Destroying the English legal system
Regular readers will be in doubt as to Dr Crippen's determination to expose the Government's policy of dumbing down professional services. Everywhere you look there are "health care professionals", teaching assistants, and pretend policemen.
Do you remember those two amateur policemen who would not pull a drowning child out of a pond?
Jordon Lyon leapt into the water in Wigan, Greater Manchester, after his eight-year-old stepsister Bethany got into difficulties on 3 May. Two anglers jumped in and saved Bethany but Jordon became submerged. The inquest into his death heard the PCSOs did not rescue him as they were not trained to deal with the incident. (BBC)What a pair of prats. They would not go into the pool because they had not got their swimming badge. I bet they are both Consultant Nurses in real life.
I have mentioned the Crown Prosecution Service before. They are being groomed to take over the criminal legal services because the properly trained lawyers, the barristers, refuse to work for £5 a day.
This morning, the CPS Inspectorate (note - it's so bad, it needs its own inspectorate) has issued its own devastating report. They focus on the state of CPS case files, a basic essential of the lawyer's business. They find that the "majority of files" are incomplete in important respects. Things are not recorded clearly and legibly, and have vital bits missing. Bail records are particularly weak - one-third of bail conditions are not recorded at all - the CPS lawyer just can't be fagged.Full report from Wat Tyler here - worth a look just for the wonderful short film he has unearthed.
Labels: crown prosecution service, dumbing down
22 Comments:
and of course our esteemed Medical colleagues are renowned for near on perfect documentation.. NOT
just like the case ongoing in Cornwall about the patient killed when a NGTube placement x-ray (reviewed by a Medical Doctor who failed to document, and turns out that the password was allocated to a doctor not on duty but who saw fit to give his password out) was incorrectly reviewed - the tube was in the wrong place, ie not the stomach
let those in glasshouse etc etc
Two thing matron:
1) Derriford is in Devon not Cornwall.
2) In the case in question it is becomingly increasingly clear that the CXR was NOT reviewed by a doctor and that in fact it may be a nurse who looked at the CXR and lied in her documentation.
Er, Matron, how about an alternative scenario?
Nurse puts down NG tube, X-ray ordered, nurse said 'reviewed by doctor', doctor can't be identified, one who was supposed to have done it was not in the hospital or on call, one on call was female, nurse said it was a man.
Could someone have fed the patient and not bothered to check at all? Is the 'doctor checking the tube' made up? Is this 'cover your arse?'
This is only one of a number of possible interpretations, of course.
There is now an investigation by Devon and Cornwall Police. The coroner has referred the case to them and inquiries by their major crime investigation team were at an early stage.
That could be interesting.
Nurses documentation is notoriously shite, matron.
The number of times incorrect diagnoses, incorrect social facts, and completely random half-assed plans for feeding etc are handed over in that sacred event of Nursing Hand Over is phenomenal!!
As a house officer I used to attend when I could just to set things straight!
crippo, I might be wrong but a CXR cannot usually be requested by a nurse.
And I would have thought that a doctor gave orders to site the NG-tube after the patient had suffered a stroke ?
If a doctor orders an investigation (CXR) associated with a prescribed intervention surely he/she then has a duty of care to review their actions, or delegate this responsibility to a suitably qualified colleague ?
Perhaps an alternative version is that a nurse decides, unilaterally, to insert the tube ?
She orders a CXR (even though this is not standard procedure) but either fails to check the position, or recognise that the tip of the NG has ended up in the lung ?
She then lies about the role of the mysterious locum SHO to save her lying ass.
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'If a doctor orders an investigation (CXR) associated with a prescribed intervention surely he/she then has a duty of care to review their actions, or delegate this responsibility to a suitably qualified colleague ?'
No question. But there are many units, mine included,where a CXR can be requested by a nurse on behalf of a named doctor. He/she is still responsible however.
This is almost certanly a number of things, accidents are almost invriably a row of domines falling over, not just the one.
How about:
Ward nurse puts down NGT, tells doctor it has been done, a CXR is ordered, doctor forgets to look at it, nurse forgets to ask, patient fed.
Although this is a result of individual failure, there is also a systematic error here. A mistake given this set up is inevitable, as too much reliance is placed on the actions of the individuals concerend. Putting down an NGT and checking it is a process that should be standardised, with appopriate checks.
Sounds like it wasn't here. And why a major crimes unit is invetigating, I'm not sure.
I'm a radiographer now working in MRI but when I used to work in X-ray it was pretty standard practice to alert the requesting clinician if an NG tube was incorrectly placed, so that they would know virtually straight away (there are inevitable delays in doctors looking at X-rays as they're usually really busy so I always thought it best to bring these things to their attention).
If this particular case is a result of a doctor having given their PACS (digital X-ray system) password to someone else, that's quite a serious breach of policy and action should be taken. Whatever has happened, it sounds as though people are trying to cover it up - which is obviously completely unethical.
I hope the investigators get to the bottom of this sad and unnecessary death and that lessons are learned (whatever they may be)
Important point(s) Emily - look how useful the red dot system has proved.
But if nobody else examined the check X/R (post-NGT) then they would not have picked up on the radiographers observations.
So, Derriford uses PACS, eh ?
As you say handing out individual passwords to locum colleagues will not go down well at all I'm afraid.
This type of technological gaffes hardly bodes well for the Spine ?
Just to stand up for the PCSO's: Dr C says "They would not go into the pool because they had not got their swimming badge."
Well I for one wouldn't jump into a pool to save a drowning child because I cannot swim, and commiting suicide to avoid some idiots indignation isn't my idea of wisdom.
Derriford is in Devon not Cornwall - oops, sorry.
but as for the review, sorry but if they use PACS, only someone with a password can review x-rays - its also apparent the Doctor whose password was used to review it, gave it to a female colleague, but the reviewing doctor apparently was a male - someone somewhere is going to be in trouble.
Personally I think NGT are not treated with enough respect, they are potentially lethal - i work in Neonates, i won't give feeds via one unless the ph paper give the right indications of ph5 or less.
As for your dig at PCSO's (my personal views on them, is that they are window dressing by a administration that have let the country go to the dogs, and now it's come round to bite us all in the arse, but i digress) Don't expect warranted officers to be jumping in and putting themselves at risk
We live in the real world.
NHS IT systems are mostly crap. Insecure crap, at that.
Of course passwords are passed around. People don't get training fast enough but are expected to work effectively, which means getting results, as soon as they arrive on the word. Screens are routinely left open. Passwords are stuck to screens on post it notes.
And don't get me started on PACS. Ours has 'National IT project' through it like a stick of rock. It was quite obviously designed by radiologists, the users find it close to incomprehensible. The password system has been designed by an IT department who insist on a certain pattern which is impossible to remember.
Garbage.
Lessons may be learned as a result of this. Let me tell you what will then happen. There will be a meeting. An 'action plan' will be agreed. It will be filed in a drawer and everyone will think they have done a wonderful job. Especially the suits with the clipboards. Someone will be thrown to the wolves, and little will change.
That's the real world too.
The fine bore feeding tubes used in adults are often impossible to aspirate from so checking pH is difficult, even if you DO get something back the chances of it being acidic are slim given the numbers of people on acid suppressing medication.
Misuse of hospital passwords is ubiquitous. IT departments invariably think that new doctors in Trusts can wait two or three weeks or longer to get access to the systems. Pointing out that you simply CANNOT do your job without access is met by incredulity every time. They also refuse to realise that, as most trusts use similar IT systems, de novo training is rarely needed. Finding yourself on call with no access to blood results or Xrays is a frequent occurrence. So yes, doctors sometimes share passwords. We know in an ideal world we shouldn't but as in many things we are willing to bend the rules to get the job done as we are not protocol driven monkeys.
Re; the PCSOs. I echo previous comments that it's not actually wise to risk your own life to save another's. RoSPA advice is to 'Reach, throw, wade, row', which has been the policy for many years. Those people who are fortunate enough to survive jumping into water to save others may feel like heroes, but in most cases they've just taken a stupid risk, as it's likely they could have found something to increase their reach, waded in carefully, found something that floated, etc, all of which are preferable to drowning whilst trying to save another. I don't know the full facts, so it's possible the PCSOs could have done more (training for these incidents comes to mind), but jumping in certainly wasn't the answer. The anger of the parents of that drowned boy is certainly understandable, but it's easy to say what should have been done in hindsight, especially if the rescuers were fortunate enough to survive.
'They would not go into the pool because they had not got their swimming badge. I bet they are both Consultant Nurses in real life.'
What a load of shit. You really are a provocative troll sometimes.
I saw a fat egotistical cunt walking down the high street yesterday. I bet he's a GP in real life.
'You really are a provocative troll sometimes. '
He's allowed to be. It's his blog.
‘but jumping in certainly wasn't the answer.’
Actually, it clearly WAS the answer because it enabled the two anglers in the story to save the life of an 8-year-old girl!
And Emma it doesn’t say they couldn’t swim, just that they weren’t trained to deal with the incident. How trained do you have to be to want to try to save a drowning child?
Oh Dr C.
Normally so good with facts.
The PCSOs arrived long after the boy had disappeared from view. They did exactly what they had been trained to do: I'm guessing you wouldn't attempt a medical procedure you haven't been trained to do, would you?
More information, should you wish to actually get your facts right, at http://news.bbc.co.uk/1/hi/england/manchester/7007081.stm
I expected more from you Doc. I certainly didn’t expect to be hearing you quoting badly reported/sensationalised Daily Mail stuff!
The reality, as has been mentioned above, is that the boy had been under the water (of a flooded quarry) for between 10-15 minutes, you’re a doctor, what’s his chances of survival? He was nowhere to be seen, not splashing about shouting “HELP HELP” as The Mail led us to believe. Plus there was only ONE PCSO by the water side, the other was trying to guide the emergency services in, as some prat gave bad directions to the call taker. So it certainly isn’t fair to have a pop at the second PCSO, who wasn’t even there. He still had reporters at his door asking him how he could sleep at night, that’s not on really. I really expected more from you Doc.
Did you, PSCO Bloggs? I certainly didn't expect more and I wasn't disappointed. Never let the truth get in the way of a good story.
Passwords are required to order tests, review results, access patients records and it is impossible to do your job without them on the wards. So why do NHS IT departments refuse to provide them on the first day of work? We aren't allowed to get one without the requisite training in their use, but training isn't organised until several weeks into the job. I agree with Crippo-the IT departments are so devolved from reality in most trusts. I've heard of folks who have blankly refused to work on the grounds that without access to test results etc they cannot work safely-password was obtained within a few hours. Take the complaints upwards to the Chief Exec-its the only way it will change, otherwise sharing of passwords will continue.
And I think the nurse is covering her ass-the doctor can't be identified because one wasn't asked to check.
Good article.Especially the language.We end up with a justice system again, where many innocent people are locked up again on the basis of an anonymous witness who may have a grudge financial interest etc in cooperating with the Police or whoever wants the defendant put away.
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