Recording a medical mistake never makes it right

Posted on: July 10th, 2015

An Inquiry has been launched into South Central Ambulance Trust.  An undercover reporter was being trained to use the nationally prescribed call-taking and clinical assessment system, NHS Pathways.  During the training the mentor stated:

One way or another, everyone in this room has killed someone indirectly because of what we’ve done but we’re covered because it’s all recorded.

Reading East MP Mr Wilson said: “These are clearly very serious allegations that have been made and they must be investigated fully and fairly.

“I will be writing to the Care Quality Commission to ask them to investigate whether my constituents were placed at risk and, if so, why this was allowed to happen and how they will ensure that it never happens again.”

If clinical advice is provided and that advice would not be supported by any reasonable body of practitioners, the practitioner is negligent, and any trust employing them would be liable for damage or injury caused by that incorrect advice. 

If this comment was made, a clear lack of understanding is shown in how healthcare workers can cause liability for the NHS as a whole.  Telephone triage systems have been used by the NHS for many years and Doug Miller of Coffin Mew Solicitors has investigated these. 

“On one occasion there was a clear dialogue in the recorded conversation suggesting a patient urgently needed to be seen by the hospital.  It was a case of meningitis and in the end the patient phoned the service 3 times.  After the second call a referral was made to an out of hour’s doctor to call back and make the assessment.  No call was received by the parents and after a 3rd call, they finally went to hospital.”

The problem with these triage systems is that they are reliant upon standard answers to standard questions for a patient to receive the correct diagnosis.  If the caller doesn’t understand the question there is no opportunity for anyone to observe the patient to qualify the answers. It is correct that the technician is reliant on the answers given, but is this good enough?

In the most serious cases this can have drastic consequences.  In the matter investigated by Douglas Miller, the teenage boy patient passed away, but earlier diagnosis and rapid hospital action could have saved his life. 

If these systems are to be used it is best that there is an audio recording.  What that does is make sure the evidence is there as to what was said.   The system must have the opportunity for review by a medical practitioner where a technician has a suspicion that a call may have serious consequences. The technician also needs the training to recognize this situation and not just think there are no consequences of incorrect advice simply because of the recording. 

It will be interesting to find out the results of the enquiry in whether attitudes displayed in training are putting the public at risk of not getting the right treatment when it is most needed.

To read the BBC’s full article, please click here.