9 ms·

Shocking hospital mistakes led to our daughter’s death

48 points by ogogmad 4y ago

tamaharbor 4y ago
Having a mother and brother in and out of hospital for eight years, I can agree that you never want the weekend crew in charge of your case.
deleted 4y ago
[deleted]
g42gregory 4y ago
This is a horror story for a parent to read. Preventable death of a 13 yr old girl, just starting her life. Tears swelled in my eyes. And yet, I am convinced that the NHS “system” does not care in the end. Diluted responsibility of a bureaucratic setup, where doctors are incentivized to follow protocols and protect themselves from liabilities. No reward for going above and beyond, no punishment for not caring. And we keep edging towards more of this all over the world. I think this is an example of the costs we will pay.
- jsmith99 4y ago
  How do other systems reward doctors who 'go beyond' or punish those who don't care?
  - kurupt213 4y ago
    This is why medical malpractice is a healthy part of the system. Bad doctors become too toxic to be employable. Another check in the system. Killing children through gross negligence should be career ending. This is exactly why PAs and NPs should always be under the supervision of an attending, and why MDs can’t practice unsupervised until they have 10,000+ hours of on the job training
    - pmyteh 4y ago
      If it's actually gross negligence then it's not just potentially career ending in England and Wales, it's potentially imprisonable (manslaughter by gross negligence, max penalty life imprisonment). You're also entirely liable to being sacked and being struck off the medical register. And the victim's family can and will win a medical malpractice claim against the hospital here (albeit probably for less money than the US: the big payouts here are for cases where long term care is needed). What we need are better staffing ratios and a proper process for designing out error. The Healthcare Safety Investigation Branch[0] has set out to do for hospitals what the Air Accidents Investigation Branch and NTSB do for aviation safety. Let's hope it helps. [0]: https://www.hsib.org.uk/ https://www.hsib.org.uk/
  - origin_path 4y ago
    Private sector systems: 1. Find it easier to promote based on skill rather than tenure. 2. Can give bonuses or fire bad employees. 3. Are incentivized to avoid horrible outcomes like this for PR/financial reasons alone beyond just the ethical issues. 4. Are also incentivized to avoid it due to liability lawsuits. None of these incentives or systems really apply to the NHS. In this case the problems seemed to be more like general management and staff dysfunction rather than a need to reward "going beyond". Constant rotation of doctors instead of assigning the patient to a single doctor, some of whom were in training, over confidence, refusal to make backup plans, apparent inability to recognize sepsis even in the most extreme stages and consequent refusal to escalate to ICU, keeping the parents and patients out of the loop, working from home despite being on call, apparent inability to preserve records, promoting a doctor just weeks after he made critical mistakes etc. In other words - rampant and systemic incompetence. The problems here were seriously compounded by a dysfunctional aspect of British culture in which the NHS is practically worshipped, and treating it cynically is deemed a severe moral failing (I'm British, I've seen this first hand). The article dwells on this near the start. Several times the mother correctly diagnose the fact that there are serious problems with their child's care and each time is basically told to shut up and Trust The NHS, which she then meekly does. It's easy to imagine American parents at this point starting to threaten lawsuits, switch hospitals, remind doctors that they're the 'customer' or take other concrete actions to express their displeasure but none of this is available to Brits.
    - jsmith99 4y ago
      Consultant roles in the NHS are competitive and are not simply based on tenure. Doctors often switch hospitals exactly as if this was the private sector, as NHS hospitals can compete against each other for staff. The NHS internal market system means the individual hospitals are very financially driven. The NHS also pays huge amounts on clinical negligence claims (they have a £60bn provision) although this is managed centrally - effectively the central NHS Resolution organisation is insuring individual hospitals in return for charging a levy.
    - DanBC 4y ago
      What on earth makes you think this hospital could not fire the responsible healthcare professionals?
briHass 4y ago
One of the major reasons why medical care in the US is so expensive is the over-reliance on expensive and often unnecessary testing. However, 'often' isn't the same as 'always'. Seeking to reduce costs means using human judgement calls to replace 'unnecessary' testing. When I was in my late 20s, I had my vision go black for a short period. A concerned doctor had a full MRI workup done on me with review by a neurology team. They confirmed from the tests, as was 99.99% likely to be the case in an otherwise healthy 20-something, that it was an ocular migraine - alarming, but harmless. Problem is, what if it was the miniscule chance of being a stroke. The original doc could've sent me home with an aspirin, but could have also caused my death or severe disability if she was wrong.
- junofan 4y ago
  I’m glad the government isn’t in charge of my family’s health. Maybe it’s not trendy, but honestly over the course of several lives lived we’ve had doctors catch one or two things.
  - fooblaster 4y ago
    I'd encourage you to think about the consequences of over testing. Although it is somewhat counter intuitive, there are many negative consequences to patient outcomes from overtesting. A deeper overview: https://www.youtube.com/watch?v=yNzQ_sLGIuA https://www.youtube.com/watch?v=yNzQ_sLGIuA
  - CogitoCogito 4y ago
    Are you saying the problems with the care of the girl in the article are due to the government being in charge?
    - macinjosh 4y ago
      The point is they _were_ in charge.
      - midasuni 4y ago
teslabox 4y ago
I noticed paracetamol was given at the very beginning of the girl’s ordeal. Acetaminophen (paractemol / Tylenol) is the standard of care for fevers and pain, but it is a terrible drug. A comment here said it’d never be approved in the modern world because the mechanism of action is unknown. But the mechanism of harm is known: disruption of the “electron transport chain” in the mitochondria. Prenatal Tylenol is now well-associated with autism. I have a friend who I talked out of using Tylenol daily - she’s doing much better. Edit: spelling (comment below)
- ogogmad 4y ago
  wrong spelling: *paracEtamol "pa-ruh-SEE-tuh-mol", with the "pa" being like the "ma" in "marriage".
- ogogmad 4y ago
  What's the alternative, ibuprofen? I think children are already discouraged from taking aspirin because it can cause deadly side effects.
  - teslabox 4y ago
    Ibuprofen is not terrible, and there's a children's version. I think it's usually better to let children have mild fevers, and do something else when the fever is more serious. Tylenol does NOT have anti-inflammatory properties. Ibuprofen is a better in many different ways.
    - midoridensha 4y ago
      And Tylenol/paracetamol will destroy your liver.
      - edmundsauto 4y ago
        Is this only in large doses (>4g/day), or does taking Tylenol a couple times a week for a headache also increase the risk? I've always read the it's the former - which is a problem, because it's so close the the therapeutic dose. But for many people who take it once in a while, it's a godsend.
darepublic 4y ago
So sorry for the parents who went through this. And yes there are doctors who are responsible. In general my experience with doctors is that they are often wrong, and often dismissive and arrogant.
gadders 4y ago
Heartbreaking.
n8henrie 4y ago
For others looking for the medically pertinent details, from what I can tell the most consequential mistakes (at least the ones being emphasized in the article) were: - failure to use a sepsis severity scoring system to determine need for higher level of care - failure to order an unnamed test to determine severity of infection (I assume lactic acid?) - failure to move to a higher level of care (ICU) earlier in the course of care It appears that the patient was on (unspecified) antibiotics from a fairly early point in the course of care. I may have missed it being spelled out more explicitly, but it sounds like the patient died from traumatic pancreatitis -> necrotizing pancreatitis. EDIT: Markdown fixes, autocorrect error
- kurupt213 4y ago
  Not improving after administration of antibiotics is a red flag
  - n8henrie 4y ago
    I think it goes without saying that not improving after administering a treatment for the purpose of improving a condition is a red flag.
llampx 4y ago
What a horrible experience for this poor family. I can see this happening in other countries as well, all it takes is to trust the doctors a little too much. Maybe the UK is unique in that criticism of the NHS is taboo.
- DanBC 4y ago
  > Maybe the UK is unique in that criticism of the NHS is taboo. Hardly taboo. For one thing this person got her story printed in national news media, and other media also covered it. And there are several national newspapers who run anti-NHS stories every day.
itronitron 4y ago
While a lot of comments here are focused on failure of the system, ultimately the death of the young girl is due to multiple negligent and incompetent doctors each failing individually to perform the work for which they have been trained and paid. I wish the author had included names and pictures of the doctors and consultants that failed in their duties. Their future patients (not that they should have any) and their colleagues deserve to know. Edit: I'll also add that if you are ever in a hospital ER or similar situation I recommend stopping everyone that comes in to the room to see the patient (your family member) before they start talking and get their name and position at the hospital before they continue. Then repeat what they said back to them and if it sounds fucked up ask them to elaborate.

48 points by ogogmad 4y ago

Having a mother and brother in and out of hospital for eight years, I can agree that you never want the weekend crew in charge of your case.

deleted 4y ago

[deleted]

g42gregory 4y ago

This is a horror story for a parent to read. Preventable death of a 13 yr old girl, just starting her life. Tears swelled in my eyes. And yet, I am convinced that the NHS “system” does not care in the end. Diluted responsibility of a bureaucratic setup, where doctors are incentivized to follow protocols and protect themselves from liabilities. No reward for going above and beyond, no punishment for not caring. And we keep edging towards more of this all over the world. I think this is an example of the costs we will pay.

jsmith99 4y ago
How do other systems reward doctors who 'go beyond' or punish those who don't care?
- kurupt213 4y ago
  This is why medical malpractice is a healthy part of the system. Bad doctors become too toxic to be employable. Another check in the system. Killing children through gross negligence should be career ending. This is exactly why PAs and NPs should always be under the supervision of an attending, and why MDs can’t practice unsupervised until they have 10,000+ hours of on the job training
  - pmyteh 4y ago
    If it's actually gross negligence then it's not just potentially career ending in England and Wales, it's potentially imprisonable (manslaughter by gross negligence, max penalty life imprisonment). You're also entirely liable to being sacked and being struck off the medical register. And the victim's family can and will win a medical malpractice claim against the hospital here (albeit probably for less money than the US: the big payouts here are for cases where long term care is needed). What we need are better staffing ratios and a proper process for designing out error. The Healthcare Safety Investigation Branch[0] has set out to do for hospitals what the Air Accidents Investigation Branch and NTSB do for aviation safety. Let's hope it helps. [0]: https://www.hsib.org.uk/ https://www.hsib.org.uk/
- origin_path 4y ago
  Private sector systems: 1. Find it easier to promote based on skill rather than tenure. 2. Can give bonuses or fire bad employees. 3. Are incentivized to avoid horrible outcomes like this for PR/financial reasons alone beyond just the ethical issues. 4. Are also incentivized to avoid it due to liability lawsuits. None of these incentives or systems really apply to the NHS. In this case the problems seemed to be more like general management and staff dysfunction rather than a need to reward "going beyond". Constant rotation of doctors instead of assigning the patient to a single doctor, some of whom were in training, over confidence, refusal to make backup plans, apparent inability to recognize sepsis even in the most extreme stages and consequent refusal to escalate to ICU, keeping the parents and patients out of the loop, working from home despite being on call, apparent inability to preserve records, promoting a doctor just weeks after he made critical mistakes etc. In other words - rampant and systemic incompetence. The problems here were seriously compounded by a dysfunctional aspect of British culture in which the NHS is practically worshipped, and treating it cynically is deemed a severe moral failing (I'm British, I've seen this first hand). The article dwells on this near the start. Several times the mother correctly diagnose the fact that there are serious problems with their child's care and each time is basically told to shut up and Trust The NHS, which she then meekly does. It's easy to imagine American parents at this point starting to threaten lawsuits, switch hospitals, remind doctors that they're the 'customer' or take other concrete actions to express their displeasure but none of this is available to Brits.
  - jsmith99 4y ago
    Consultant roles in the NHS are competitive and are not simply based on tenure. Doctors often switch hospitals exactly as if this was the private sector, as NHS hospitals can compete against each other for staff. The NHS internal market system means the individual hospitals are very financially driven. The NHS also pays huge amounts on clinical negligence claims (they have a £60bn provision) although this is managed centrally - effectively the central NHS Resolution organisation is insuring individual hospitals in return for charging a levy.
  - DanBC 4y ago
    What on earth makes you think this hospital could not fire the responsible healthcare professionals?

briHass 4y ago

One of the major reasons why medical care in the US is so expensive is the over-reliance on expensive and often unnecessary testing. However, 'often' isn't the same as 'always'. Seeking to reduce costs means using human judgement calls to replace 'unnecessary' testing. When I was in my late 20s, I had my vision go black for a short period. A concerned doctor had a full MRI workup done on me with review by a neurology team. They confirmed from the tests, as was 99.99% likely to be the case in an otherwise healthy 20-something, that it was an ocular migraine - alarming, but harmless. Problem is, what if it was the miniscule chance of being a stroke. The original doc could've sent me home with an aspirin, but could have also caused my death or severe disability if she was wrong.

junofan 4y ago
I’m glad the government isn’t in charge of my family’s health. Maybe it’s not trendy, but honestly over the course of several lives lived we’ve had doctors catch one or two things.
- fooblaster 4y ago
  I'd encourage you to think about the consequences of over testing. Although it is somewhat counter intuitive, there are many negative consequences to patient outcomes from overtesting. A deeper overview: https://www.youtube.com/watch?v=yNzQ_sLGIuA https://www.youtube.com/watch?v=yNzQ_sLGIuA
- CogitoCogito 4y ago
  Are you saying the problems with the care of the girl in the article are due to the government being in charge?
  - macinjosh 4y ago
    The point is they _were_ in charge.
    - midasuni 4y ago

teslabox 4y ago

I noticed paracetamol was given at the very beginning of the girl’s ordeal. Acetaminophen (paractemol / Tylenol) is the standard of care for fevers and pain, but it is a terrible drug. A comment here said it’d never be approved in the modern world because the mechanism of action is unknown. But the mechanism of harm is known: disruption of the “electron transport chain” in the mitochondria. Prenatal Tylenol is now well-associated with autism. I have a friend who I talked out of using Tylenol daily - she’s doing much better. Edit: spelling (comment below)

ogogmad 4y ago
wrong spelling: *paracEtamol "pa-ruh-SEE-tuh-mol", with the "pa" being like the "ma" in "marriage".
ogogmad 4y ago
What's the alternative, ibuprofen? I think children are already discouraged from taking aspirin because it can cause deadly side effects.
- teslabox 4y ago
  Ibuprofen is not terrible, and there's a children's version. I think it's usually better to let children have mild fevers, and do something else when the fever is more serious. Tylenol does NOT have anti-inflammatory properties. Ibuprofen is a better in many different ways.
  - midoridensha 4y ago
    And Tylenol/paracetamol will destroy your liver.
    - edmundsauto 4y ago
      Is this only in large doses (>4g/day), or does taking Tylenol a couple times a week for a headache also increase the risk? I've always read the it's the former - which is a problem, because it's so close the the therapeutic dose. But for many people who take it once in a while, it's a godsend.

darepublic 4y ago

So sorry for the parents who went through this. And yes there are doctors who are responsible. In general my experience with doctors is that they are often wrong, and often dismissive and arrogant.

gadders 4y ago

Heartbreaking.

n8henrie 4y ago

For others looking for the medically pertinent details, from what I can tell the most consequential mistakes (at least the ones being emphasized in the article) were: - failure to use a sepsis severity scoring system to determine need for higher level of care - failure to order an unnamed test to determine severity of infection (I assume lactic acid?) - failure to move to a higher level of care (ICU) earlier in the course of care It appears that the patient was on (unspecified) antibiotics from a fairly early point in the course of care. I may have missed it being spelled out more explicitly, but it sounds like the patient died from traumatic pancreatitis -> necrotizing pancreatitis. EDIT: Markdown fixes, autocorrect error

kurupt213 4y ago
Not improving after administration of antibiotics is a red flag
- n8henrie 4y ago
  I think it goes without saying that not improving after administering a treatment for the purpose of improving a condition is a red flag.

llampx 4y ago

What a horrible experience for this poor family. I can see this happening in other countries as well, all it takes is to trust the doctors a little too much. Maybe the UK is unique in that criticism of the NHS is taboo.

DanBC 4y ago
> Maybe the UK is unique in that criticism of the NHS is taboo. Hardly taboo. For one thing this person got her story printed in national news media, and other media also covered it. And there are several national newspapers who run anti-NHS stories every day.

itronitron 4y ago

While a lot of comments here are focused on failure of the system, ultimately the death of the young girl is due to multiple negligent and incompetent doctors each failing individually to perform the work for which they have been trained and paid. I wish the author had included names and pictures of the doctors and consultants that failed in their duties. Their future patients (not that they should have any) and their colleagues deserve to know. Edit: I'll also add that if you are ever in a hospital ER or similar situation I recommend stopping everyone that comes in to the room to see the patient (your family member) before they start talking and get their name and position at the hospital before they continue. Then repeat what they said back to them and if it sounds fucked up ask them to elaborate.