Medical mistakes

Here’s another question of an order of magnitude… Daniel Ubani, a German ‘stand-in doctor’ who was over in the UK doing a shift as an on-call GP and gave a patient a fatal overdose of diamorphine (Guardian again). He gave the patient 10 times the amount – at first I wondered if he’d got millilitres and centilitres mixed up. However, you can now read the inquest material and it makes for interesting reading.

It seems that the mistake came when David Gray’s partner mentioned 100mg and 10mg, pethidine and diamorphine, in the same conversation. Having no pethidine, Ubani chose the diamorphine. Hearing 100mg, he chose the bigger vial. As diamorphine isn’t used in Germany he wouldn’t know the correct dose: he didn’t look at the instructions kept with the drugs, hence ‘manslaughter by gross negligence’. However, the death could have been prevented by proper induction. It seems that no-one showed Ubani round his equipment: he should have known that the 100mg vial was for palliative care and used in slow release with a syringe driver, as opposed to all at once.

At the inquest there was a some discussion about Ubani’s proficiency in understanding English. However, one of his employers said that his English was OK, and it seems unlikely that this was a huge factor. His unfamiliarity with NHS kit and procedures was more to blame. However, the papers seem to have decided that the black African with a German passport was an example of non-English speaking foreigners making a mess of things (see the Mirror). There’s a lot of blame on the profit making agencies too.

But, as noted in the report, this has happened before, and the month before the deaths NHS Cambridgeshire were discussing changing the boxes of drugs to avoid this:

“In attempting to relieve patients in acute pain, doctors in two different situations erroneously selected the 30mg diamorphine vial…and administrated the entire contents to their patients by injection.

“This six-fold overdose caused respiratory depression and collapse; the patients had to be admitted to hospital for resuscitation. If this is repeated and the patient not rescued in time, death could result.” (C4)

I don’t know if these doctors were the stereotyped foreign doctor, unable to speak English, or not. The lack of media interest suggests not as I’m sure a scandal would be being promoted as I write.

Indeed, focusing on this rare occurence misses the wider issues in ‘patient safety’. If society is fixated on this one fatal mistake, then it can ignore the fact that in 2007 there were ‘as many as 860,000 errors or near misses involving medicines’ in the NHS (Guardian). I’m sure that not all these mistakes were down to foreign doctors, but are down to normal human error, the kind of error that can often be avoided with the right systems in place, good management and so on. Dull (and expensive but that’s another story).

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An order of magnitude

We know many people are bad at maths. However, most mistakes are easily spotted through experience and common sense. But sometimes, common sense is lacking: here I’m talking about the Conservatives gaff on teenage pregnancy.

So first, the Conservatives. A few days ago they launched a document called Labour’s Two Nations, that was supposed to show how there is great inequality in Britain today (let’s ignore the fact that the rise in inequality happened in the 1980s). What they wanted to point out was that under-18 girls in the most deprived areas are three times more likely to become pregnant than in the least deprived areas (Guardian). It’s not clear what this means with regards to ‘most deprived’ and ‘areas’ – I think it’s top and bottom centiles and districts – and I’m sure I could find a more shocking figure if I chose a harsher definition of most and least deprived. The mistake they did make, though, was to divide 54 by 1000 and come up with 54% not 5.4%. That’s if they did a calculation: some social statistics come as ‘per 1000’ or ‘per 10,000’ and it’s important to notice this.

This matters for two reasons. First, because 54% v 18% is a big difference and much more significant than a difference between 5.4% and 1.8% (significant thought this is). Second, because anyone with any sense would realise that 54%, that is over half, is completely absurd.  Anywhere with 54% of its teenagers pregnant would have babies everywhere. Either the writer and editor just missed this, or they genuinely believed that there could be such a place and they are massively out of touch with normal life.

Chinese whispers

While reading my local paper online, I came across a contribution from the public that complained that Muslims in the UK are given latitude to act differently to the rest of the people, showing that Muslim lobby groups have the government in their pocket. Combined with the Islamophobia that is prevalent now, it feeds into the idea that a different group is somehow taking over. And as ever, the full story is ignored for the game of Chinese whispers that is our media machine.

The specific claim is that ‘Ed Balls has made it legal to smack children in muslim schools’, and this something that can’t be done elsewhere. As ever, the object of the attack is the Labour government, who are seen to be ‘bending over backwards’ to incorporate minority viewpoints (usually accompanied by the claim that they rely on minority votes).

Reading this, I thought ‘this seems unlikely to be true’. Making opt-outs from laws on ‘community’ grounds, whether religion/ethnicity or anything else is fraught with danger, and the government would avoid it at all costs. And, of course, it isn’t true. The truth behind this story is that staff in schools haven’t been allowed to use physical punishment children since 1999 (for England and Wales) and in state schools this happened earlier. However, parents aren’t banned from smacking their children (unless it is ‘cruel and degrading’), and thus anyone standing in for parents (in loco parentis) isn’t banned either. The only people banned are teachers in schools. And to define a school, the government chose to define them as establishments where kids go for 12.5 hours or more. Therefore, football or gymnastics coaches, sunday school teachers, music tutors, home schooling tutors, scout masters, parents’ friends and family, and anyone who is asked by a parent to look after children is allowed to smack. The BBC have posted a good history of the law, and point out that:

‘Some MPs have proposed a new clause for an education Bill currently before Parliament… meaning that only a person with actual parental responsibility for a child could continue to justify battery of that child as “reasonable chastisement”.’

So how did this claim about muslim schools come about? First Ann Cryer, MP asked a question in parliament about ‘teachers in madrassahs or in other religious schools’ (Hansard, BBC). Ed Balls pointed out that ‘there is not one rule for a child in a madrassah and another for a child in a school or in any other circumstance’ but didn’t promise to do something about part-time settings, presumably knowing that it would be a step towards a ban on smacking by parents too.

Next, and because of the simplification required for the headline and first two or three sentences in news pieces (see Wikipedia for a good explanation – I think this is a Nut Graph(!)) the story became:

‘Under existing law, teachers at state and private schools are banned from smacking children but their counterparts in faith schools are not.’ (Keighley News)

This claim is a lie, and is only explained properly at the middle of the piece.  But this sentence gets repeated:

‘A loophole in the law means that while teachers in state and private schools are banned from smacking children, their counterparts in faith schools are not.’ (Guardian)

This is so close that in an academic context could be considered plagiarism, unless citing the source. Again, explaining the actual law comes later.

But that dig at journalism is a digression. Now we have the idea that all faith schools are exempt (due to simplifying the story), and that it’s got something to do with Islam. Then politicians get back in on the act with the Lib Dem spokesman saying “The government needs to legislate to protect children – not leave an opt-out simply because it fears some ethnic or religious backlash.” (Guardian).

So instead of a bigger story about the fact that piano teachers are still allowed to rap children’s fingers with a ruler, Koran and Bible classes can enforce rote learning with similar methods, and parents, friends, family and babysitters are allowed to smack children in their care, we end up with the false claim that teachers in Muslim schools can smack and other teachers can’t. Is that right? No. Is it true. No again.