Victim of a killing machine

After removal of the wrong kidney during an operation at Crumlin Hospital, IMT looks back at a case where a Cork man, whom the health service ‘failed at every point of contact’, died as a result of medical bungling.
One tiny gleam of comfort from last week’s ‘unprecedented event’ where the wrong kidney was removed from a child undergoing an operation at Our Lady’s Hospital for Sick Children, was that the hospital came out with its hands up and admitted the error. But was it that unprecedented?

One person with particular experience of how the health service handles tragic errors is Margaret Murphy from Cork, whose 21-year-old son Kevin died as a result of health service bungling. There is a huge concern surrounding litigation and a consequent reluctance to disclose information in the health service, Mrs Murphy believes.
“What occurred in Crumlin should never happen. In my case though, what really got to me was that people whom I really respected didn’t display honour,” she said. “That was an awful pity.”
h4. Damage limitation
When a major error happens, people working in the health service don’t know what to do, Margaret believes. “Initially after Kevin’s death, there were decent responses from people who said: ‘that should never have occurred.’ Once damage limitation came into play, the whole climate changed. Then we were forced down the road of litigation. Kevin was my son. I was there when he was born. I know every detail and circumstance of his life. I sat at his bedside when he died: I deserved to know the detail of what happened.”
The culture of not facing up to mistakes is deeply ingrained. Margaret’s son Kevin – who had just returned from the United States on a J1 visa – died in 1999, as a result of medical error. Kevin had an eminently treatable condition called primary hyperparathyroidism. The success rate for treatment is 96 per cent, with a one per cent complication rate.
“At every point of contact, the Irish healthcare system failed him totally. We started the litigation because we needed proof and we needed to come to terms with what had happened. There had been cover-ups and muddying of the waters,” Margaret said.
Kevin was seen at primary care level. He was referred to an orthopaedic consultant who had blood tests and scans done. The tests revealed levels of calcium in Kevin’s blood stream which were well outside the very narrow acceptable blood calcium range. “That was underplayed when the consultant wrote to the GP,” Mrs Murphy said.
h4. Off the scale
“That letter was not in the GP’s file. The consultant’s wish to see Kevin again in the New Year was not conveyed to Kevin or the family. We were repeatedly taking him back to the doctor. He was presenting with various symptoms. All of two years later, the GP again did blood tests. The laboratory were concerned: the calcium levels had gone up to 5.73. The normal range was between 2.05 and 2.75. Kevin’s results were off the scale.”
The GP diagnosied leptospirosis, which wasn’t an issue at all. The practice nurse wrote the blood results on a post-it note, when she was taking a message from the lab over the phone. The GP did send the post-it note with the letter but in the hospital, the note was stuck to the back of the letter and wasn’t seen until six weeks after Kevin’s death.
“The nurse had written calcium as ‘cal’ and potassium as ‘pot’,” Margaret said. “Afterwards, we spoke to a senior person in Cork University Hospital. He suggested that even if the consultant had seen the post-it note, it wouldn’t have meant anything to him. I challenged him on this. He said: ‘it is not written as we would write it.’ I asked ‘are you saying that because it was not written in scientific notation, it wouldn’t mean anything to somebody like you?’ The man actually said ‘yes’. That’s where I lost faith.”
h4. Nothing was disseminated
Murphy bemoans the fact that nothing appears to have been learned from Kevin’s death. “Nothing was disseminated so that similar errors would be flagged in future. I was not aware of any root-cause analysis or anything put in place to prevent it happening again,” she said.
“When we, lay people, had access to the medical records after the event, we plotted things as they occurred on paper. We saw the numbers changing drastically in his various blood test results. We could see something significant was happening, though we couldn’t interpret it. No similar exercise had been done by the medics when Kevin was alive,” Margaret said. There was no overarching monitoring, she said and no system in place to say ‘this is not as it should be and something needs to be done,’ she added.
The hospital itself did its own standard SNAC battery of tests, that are done when a patient is admitted. The SNAC in that hospital did not include a test for calcium. “It can be Russian roulette when you go to hospital,” Margaret said. While he was in hospital, no-one was aware of his high calcium level: a condition known as hypercalcemia. Calcium entering the blood can be brought about by a malignancy.
In Kevin’s case he had primary hyperparathyroidism. The parathyroids are two small glands on either side, behind the thyroid. The autopsy showed Kevin had a tiny benign tumour which was stimulating one of these glands, causing it to behave in a rogue way by sending out the wrong signals. Calcium was being directed to his blood stream, rather than to his bones.
Consequent to that, his bones were softening and the viscosity of his blood was thickening, causing a huge strain on Kevin’s heart. The hypercalcemia was identified in 1997 in the original blood test. Kevin was initially admitted to the Mercy Hospital in Cork in September 1999, but did not receive treatment there for his condition. Kevin was transferred from the Mercy Hospital, where he spent a few days, and then to Cork University Hospital (where the hypercalcemia was glaringly obvious – his calcium level was now at 6.1 – when CUH did their SNAC).
h4. A textbook case
He spent less than 24 hours in CUH. It was a weekend and he was treated at Registrar level. “When we went through the litigation process, one of the peer reviewers, an endocrinologist, trawled all his colleagues internationally and he couldn’t find anyone who had come accross such a high blood calcium level in any patient,” Margaret said.
Kevin’s was a textbook case. There are three possible causes for such a high level of calcium and it should have been investigated as a matter of urgency. One is malignancy in the pancreas, another possibility is a problem with the pituitary glands and the third is primary hyperparathyroidism.
But there was no integrated care pathway and no seamless transition between primary care and secondary care. “All the indications were there but there was no integration,” Margaret said. “Every point of contact Kevin had with the Irish health service failed him.”
One irony is that three months after Kevin’s death, his father was in hospital for other tests. He was found to have the same levels of calcium in his blood that Kevin first presented with. His father spent two days in hospital and had the very minor operation that Kevin should have had.
What should have happened is that Kevin should have been referred to an Endocrinologist in 1997, who would have immediately understood what was occurring. The condition would have been investigated. The benign tumour would have been removed. As the peer reviewers said after Kevin’s death, he would have had a normal life expectancy.
h4. Settled in the High Court
The family took a case against the Mercy Hospital, Cork and four doctors who treated Kevin at various stages. The litigation was settled in the High Court in May 1999. Two GPs, a private consultant and a hospital consultant all admitted liability.
Sir Liam Donaldson, the NHS’s Chief Medical Officer, now uses Kevin’s case as a learning tool. Margaret Murphy has become an international spokeswoman for patients. She is a member of the Steering Committee WHO World Alliance for Patient Safety which was set up to improve patient care and develop a partnership approach on a global level.
In the last three to five years, there is a tendency for the health system to be a bit more open than it used to be. “Things may be beginning to change,” she says.
“Most big medical errors are caused by a weak system – such as doctors making snap decisions after working for 40 hours or with too many patients under their care, not one individual person who makes a mistake,” she says.
She contends that once medical personnel really understand the various aspects of patient safety, they become less threatened and are more willing to be involved, to ensure the system is as safe as possible. Patients and families need to participate in hospital fora, so they are involved in the hospital agenda as well as at national level. “Collaboration and partnership – including the patient and family through the continuum of care – is a better way forward, she says.
In January 2007, Margaret was appointed to the Commission on Patient Safety and Quality Assurance by Health Minister Mary Harney. In July it is expected to make recommendations in audit and governance, and involving patients and families in patient treatment. If implemented, it will change enormously the experience of patients. “There is a huge number of people who have been affected by adverse events and they want to be part of the change process that can make healthcare safer in the future,” she said.