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Commentary from Westminster

Inquiries into Medical AccidentsBY the autumn the D.H.S.S. hopes to circulate health

authorities with a new set of guidelines on the conduct ofinquiries into clinical mishaps, and thus to clarify a situationwhich has grown more confusing for doctors andadministrators over the past year. One of the main catalysts tothis move (which is still at an early consultative stage) was thetragedy of a Hereford man, Mr David Woodhouse. A fitsoldier and a father of three small children, he enteredHereford County Hospital in May, 1981, for a routine

appendicectomy. During the operation something wentwrong, and Mr Woodhouse has been in a coma ever since.

Eventually the cause was established to be faulty use ofanaesthetic equipment, compounded by inadequateoperating instructions for the machine. These have sincebeen rewritten by the manufacturer.

But the affair was distinguished from most other medicaldisasters by the part played by the Medical Defence Union.After the hospital authorities had held an immediate "fire-brigade" inquiry within 48 hours, to prevent a recurrence,the Hereford and Worcester Area Health Authority (now theHerefordshire District Health Authority) attempted to start afuller investigation. At this stage doctors were advised by theM.D.U. not to give any further evidence for the time being.When no further progress had been achieved in the

investigation by the following December, and with MrWoodhouse still in a coma, the local Conservative M.P., MrColin Shepherd, raised the matter in a late-night Commonsdebate. He told M.P.s he understood the M.D.U. was worriedabout the effect of a High Court judgment (Waugh v BritishRail) which apparently had the effect of "undermining thelegal privilege of evidence given to an (internal) inquiry." Butaccusations were being made, Mr Shepherd said, that theM.D.U. was "merely seeking to minimise its financial

exposure... because it is cheaper to settle on behalf of a deadman than a living man." In order to end this unsavourysituation Mr Shepherd called for a full-scale Ministerialinquiry into the mishap. The then Health Minister, DrGerard Vaughan, refused the request, which, he believed,was a sledgehammer to crack a nut. He decided instead to tellthe AHA to forward the available information to a three-manad-hoc inquiry under the chairmanship of Prof. James Payne,professor of anaesthetics at the Royal College of Surgeons.This inquiry isolated the anaesthetic mishap as the cause.

But Professor Payne was not charged with considering therole of the M.D.U. That task has been preoccupying theD.H.S.S. Consultations have taken place between the

present Health Minister, Mr Kenneth Clarke, and M.D.U.representatives, as well as with B.M.A. officials, in an

attempt to lay down new and generally acceptable groundrules for the future. The M.D.U.’s deputy secretary, Dr JohnWall, who has played a part in the discussions, says theWoodhouse case was not the only impetus for change in therules. Extant circulars on the subject have been outdated bychanges in medical practice and techniques, since thecirculars date from the mid ’50s and the ’60s. The Waughjudgment-which is the subject of differing legalinterpretations-has certainly complicated the position ofmedical staff, Dr Wall believes. He thinks it means that any

notes and memoranda on a mishap, compiled internally andprobably more or less immediately, by doctors who may haveplayed no part in the mishap itself, are now "discoverable"for the purposes of official inquiries and of litigation byrelatives. The M.D.U. silenced the Hereford doctorsbecause: litigation was already in hand when the AHA tried toset up its inquiry; there had already been an instant inquiry bythe hospital; there was "such a wave of understandableemotion" that the AHA set up its own inquiry "in order to beseen to be doing something", but it was an inquiry which didnot follow the protocol. When the M.D.U. complained aboutthis last point, "the AHA changed some aspects of theprocedure, but not others". What Dr Wall seeks from theprojected new rules is consistency up and down the country,"so that everybody knows what will be the normal procedureof an investigation". In such an investigation everybody’sinterests must be safeguarded. But under presentarrangements different local initiatives to investigate mishapswere capable of abuse. Health authority representatives havealso taken part in the D.H.S.S. talks, so their interests shouldalso, in theory, be safeguarded in the formula which finallyemerges.

But Mr Bob Dearden, administrator of the formerHereford and Worcester AHA (now district administrator ofHerefordshire DHA), is not so confident. He fears that only achange in the law will improve the situation. "If the circularcan find a form of words which enables clinicians to giveevidence freely to health authorities in inquiries, all well andgood. But I would like to see how the Minister can talk hisway round the Waugh v British Rail judgment. I know thereis argument between the legal eagles about its exact

ramifications, but there is no doubt about the practical effectit has had." Mr Dearden adds that he has no criticism of theM.D.U., who are obliged to safeguard their members’interests. But he still awaits the promised circular with somescepticism.

More Bad News for N.H.S.

GOVERNMENT warnings of a major slowdown in the

growth of the N.H.S., as a result of the pay offer now beingmade to the nurses and the N.H.S. ancillary workers, havebeen translated into some disturbing figures by the SocialServices Secretary, Mr Norman Fowler. The Governmenthad always made it clear that increases in pay must affect thenumber of jobs, he reminded the Commons when heannounced revenue allocations for regional health authoritiesfor 1982-83. Mr Fowler maintained that he had tried tominimise the effect of the cutback on existing services byloading a higher proportion of the cost of the pay offer (whichhe insists is absolutely final) onto authorities which have hadthe highest proportion of development money in recent years.This means the greatest budget reductions will be made inEast Anglia, Oxford, Trent, North-Western, Yorkshire,Northern, Wessex, and South Western health regions. Thereductions would be greater if Mr Fowler was not expectinghealth authorities to contribute an extra 0’ 5% per year oftheir costs through greater efficiency. This had enabled himto continue the Government’s policy of reducing thehistorical differences in health care provision betweendifferent parts of the country, he assured the Commons.What he did not say was that the equalisation process will, ofcourse, proceed rather less vigorously for the forseeable