Dear Editor,

PLEASE permit me to respond to an editorial by the Stabroek News, titled, “Death of three children”.

The editorial was in response to the three unfortunate deaths at the Paediatric Oncology Ward. While I recognise that the Editor in Chief, Anand Persaud, is not medically trained, at a minimum, I would expect that he would seek the opinions of a medical professional who is trained at investigating Serious Untoward Incidence (SUI). Unfortunately, a fellowship specialist would not cut it. As a result, I do wish to correct the multiple inaccuracies in that editorial.

Stabroek News had this to say, “It is noteworthy that it took the GPHC more than six weeks to deliver a report on the deaths. That is completely unacceptable, for what was a straightforward investigation.” Has Stabroek News ever investigated a SUI before? How do they know six weeks is too long? How do they know it’s a straightforward investigation? Please permit me to highlight the folly in that statement.

When there is an investigation into an unexpected death, firstly, the Terms Of Reference (TOR) of the investigation needs to be formulated. The death did not occur in isolation. A sequence of events occurred, which resulted in the deaths. That sequence of events needs to be identified, and the most appropriate process needs to be determined to investigate that sequence of events.

Also, in formulating the TOR, appropriate witnesses need to be identified. This preliminary TOR is then shared with the parties involved for their comments, and the comments and amendments of their representatives and lawyers. This process can take up to two weeks, minimum. The fact is that this is a legal process, and needs to be able to stand up to legal scrutiny. Once that TOR hurdle is overcome, then statements are taken. Stabroek News may believe that statements are only taken from the two doctors involved.

WRONG. The whole department should provide statements to give a complete picture of what happens on that ward daily. Was this unsupervised junior an isolated event? Were there near misses that were never investigated? This process may take up to six weeks for each death. The reason being is that healthcare professionals are busy. They cannot leave the other patients to die so that they can provide a statement. The investigators need to work around their schedules. Then the post-mortem. In a previous letter, I explained why they were inconclusive. So it was likely toxicology and body samples were taken.

This can take up to eight weeks to be reported on. Don’t believe me! Just google how long it took to confirm Whitney Houston’s, Bobby’s, Amy Winehouse’s, Prince’s and Michael Jackson’s causes of death. These toxicology tests are not done in Guyana, hence samples are taken overseas. We can add another two weeks to that. Then the investigators read the statements, read the post-mortem reports, and read the toxicology report before making a final report on the deaths. For each death, this can take a good week.

So, in total, if done thoroughly, it can take up to 25 weeks. If some investigations are run concurrently, then this can be reduced. But clearly not less than six weeks as Stabroek News is suggesting.

Secondly, Stabroek News is suggesting that investigations of these deaths were straightforward. WRONG. You have that silly position,and a below-average defence attorney will destroy you on the witness stand. No death investigation is straightforward. It’s a legal process, hence it needs to be done thoroughly. Anand Persaud, this is not like editing papers. This is investigating a death.

Stabroek News then erroneously suggested that the problem is only at GPHC. That’s a simplistic approach. The problem is systemic, but with GPHC being the main referral hospital, it is more evident there. When did this problem start? For years I’ve been arguing that the healthcare system in Guyana is a complete failure. This failure is long before this government. The PPP had 23 years to address it. Successive Ministers of Health have been complete failures. Dr. Leslie Ramsammy, Dr. Henry Jeffrey, Dr. Bheri Ramsaran et al were all complete failures. Dr. Ramsaran was the worse of the incompetent lot.

He couldn’t even dress the part. Should have spent more time attacking the problems of the health service and not protestors. Dr.Leslie Ramsammy was better off remaining in his ‘lab’ counting bacteria. Dr. Henry Jeffrey passed around from ministry to ministry like an unwanted stepchild who is the black sheep of his family. All complete failures. All answerable to party and not the patients. This government should have shown leadership and courage in addressing the problems of the obviously failing health service. In my opinion, they were hesitant out of fear of the political fallout. I guess the political wounds inflicted by addressing the failing sugar industry were paramount on their minds.
In my opinion, that is no excuse. It should have been addressed. It needed to be addressed. So, Stabroek News, this problem is a reflection of a system failure that the PPP is responsible for. Twenty-three years were more than enough time to fix them.

Don’t get me wrong. GPHC is not without blame. The present Director of Medical and Professional Services, Dr. Fawcett Jeffrey is reported to have said the errors were down to human errors. The fact is that to err is human. Errors will occur, but processes should be put in place to mitigate this. Regular risk assessment undertaken. Also. it is reported that there was a shortage of staff, hence the staff was spread thin. That in itself poses a series of questions. Why provide a service if they do not have the expertise? The exact point I made on multiple occasions about the Caribbean Heart Institute (CHI).

Next question is: What reporting processes GPHC has in place for concerned health professionals to report when a service is not safe due to a lack of minimum numbers of staff? I cannot hold Dr. Fawcett Jeffrey responsible for this, since he took up his role after or around the time of these incidents. Dr. Madan Rambaran, a PPP square peg, should have addressed this. The main responsibility of the Director of Medical and Professional Services is patient safety. Dr. Madan Rambaran had that position for over a decade.

Thirdly, was the junior doctor ever given an induction into the hospital and the department? When I worked at GPHC, I was not. We were just dropped in at the deep end and left to find our way, unsupervised and unsupported. Many of us spent hours in tears.
Stabroek News further had this to say, “The sequence of events shows clearly that GPHC has major problems with the quality and supervision of its staff.” Let me share these experiences with the readers. I had worked in Guyana for a little under two years after medical school. Most times as a junior doctor, I was unsupervised. We were unsupervised. The senior doctors who should be supervising us were at their private practices or private hospitals despite being paid by GPHC. They were paid to be eight hours at GPHC, but if they spent two hours they spent a lot.

The fact is the evidence shows that most healthcare errors are down to system failures. That’s a fact. When a doctor makes an error, that is just the symptom of a failing healthcare system. A well-functioning system supports doctors, ensures doctors are adequately trained and supervised, ensure th e credentials of doctors claiming to be specialists are scrutinised; ensure that a medical council is fit for the purpose etc. I know everyone would be calling for the head of the doctor who administered the drugs. I would suggest caution on this position. The junior clearly made a series of errors. The fact that it was repeated three times would suggest that there was a knowledge gap. He or she clearly did not know an error was being made. Where was the senior supervising doctor? Dereliction of duty.

As consultants in the UK, when things go wrong, we as the attending consultants take ultimate responsibility. We face the coroner’s court to explain what went wrong. We face the patient’s relatives to explain what went wrong. It is irrelevant whether or not we were not present when the error occurred. It is irrelevant if we had not known about the patient. We are the responsible consultants for those patients. The buck stops with us. I say this to highlight the fact that whoever was the senior doctor supervising that junior doctor has to take ultimate responsibility. The junior was undertaking a medical intervention on his or her behalf. It was his or her responsibility to ensure that the junior doctor was adequately trained and supervised. The junior doctor should be supported and not made a scapegoat.

I would hope that these deaths serve as a stimulus for a complete revamp of the healthcare system. Their deaths should not be in vain. Rename that paediatric oncology department after them. Let their voices drive the ministers to make those changes. Revamp the Medical Council. Frankly, that’s a boys’ club dominated by PPP-aligned doctors and a lawyer. No diversity in either gender or race. Doctors investigating doctors is completely shocking to the rational mind. Who is there for the patients? Revamp GPHC. Get rid of those square pegs in one round hole. Scrutinise masqueraders who are calling themselves specialists. Focus on the simple, and forget about the tertiary centre complex services. GPHC is not a tertiary centre.

It lacks the medical skills, expertise and investigatory tools among other things, as evidenced by this tragedy. Revamp and focus on the health centres. Preventive medicine is what Third World countries should focus on. The health centres need adequate staff. Nurses, pharmacists etc. No junior doctor should be working at a health centre unsupervised. Have systems in place where doctors and nurses are appraised regularly. Empower patients to provide feedback on the care doctors and nurses are providing. Make it simple for patients to make complaints. Support them during the complaint process. Let doctors and nurses know they are not gods.

Deficient doctors and nurses should be provided opportunities to develop their skills. Make medicine in Guyana patient-centred and not healthcare professional- centred. We doctors are there to serve and not to be served. Most importantly, learn from mistakes. Avoid the temptation to find a scapegoat. And many other suggestions I have made in the past. For too long poor patients have been paying with their lives. That’s what gets me angry, since my mother also died when I was a child, which made me who I am today: An outspoken and rebel doctor. An advocate for the suffering patients.

Regards
Dr. Mark Devonish MBBS MSc MRCP(UK) FRCP(Edin)
Consultant Acute Medicine
Nottingham University Hospital
UK