Lessons won’t be learned until system changes

By D Cole

Friday, May 9, 2014



From D. Cole, Chale:

THE letter from Dr Mark Pugh (CP, 02-05-14) regarding the tragic death of five-year-old Leon Hamman does little to convince me lessons will be learned.

Having worked at St Mary’s for years, I always try to defend staff because I know the pressure they are under.

But a spreading rash and vomiting as reported are classic symptoms of sepsis, added to his medical history. Guidelines, meeting objective criteria, is meaningless and is not new.

After the disastrous reforms of 1984, which got progressively worse, heads of department like myself, nursing sisters and other medical professionals were sent to Frank James to learn to be managers. After the first week, I asked the tutor why one word was not mentioned. Patient.

The tutor was not amused but it basically sums up the NHS today. In other words, it would be run well if there were no patients! Politicians do not seem to understand health is like no other industry — get it wrong and the patient dies. Before reforms, doctors treated, nurses nursed and other medical professionals, like myself, did the job we were trained for. It was not the perfect system, but worked, and was kept in house, no outside companies or managers who knew nothing about health matters and no tick-box culture.

I was also a nurse on land and at sea before branching into anatomical pathology technology.

When a patient was admitted to our wards every case was different, as I also found when working for the coroner, dealing with thousands of cases.

Dr Pugh is clearly distraught, but it is the system that failed Leon and his parents so badly. Indeed, two of my own family were told they had nothing wrong, so were sent away, but I knew differently.

The government must take some of the blame because it is their reforms the medical profession has to follow, which is why the system needs changing. That is why I fear lessons will not be learned.

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