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Tuesday, 13 June, 2000, 13:51 GMT 14:51 UK
Spotting medical mistakes
smear test
There is a chronic shortage of pathologists
There will always be doctors who make errors - but what can be done to reduce the risk, and spot the worst offenders early?

If the government needed any help to ensure popular support for increased controls on doctors, then the medical profession itself appears to be providing it.

A rash of recent cases involving cases of apparent bad doctoring left unchecked or unnoticed for years are accelerating calls for change.

In the latest instance, Dr James Elwood, a 78-year-old pathologist, responsible for checking tissue samples for signs of serious disease like cancer, was found to have made a number of serious mistakes.

In some cases cancers were missed, while in another a breast was removed unneccessarily.

But despite an audit in 1997 which revealed cause for concern, he was allowed to continue working as a locum by both a hospital - and the Department of Health, who extended his employment.

However, the evidence from the new checks of 10,000 women reveal an error rate of just over 2% - roughly the expected norm from a competent pathologist.

The case comes hot on the heels of a report condemning delays in detecting a pattern of botched operations by surgeon Rodney Ledward.

And this week yet another hearing opened into a gynaecologist who is accused of similar misdemeanours.

The government is hoping that a raft of measures announced since it came into office will make the NHS far more sensitive to "problem" doctors.

It plans to create a register of "near misses" - situations in which a patient could have been harmed by a doctor's mistake.

This could be up and running by the end of the year.

Early detection

Hopefully, if there was an emerging pattern of poor practice, the register might reveal it a little earlier.

This has however, been condemned as "gimmickry" by the Opposition, and there are certainly doubts as to the practicality of the scheme, which in many cases relies mainly on honest reporting by doctors and hospitals.

However, the Royal College of Pathologists, the body which sets standards for the profession, is considering its own "mistakes register".

Confidentiality, it says, is key to ensuring the cooperation of doctors.

Vice-chairman Professor James Underwood said: "Whatever errors are made could be fed into the register in a confidential way, and if that is built up over time it could reveal problem areas."

More key to the government's reforms is the increased emphasis on clinical audit, and the appraisal and assessment of doctors.

This means it would be compulsory for doctors to compare their results against, where possible, a national average, or those of neighbouring hospitals.

Some mistakes are inevitable in a discipline like pathology, in which experts are scanning microscope slides for very subtle changes in cells.

But if one doctor is making significantly more wrong diagnoses than others, then alarm bells would ring.

The government has also set up a body, called the Commission for Health Improvement, which would undertake regular inspections of hospital trusts and health authorities, looking for anything out of the ordinary.

Quality costs

The problem with good quality audit - and inspections - is that it is expensive, both in terms of time and money.

The particular problems in pathology - first illustrated by the scandal of missed cancers at the Kent and Canterbury Hospital - has been accentuated by a chronic shortage of trained pathologists.

The hospital itself has admitted that the only reason why an elderly locum was considered was because the post could not be filled any other way.

And while the Royal College of Pathologists helps vet doctors filling full consultant posts, they are not involved in the hiring and firing of locums.

Professor Underwood said: "I personally think it is unacceptable that someone of that age was still working as a pathologist."

He said that much of the blame for the current shortage of pathologists could be laid at the door of the government, who, in the early 1990s, miscalculated the number of pathologists that had to be trained.

He said: "We now have a crisis in pathology - just under 10% of consultant posts are currently unfilled."

Doctors' leaders, such as the British Medical Association, want the government to increase the number of trained consultants.

And they think that, far from revealing a host of new scandals, tougher checks will reinforce the public's trust by revealing the vast majority of their doctors to be skilled and conscientious.

But Dr Ian Bogle, BMA chairman, warned: "Like any large organisation, and particularly one that deals with disease and illness, the NHS experiences errors and near misses. Medicine is not an exact science and cannot be error-free."

Ministers have a pot of money destined for radical reform of the NHS.

Last month the public was told that it could be used to transform the length of time patients have to wait for their operations.

But the quality issue is also demanding money, and despite the extra billions on tap, compromises may be just around the corner.

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See also:

13 Jun 00 | Health
Plan to stop dangerous doctors
13 Jun 00 | Health
James Elwood: Chronology
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