MrsBwasexpectingtwinsin1994.Thefirstbabywasbornwithlittledifficulty.
Thesecondbabybecamestuckandaftertwentyminutestheregistrarappearedto
panic and an emergency Caesarean section was carried out. The baby suffered
severebraindamageanddiedafterthelifesupportmachinewasswitchedoffwith
theconsentoftheparents.Themotherwasfullofpraiseforthetreatmentreceived
atthehospitaltowhichthebabyhadbeentransferredforspecialisttreatment.She
wrote:Thehospitalstaffat...werebrilliant,sosensitivehelpingusthroughevery step of the whole terrible business...' Neverthelesstheparentswerenothappyaboutthereasonsforthedeathoftheir son.Theycarriedouttheirownresearchanddiscoveredthatthemedicalrecords showedclearlythattheCTGtracingshaddisclosedfoetaldistressandthedelayin delivery.Theyvisitedtheoriginalhospitalonanumberofoccasionsandspoketo the various members of the obstetric team. All denied that there had been foetal distressandinsistedthateverythinghadbeenproperlydone.Theyweretreatedin apatronising manner and no allowance was made for the fact that they were grieving parents. Their last meeting was with a number of maternity staff and a consumers affairs manager when they met with the samebrick wall'.
In November 1995 Mrs B contacted AVMA. After they had read the notes they
referredhertoasolicitor.Shewasadvisedbythesolicitorthathercasewasoneof
the strongest he had seen. Mrs B said that the three years of her case were extremelystressfulonmanylevelsbutatleastwegotsomeanswers'.Threeweeks before the trial the Trust offered a settlement which she was advised to accept. Even after this settlement the parents wrote to the Trustpleading for a full
explanationandadmittanceoferrors'.TheChiefExecutiverepliedthatbecauseof
thelegalcasehewasnotobligedtocomment.Bothparentsareadamantthatifthe
Trusthadgiventhemafullexplanationandapologyinthefirstplacetheywould
not have embarked on litigation.
4.7 The ethical aspect
Aswillhavebeenseen,therehavebeenmanychangesandnotafewadvancesin
the patient's situation with regard to complaints. We have seen that it is now
recognisedthatacomplaintcanbedealtwithaspartofthecareofapatientandas
such the obligation to deal with it properly comes within the duty of care of all
health care providers. There remains, however, a fundamental flaw in the
approachbythehealthservicewhenthereisabreachinthatduty.Itshouldnotbe
an issue of complaint, blaming someone, some institution or even a system. A
complaintexposesadefectincare.Thatshouldberecognisedbythoseproviding
the care when it happens, not when the patient draws attention to it. But if the
health careproviderhaswaiteduntilthepatientdrawsattentiontoitthenthatis
howitshouldbeseenandcategorised±notasacomplaintbutasanissueofcare
to be dealt with.
One major advance in dealing with complaints along these lines would be for
thebodycomplainedagainsttoobtainanindependentmedicalreport.Atpresent
clinical advice is obtained internally. It is the experience of many representing
patients that this advice often results in a false approach to the complaint. The
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