I start by thanking everyone involved in allowing me this debate. Many times in the six years in which I have been honoured to be a Member of Parliament, when people have come to me with a case of a medical nature, I have regrettably had to say that I could not assist them because there was no way to take the case forward. I want to make it clear that this case is not one of them.
I shall start with a brief case history, and the family’s attempt to understand how a normally fit woman went from being perfectly healthy to tragically losing her life during an everyday, routine procedure from which, I am told, no one has ever died. Carmel Bloom, a healthy 54-year-old woman, walked into Bupa Roding hospital on the evening of 27 August 2002. She was found to be suffering from pain in her left side, and was therefore admitted as an in-patient. Earlier that evening, she had gone to the accident and emergency department at the King George national health hospital in Ilford, but because there was a 14-hour wait, she had gone on to the Bupa hospital.
The following day, 27 August, a scan and blood test showed that she had a urinary tract infection and that a stone may have lodged in her lower left urethra. The following evening, exactly 24 hours later, an everyday procedure was commenced in an effort to bypass the blockage and enable the free flow of urine. That was done by inserting a JJ stent—a small J-shaped rubber tube—into her urethra.
Seven hours after the procedure, Carmel was transferred by emergency ambulance to the intensive care unit at the NHS Whipps Cross university hospital. During the transfer, Carmel collapsed into an irreversible coma; she never regained consciousness. Tragically, 10 days later, on 8 September 2002, her life-support machine was switched off, and she was certified dead. Carmel’s family has spent nearly nine years trying to discover what happened on that fateful night, and to understand how a normally fit and healthy woman could die of an everyday complaint with which, I am told, no fatality statistics are associated if it is properly treated in a hospital environment.
The family told me that following Carmel’s admittance to Whipps Cross university hospital’s intensive care unit, it quickly became apparent that the doctors and nursing staff were ill at ease, and I am told that they became quite agitated when asked for further particulars of Carmel’s condition by Carmel’s sister-in-law. I should explain that she is a qualified medical doctor; she resides in Canada, which is why that had to be done by telephone. Which one of us, if we had a qualified doctor in the family, would not ask that person to request information? However, the doctors refused to accept any further calls from her after she requested further details of Carmel’s condition and treatment. I cannot say why that happened.
On 9 September 2002, Carmel’s death was referred to the Walthamstow coroner, as it had become apparent that her death was anything but straightforward. The following time line demonstrates the due process that the family were obliged to follow in their quest to find out how and why Carmel died. As you will hear, my involvement came seven years down the line, as I was not Member of Parliament for Ilford North at the time. Nearly nine years after Carmel’s death, the evidence shows that questions about the causes of her death have still not been properly answered. A number of agencies come into play, but today I shall restrict my comments to the health aspects of the case. At a later date, I shall seek to revisit other justice matters.
In 2002, the first inquest was adjourned; coroner Dr Stearns stood down because of a conflict of interest. In 2003, the inquest was adjourned again; Dr Dolman, the second coroner, stood down but refused to disclose his reasons. In 2003, the third coroner, Andrew Walker, brought in a verdict of death by natural causes. In 2003, the Home Office suggested that application be made for a new inquest.
In 2003, Lord Goldsmith, the Attorney-General, intervened. In 2004, he granted consent for the High Court to quash the inquest verdict of natural causes. In 2004, in the High Court, Lord Justice Tuckey quashed coroner Andrew Walker’s verdict, and ordered that a new inquest be held with a jury. In 2005, the inquest jury overturned the natural causes verdict, finding that a series of failures had contributed to Carmel’s death.
In 2006-07, the Healthcare Commission investigated Bupa Roding hospital. I should say that it is no longer a Bupa hospital. The commission found a series of shortcomings and a serious lack of training and equipment in the hospital, together with false reports being given to them following Carmel’s death. The commission brought no charges against the hospital, stating that it had no power to act in retrospect. Following the investigation, Bupa sold its 26 hospitals.
In 2007, the General Medical Council started an investigation into the conduct and fitness to practise of Mr John Hines and Dr Paul Timmis. In 2007, the London ambulance service disclosed previously withheld evidence—the AS/1 emergency call receipt document and Bupa Roding Hospital’s 999 tape recording. I have seen the transcripts and heard the tape, and there is a gap of approximately 15 seconds in the recording; to the best of my knowledge, it remains unexplained to this day.
In 2007, the police began an investigation into Carmel’s death and looked into Bupa’s alleged false report to the Healthcare Commission on the events that led to her death. As I said earlier, I shall not speak about the police at this stage, except to say that, between 2007 and 2009, the Ilford criminal investigation department referred the case to the Metropolitan Police Service’s homicide and serious crime command unit, following the discovery of new evidence. In 2008 and 2009, the homicide unit referred the case to the Crown Prosecution Service. In March 2008, Bridget Matthews, the night sister on duty at Bupa Roding hospital on 29 August 2002 and the nurse in charge, was interviewed under caution by the Met’s homicide and serious crime command unit, SCD1.
In 2009, the Ministry of Justice investigated a complaint against the 2005 coroner. It was said that the coroner withheld key evidence from the inquest jury. Unfortunately, however, no inquiry took place; the judicial review office cannot investigate coroners’ non-disclosure of evidence to a jury. The non-disclosure of evidence enabled the court to understate Carmel’s condition, but that issue is not the object of today’s debate. I became involved in 2009, when my constituent’s family came to see me. I intervened, and approached the right hon. Member for Blackburn (Mr Straw), then the Secretary of State for Justice.
In 2010, the General Medical Council’s fitness to practise hearing against Bupa doctors Mr John Hines and Dr Paul Timmis commenced. At that stage, I wrote about the case in my newspaper column and in articles, and I thank the Ilford Recorder and the Wanstead and Woodford Guardian for printing them. In my writings, I asked if anyone had information relating to Carmel’s tragic death. I pay tribute to Julie Moody, who came forward as a whistleblower. She made a statement, which caused her great difficulty; that was done at great cost to her personal and professional life, and I record my gratitude for her bravery. She displayed enormous courage and compassion. She was a senior nurse and an ex-employee at the Bupa Roding hospital. She contacted me with vital new evidence about Carmel’s treatment during the night following her operation. I provided this new evidence to the Ministry of Justice and the Met borough commander, but it was withheld from the GMC’s fitness to practise panel hearing against Mr Hines and Dr Timmis. The GMC decided to proceed with the hearing, even though a whistleblower had come forward, casting new light on Carmel’s treatment at the Bupa Roding hospital, with evidence of serious negligence during Carmel’s operation. Entirely inappropriate post-operative treatment was also alleged.
Let me read out the remit of the General Medical Council:
“Our statutory purpose is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.”
It is vital, not only in this case but a number of cases, to decide whether the GMC is a union for doctors—if it is, fine—or whether it is there to represent patients’ interests.
In 2010, the Council for Healthcare Regulatory Excellence considered an appeal to the High Court against the GMC hearing’s decision not to prosecute or even issue a warning against the two doctors, even though, between them, they pleaded to, or were found guilty of, 79 charges, including one where the doctors’ conduct was so serious that it increased the risk of Carmel suffering hypoxia—I apologise for any mispronunciations of medical terms; I know that the Minister is medically qualified, but I am afraid that I am not—cardiac arrest, brain damage and/or death.
In 2010, there was an unsuccessful appeal against a decision of the Independent Police Complaints Commission. The Metropolitan Police Service’s homicide and serious crime unit interviewed the night sister. In an extraordinary development that has still not been explained, the night sister said in her statement that she had been given the whistleblower’s highly confidential statement. That statement had been given only to me—I immediately put it in a solicitor’s safe in north London—the police and the Ministry of Justice. I cannot explain how that could have possibly happened.
In 2010, the Crown Prosecution Service was approached for the third time by homicide detectives who were considering instituting a criminal prosecution, but the CPS failed to reopen the case. In the same year, the GMC referred the Bupa nurses to the Nursing and Midwifery Council for misconduct in relation to the care and treatment of Carmel, leading to her death. Bupa’s resident medical officer, Dr Darko, was also referred to the General Medical Council. Further evidence from the whistleblower—Julie Moody—and a 500-page report were provided to: the Met’s homicide unit; my right hon. Friend the Secretary of State for Work and Pensions; my right hon. and learned Friend the Lord Chancellor and Secretary of State for Justice; the General Medical Council; the Nursing and Midwifery Council; and myself.
All the way along the line, the family, who have suffered great distress over a prolonged period of time, have said that they simply want to know what happened, and want closure. That is why they asked for my assistance, and I have been trying to help to the best of my ability. We are awaiting a number of key developments: the Attorney-General’s consent to apply to the High Court for a fresh inquest; the outcome of a Nursing and Midwifery Council action against the two Bupa nurses; a decision to call for a full police investigation into the death of Carmel Bloom; the GMC’s decision to recharge the two doctors involved; and the decision by the health service ombudsman regarding the London ambulance service’s actions and the part that it played.
I have a number of questions for the Minister. I appreciate that she will not be able to answer them today. I let her see a copy of what I was intending to say last night, but it was too late for her to get any replies to me. The family are concerned that the GMC, the Nursing and Midwifery Council and the Healthcare Commission did not investigate the causation of death. I am not making any accusations against anyone; I am neither a lawyer nor a doctor. None the less, there are so many questions that need to be answered before the poor family can move on and have closure.
The coroner at the 2005 inquest wrongly withheld key evidence—I cannot give any reasons for that; I am not making accusations—contained in the London ambulance service’s emergency 999 call receipt document, to which I referred. That evidence was introduced into the inquest’s rule 37 bundle as an exhibit, but the detail and significance of this document was never pointed out to the jury. The information in that 999 call, which was made by the Bupa Roding hospital to the ambulance service, is significant.
The fact that there is a two-tier legal system is clearly demonstrated by the shocking and disproportionate lack of prosecutions. I am not saying who should or should not be prosecuted, or even whether anyone should be prosecuted. As I have said, I do not have the ability to go into that. However, there are so many conflicting reports and unanswered questions.
Before a fresh inquest for Carmel can be held, some medical personnel must be questioned and a number of medical documents must be disclosed. The X-rays taken during Carmel’s procedure, which would have shown the condition of Carmel’s kidney, have been removed from the hospital’s notes. The chest X-rays taken on Carmel’s arrival at the intensive care unit would show the condition of Carmel’s lungs. The hospital notes state that on her arrival, Carmel had a maximum four-star pulmonary oedema—fluid in her lungs—and no heartbeat. She was cold to the touch, had shut down, and her pupils were fixed and dilated. Forgive me—I am a layman—but those symptoms suggest to me someone who is, sadly, deceased. The operating department assistant anaesthetist who was present during Carmel’s botched operation needs to be questioned, and we need to know the identity of the radiologist who took the X-rays during Carmel’s operation. An investigation is also needed properly to establish the true identity of the anaesthetist who accompanied Carmel in the ambulance.
Let me stress again that Carmel was not suffering from a life-threatening condition. It was a regular occurrence that could happen to any one of us in this Chamber today. If a person dies unexpectedly in a hospital and relatives suspect wrongdoing, negligence or criminality, there is no Government body or organisation— apart from the police, who refused to get involved—willing to assist.
One of the difficulties that I have found with this case is that it falls under the remit of a number of Departments, which is why I have not included certain aspects of the case in my speech. The Minister could not be expected to respond to them, so I will have to revisit them at a later date. I will wind up, because time is moving on and I want the Minister to have the opportunity to reply. Let me, in a removed way, make my own comments. During this case, I have been moved by the dignity of the family and the whistleblower. There have been times when the family have been under great pressure and stress, and I have had to explain that there are things that I can do, and things that I cannot.
When I first met the family more than two years ago, I pledged that I would stick with the case to try to get the answers and the closure that they need and deserve. I pledge again today that I will stay with the case. When this first started, I received a phone call warning me off the case. To this day, I do not know who that was or what their reason was. I do not pretend to be a remarkably brave person, but if I give my word, I stick to it. I brought this case before the Chamber today, and I feel honoured to have done so. I thank you, Miss McIntosh, for your time and await the Minister’s response.
It is a pleasure to serve under your chairmanship, Miss McIntosh. I congratulate my hon. Friend the Member for Ilford North (Mr Scott) on securing this debate. He has set out, with considerable passion, some of the detail that led to the death of Carmel Bloom following her operation to remove a kidney stone. It was a moving speech and I commend him for the support that he has given to Ms Bloom’s brother, Bernard, who has worked tirelessly to try to establish the sequence of events that led to his sister’s death.
My hon. Friend has worked tirelessly to give support not only to Ms Bloom’s brother but to the family. I should like to take this opportunity to extend my sympathies to the family. Being unable to find out the circumstances of Ms Bloom’s death or to get any closure is a terrible burden to live with.
As my hon. Friend has eloquently said, there have been numerous investigations and inquiries into the treatment that Ms Bloom received. I know that in 2002 there was a coroner’s inquest that recorded a verdict of death by natural causes. The second post mortem did not provide conclusive statements and a further inquest in the presence of a jury found the cause of death to be
“progression of pre-operative infection following surgery, to which the absence of post-operative intubation, ventilation and monitoring contributed.”
However, none of those investigations or inquiries has brought the closure that is required by the family, or a feeling that they have found out the true circumstances of what happened.
As my hon. Friend has said, there were fitness to practise hearings into the behaviour of two clinicians, but those hearings found that the failings of neither clinician amounted to misconduct. The hearings came to the judgment that it was not necessary to issue a warning in either case. As I say, none of those investigations or hearings has resulted in an explanation that has satisfied my hon. Friend or indeed Ms Bloom’s relatives.
I have nothing but admiration for people who pursue answers to questions, sometimes, sadly, in the face of considerable adversity. Unfortunately, it is really down to their tireless efforts that we learn more and more about the failings of systems. What is important is that we ensure that we learn lessons and that those failings do not happen again.
As my hon. Friend said, Mr Bloom has taken up his case with the Metropolitan Police Service and so my hon. Friend will appreciate that, in the light of ongoing inquiries, I cannot comment further on any police action. I know that that might be a disappointment to Mr Bloom, but it is essential that due process is allowed to take its course free from interference from the influence of Government Ministers.
I also want to commend my hon. Friend for his tribute to Julie Moody. Whistleblowers, for want of a better word, are an important part of this process and we have strengthened the protection of people who have information that we feel is important. That information, when it reflects on the safety and efficacy of treatment, is absolutely vital and it is important that those people are protected.
Services provided by independent hospitals such as the Spire Roding hospital are subject to regulation and inspection. All health care providers in England, whether they operate in the independent sector or in the NHS, are subject to both professional regulation and system regulation. It is important that those things work and are effective.
Health care professionals are required to be registered with their relevant professional regulator. As my hon. Friend knows, in the case of doctors, that is the General Medical Council. He is absolutely right that the GMC’s purpose is not to act as a trade union—the British Medical Association is the trade union for doctors—but to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine. It does that by controlling entry on to its register, and by setting standards for medical schools and postgraduate education and training. The GMC registers doctors to practise in the UK and, where necessary, it has the power to issue warnings, remove a doctor from the register, suspend a doctor or place conditions on a doctor’s registration.
Interestingly, in preparing for this debate, I got out some figures about the GMC. In the last year that we have figures for, the GMC undertook 270 fitness to practise hearings, which resulted in 68 instances of doctors being struck off the register and 77 instances of doctors being suspended. I think that those figures give my hon. Friend some idea of the sort of activity that the GMC is engaged in.
At the time of Ms Bloom’s death, independent hospitals were registered with the then Commission for Health Improvement, but since that time a new system of registration has been introduced, which focuses on the outcomes of care that matter most to patients. Although I will not be able to respond to all my hon. Friend’s comments and questions today, it is perhaps important for me to set out some of the changes that have been made.
All health care providers are required, as part of their registration with the Care Quality Commission, to have an effective complaints mechanism that will enable them to learn from the experience of patients. That is an important point to make. Often we cannot change what has happened and we cannot always correct mistakes. People want to know what happened, but most importantly they want to know that things have changed as a result of what has happened to them or to their family and that lessons have been learned.
In the first instance, a complaint would be considered by the provider itself. In the case of the Spire Roding hospital, if a complaint is not resolved to the satisfaction of a patient at the hospital level, I understand that an independent review can be requested from Independent Healthcare Advisory Services. On 1 October last year, the registration of independent health care providers was transferred to the new registration system operated under the Health and Social Care Act 2008. Under that new system of registration, all providers of a regulated activity—whether they are privately or publicly funded—are legally required to register with the CQC. Providing a regulated activity without being registered is indeed a criminal offence and in order to be registered a provider has to meet and must continue to meet 16 registration requirements. Those requirements set out the essential levels of safety and quality for the provision of health care and adult social care in England. Those are essential levels of safety and quality, and as I have said already they focus on the outcomes that matter to patients and all service users.
Where a provider provides services that do not meet those essential levels of safety and quality, the CQC now has additional enforcement powers that were not available in 2002. For example, it can now issue a warning notice for non-compliance and a new financial penalty notice can be issued in lieu of prosecution through the courts. In extreme cases, the CQC has the power to close down a specific service or ward, or to cancel a provider’s registration and/or to bring a prosecution for non-compliance. If the CQC does bring a prosecution, the courts are now able to impose a larger fine of up to £50,000 where a provider has failed to meet essential levels of safety and quality. Those powers should provide some assurance to patients and service users that wherever they access health and adult social care they will receive a service that at the very least meets essential levels of safety and quality.
The CQC is risk-based and it should be a transparent regulator. That transparency is very important. Its inspections are informed and guided by the intelligence that it gathers about providers, and its inspection reports are publicly available on its website. I understand that there have been three inspections of the Spire Roding hospital in the last few years and that there were two inspections in 2009.
I can assure my hon. Friend that we want robust and effective regulation of health care providers and that we want to improve current arrangements. The health reforms that are currently before Parliament will strengthen the role of the CQC, by giving it a clearer focus on regulating the essential levels of safety and quality. In addition, we have also set up HealthWatch as a new and powerful consumer champion for users of health and social care services. It is very important that that voice for patients and the public is heard. HealthWatch will be established as a committee of the CQC and it will provide a direct route for the views of service users to reach the regulator.
I know that time is running out on us and I will certainly get back to my hon. Friend. My door and the doors of other Ministers are always open if it would be useful to have a meeting to clarify some of the issues that we have discussed. Of course, as I have said we cannot necessarily interfere in processes that are already under way.
I know that what I have said today will not change things for Ms Bloom’s brother and the rest of her family and friends, and I also know that the ripple effect of a case such as this one goes far and wide. Sadly, what I say today cannot provide the closure that they want, but hopefully I can work with my hon. Friend to give him and Ms Bloom’s family and friends some of the answers that they so desperately seek.