major London hospital brought back bitter memories of the death of one of my own patients.

It also confirmed for me why, sadly, the plan to introduce Martha’s rule — which would give every patient in hospital the right to a second opinion from other experts at the same hospital — won’t help.

In February, the Government announced that hospitals in England were to be offered funding to roll out the rule. Already 143 have signed up, it was reported today, and should be operating the scheme by 2025.

Martha’s parents have been heroic in their efforts to try to spare others the awful, needless loss of a loved one.

But Martha’s rule, while laudable, cannot, I am afraid, do one thing that’s vital to its success: and that is to change our hospital culture.

I don’t mean just that people are afraid to speak up, to challenge the hierarchy of senior doctors, for that is still an issue (although it is improving, slowly).

I mean the lack of continuity of care — no longer taking full responsibility for a patient for their whole hospital ‘journey’ — which came when the structure of hospital care changed from the late 1990s.

There’s no doubt that when you have concerns, questioning the doctor is an entirely acceptable and justified approach. And it can save lives.

I have never forgiven myself for not intervening more aggressively on one of my own patient’s behalf, with hindsight knowing that if I had, he would have survived.

The only way to stop preventable deaths occurring in the NHS is to change our hospital culture, writes Dr Martin Scurr

He’d taken himself to A&E — as in Martha’s case, to a top London hospital (although a different one) — on a Friday night with a high temperature, rigors (sweating and shivering) and severe pain down one side of his abdomen.

Yes, he was nearly 90 and had type 2 diabetes and a history of heart surgery, but until the day he fell ill with a kidney infection, he’d been able to work — full time.

Always dressed in a three-piece suit and the upright bearing of a gentleman, he was the image of how many of us would like to be seen at that seniority: elegant and cognitively intact.

But when I went to the hospital to see him on the Monday afternoon after my morning appointments — with three days’ beard growth, desperately ill with developing sepsis, dehydrated and now slightly confused — he was lying parked in a corner bed, where he’d spent all weekend on a small dose of an antibiotic, by mouth: with sepsis he should have been on an antibiotic drip.

I was worried about his state and I phoned the consultant (the ward staff were unhelpful, but I found the name of the consultant over the head of the bed).

The consultant told me that as it was nearly 5pm, the patient would now be handed over to a new team.

That was where I should have intervened — even though as just his GP, I had as much authority as any loved one.

What my patient needed was immediate intensive care, but as I suspect many medics would do, I deferred to the hierarchy — I was treading on territory where I had no mandate, hoping instead that the consultant would inform the colleague who was about to take over, about my concern.

But I should have stepped over that invisible line.

For while those who cared for him in the real world knew this man in his normal, healthy and magnificent self, the hospital team clearly viewed him as a pre-terminal geriatric with a urinary infection.

He died the next day having received minimal care with nobody keeping an eye on him to witness his rapid deterioration.

I took his death very badly. I felt very guilty that I had not intervened more successfully.

As I see it, a major contribution to this sort of tragedy is fragmentation of care — lack of continuity under one single hospital team.

This is the result of the loss of the old system where care was provided by a traditional ‘firm’, a team headed by one or two consultants with senior registrars (just below the level of consultant), registrars, senior house officers (two to three years out of medical school) and housemen (recent graduates from medical school).

In the old ‘firm’ system there was accountability going up through each level of the team: the most junior members saw the most of the patients and when things went badly, they aired their concerns with the next level up; for example, to the registrar, who may well discuss with the senior registrar, and at times the consultant was then involved.

This might sound like a recipe for ‘group think’, a sort of mindless consensus of opinion — but my argument would be that the recurrent audit and introspection about whether the right action is being taken countered that.

Also, it was not unheard of for a consultant or senior registrar to make a decision to ask another team to come and have a look — a sort of joint team meeting.

The sense of responsibility of the firm meant you would often see the senior doctors pop in on the weekend if they were worried about a particular patient.

But in my patient’s case, the old type of ‘firm’ had long gone (the victim of the shift in power to management and new restrictions on working hours). It was a weekend and so there was probably only one harassed junior doctor around, there was no Saturday ward round, probably nobody came to see my patient at all unless maybe one of the nursing team called the duty doctor to come along, who may have then shrugged their shoulders and noted that this was an old person on their way out…

The old tight-knit team — caring for patients right through the duration of their period of treatment, holding full responsibility — has evolved into what we have now, with experience and increasing responsibility (and full accountability) lost.

We will never get the genie back into the bottle and no amount of increased regulation or Care Quality Commission inspections and sanctions can possibly achieve the diligence of the past.

Nor will a legal framework, Martha’s rule, enforcing the option of a second opinion when requested.

Despite its undoubtedly good intentions, driven by such heartbreaking and needless tragedy, I believe that such a rule will be a non-starter: fiddling while Rome burns.