My constituent Edward Maitland was a frail man who could not eat solid food following tongue surgery. He was admitted to Wycombe hospital from his warden-controlled accommodation suffering from dehydration, shortness of breath and weight loss, things from which he should have recovered. His son, a paramedic, clearly explained on his father’s admission that Mr Maitland could not eat solid food and he also provided liquids. About three weeks later Edward Maitland had died from aspiration pneumonia. At the post-mortem, Weetabix was found in his lungs.
Of course, the investigation was taken extremely seriously and the documentation is, up to a point, very professional. Under “root cause”, it states:
“The investigation found that there is no evidence to support robust communication between nursing and medical staff…No SBAR”—
situation, background, assessment and recommendations—
“documentation was used in EMC or in handover to Ward 6B this would have highlighted the patient’s nutritional needs.”
It proceeds to make some “recommendations”, but I want to highlight the “lessons learned”:
“To care for all patients with a holistic approach and the multi-disciplinary team must focus on all health concerns.
Better communications between all staff members, this should be ongoing and involve all the different professionals who may need to collaborate the care delivery plan. This collaboration and communication should involve the patient, family and the healthcare staff.”
Unfortunately, that is bread-and-butter, typical stuff—and managerial gibberish.
What I learned is that two words would have saved the life of Edward Maitland: “no solids”, written on the records at the end of his bed, on his wristband, and above his bed. The situation in his case is very simple. A man died who ought not to have died. He should not have died in these circumstances.
I have the hard task of saying, therefore, that I look to the courts, and the Francis report helps me. Recommendation 13 of the report, on fundamental standards, refers to:
“Fundamental standards of minimum quality and safety, where non-compliance should not be tolerated. Failures leading to death or serious harm should remain offences for which prosecutions can be brought against organisations.”
Elsewhere, the report discusses at some length—I do not have time to go into detail—a regulatory gap in relation to the Health and Safety Executive:
“It should be recognised that there are cases which are so serious that criminal sanction is required, even where the facts fall short of establishing a charge of individual or corporate manslaughter. The argument that the existence of a criminal sanction inhibits candour and cooperation is not persuasive. Such sanctions have not prevented improvements in other fields of activity.”
I took legal advice. I approached a retired circuit judge in my constituency, who in turn approached a firm of lawyers. I am most grateful for the guidance of Kate McMahon, of Edmonds Marshall McMahon, who has provided me with considerable free legal advice in relation to this case. The firm specialises in private criminal prosecutions. She has explained that, at least at the preliminary stage, there may be a corporate manslaughter case to answer, and liability for gross negligence manslaughter may well be attributable to one or more employees of the hospital.
I do not want people to be prosecuted unnecessarily, or to see taxpayers’ money wasted, but I do want accountability, and I believe that in the end the courts provide that crucial accountability. Edward Maitland’s son Gary now has this advice, and I have left it to him to decide whether to approach the police. I have briefed the police superintendent in Wycombe on the circumstances. I believe that the courts should be the ultimate way of sanctioning the NHS. Francis agrees, and I hope he will provide a policy in this area.
There should be more democratic control. I am delighted—