By Gabriel Princewill And Samantha Jones-
The CEO of Whipps Cross hospital has hung unto his job, after both the Care Quality Commission (CQC)and the General Medical practise said that an individual doctor must be complained against for accountability in the case of Mohammed Tariq who was left to die at Whipps Cross hospital.
Doctors at Whipps Cross hospital in 2017 neglected Mohammed Tariz who suffering with heart problems and left him unattended for 10 hours until he died, but no professional has been severely disciplined or fired for the abysmal level of carelessness that led to the poor man’s death. The trust has no words for accountability in terms of the dire failure of the trust to uphold its statutory responsibility to save lives, without due explanation.
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Calls have been made to the GMC to hold a doctor responsible for the manner in which Mr. Tariz died in a hospital where he should have had the trust of the professionals around him to do their best to save his life.
Ralph Coolbeck was originally asked to step down from his position following the negligent way in which Tariq was allowed to die. His failure to hold anybody accountable questioned the competence of his leadership and raised issues of credibility too.
The CQC told this publication it following our investigation into the affair that: ”it has followed up directly with the trust to ensure they had reviewed the case and identified any learning as a result.
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It added that ”subsequent contact with the trust has also included seeking evidence of the action they have taken in response to that learning, and we continue to monitor trust services closely.
”While we don’t have the power to investigate individual complaints we do use any concerns shared with us to inform our regulation and where patients, staff or other organisations share information that indicates any risk we will always follow that up.
Also worth noting is the fact that the CQC’s role is to regulate the quality and safety of care being delivered by a registered provider (in this case the hospital trust), but we have no remit over individual clinicians. Professional regulators such as the GMC and the NMC have responsibility for regulating the conduct of individual healthcare professionals”.
The CQC’s suggest they have no authority to to take any affirmative action to ensure punitive measures against individual transgressing medics. Their remit is to conduct an investigation and point out where lessons can be learnt, they say, as they allow negligent doctors to evade accountability, especially when they hide behind a crowd of other doctors.
But what is actually learnt is that an abysmal level of negligence of doctors contributed to the death of an ill man under their charge . The individual doctor in charge of the emergency section for that day would normally be the most accountable doctor on that occasion to be presented to the GMC for investigation.
When those individual doctors to be held accountable are obscure, the GMC appears to have no provisions in place to identify them through investigation, even when a significant level of negligence has been displayed.
Ralph Coulbeck should have stepped down as a result of this blunder , following his failure to account for the potentially needless death right within the trust he heads. That a man was left unattended for 10 hours until he died without any proper accountability that held somebody responsible for the failing which culminated in his death is mind boggling. Action should have been taking against at least one negligent doctor who shares responsibility for the seriously ill man being left unattended until he eventually died. The fact none of the staff under his charge have been held accountable is why we believe he is unfit for his post.
Muhammad Tariq, 55, died in the late hours of August 7, 2021, after being admitted with radiating neck pain and heart palpitations at Whipps Cross hospital.
The GMC said that complaint will have to be made against an individual doctor.
A request has been made to them to identify the individual doctor under whose charge is the duty to address that neglect . According to the conventional rules of the GMC, a complaint must be made about an individual doctor. No action as of yet has been taken.
Mr Tariq was sent to an acute assessment ward, where he remained without being checked by doctors on their day shift, until he was found struggling to breathe at around 10pm. He was abandoned for over 15 hours. Despite this major failing, there has been no openly known accountability for the unarguable professional negligence which likely contributed to his death.
Medics at the London hospital claimed the eventual demise of the patient to have been inevitable, arguing that he would have died even if he had been treated promptly.
Their unproven assertion overlooks the fact he should not have had to endure such a painful death without the care which should have been offered to him.
The inquest heard that doctors fitted a mask ventilator and attempted needle decompression to clear blood which they believed had accumulated around his heart, but he was pronounced dead at 11.16pm that night. He had been left unattended too late.
The inquest into Mr Tariq’s death at The Adult College of Barking & Dagenham, assistant coroner Dr Shirley Radcliffe ruled that he died of natural causes linked to heart disease. The ruling of natural causes does not prove that timely intervention may not have ultimately saved his life.
Whipps Cross hospital told The Eye Of Media that the finding of the inquest that the man would have died even if he had been treated promptly, absolves their professionals of blame as far his death is concerned.
However, a number of professionals in the field disagree for a number of reasons. For one, inquests are themselves prone to erroneous conclusions, especially with the occasional fallible professional judgement some of independent experts. The fact it appears a patient is about to die does not mean they would definitely die and should be abandoned to die.
Secondly, the finding that Mr. Tariq’s death is irrelevant to the fact he was made to endure avoidable pain for too long before his eventual death. Medical assistance would unarguably have alleviated his pain and potentially saved his life.
Accountability
Accountability for the suffering Mr Tariq had to endure is imperative, but offending institutions always try to evade such scrutiny as much as possible. They wallow in the presentation of untenable arguments even if they amount to an affront to the intelligence of the British public.
It is a crying shame that Whipps Cross hospital believes it can shirk its responsibility to be held accountable for its serious failing.
The systems in place to ensure accountability in the Nhs are far too weak and need to be overhauled. Even the framework within which the Care Quality Commission operate is far from satisfactory when it comes to ensuring accountability. It is tantamount to treating serious cases with kids gloves.
The only response given so far to explain the inexplicable level of neglect Mr. Tariq was subjected to has been a generic statement expressing sympathy to the family and claiming lessons learnt would be shared. They are empty words without any real substance.
Several months after the superficial statement, no lessons supposedly learnt have yet been shared to the utter disgrace of the entire hospital.
Loss For Words
A senior doctor at the Whipps Cross was at loss for words to explain why Mr Tariq had stayed on the ward all day without being reviewed in-person by a doctor.
Dr Simon Green, clinical director for acute medicine, said: “It isn’t at all clear why the junior doctors didn’t alert Dr Rizvi about the fact that there was a patient that hadn’t been checked.
“My personal practice is to check the list myself and I believe it is now Dr Rizvi’s procedure. Furthermore, it’s normal procedure for the nurses to flag it to us if a patient isn’t being seen.
“Normally there are safeguards against this happening and it really wasn’t possible to work out why none of those happened on this occasion.”
Giving evidence, on-duty consultant Dr Fareeha Rizvi said she suspected Mr Tariq was suffering from an angina but that most of his tests had come back as “normal”.
She added: “If I had seen him I would have had a very low suspicion of his level of risk, in my past experience these cases are usually very traumatic.
“Mr Tariq was unusual in that when he presented he was quite well, if I had done a CT scan I would have agreed with the plan.”
The hospital escaped any legal consequences because of their argument that timely intervention would have made no difference to his chances of survival- a position that does not mitigate the severity of the negligence by the hospital.
Dr Radcliffe accepted the doctors’ evidence that their professional plan would have been unchanged if they had seen him earlier and that efforts were made to treat him on the evening of his death.
Yet, the credibility of professionals who have fundamentally failed to fulfil their remit is invariably damaged under circumstances like these. Comments made to mitigate an appalling failing avowedly render them lacking in substance.
Catalogue Of Ailments
Mr Tariq had a catalogue of ailments which predisposed him to the possibility of an untimely death.
Dr Radcliffe said Mr Tariq’s medical records showed he was pre-diabetic, a smoker and had “significant” hypertension, and his cause of death was recorded as hemopericardium, which is an accumulation of blood in part of the heart.
Dr Rina Davison, acting medical director at Whipps Cross Hospital said: “We offer our sincere sympathies to the family of Mr Muhammad Tariq.
“Although the inquest concluded he died of natural causes, we assured the coroner we will share the learnings from this case widely across our hospitals.“
Learnings
Whipps hospital was unable to explain to this publication what the learnings from this case were, and why after nearly a year, they still haven’t been shared widely across hospitals.
Mental health analysts Denise Verhnoven, described the conduct by Whipps Cross as: irresponsible behaviour. It is bad that this level of irresponsible can go on even with a man six feet under, potentially due to their negligence. Someone should ahve been held responsible for it, and the buck stops on the CEO, but the GMC says an individual doctor must be identified. . There seems to be no explanation why their investigation cannot identify the dcctor responsible for the death of Mr. tariz
An independent expert opinion told the inquest that Mr Tariz would have died in any eventuality.
Ralph began his career on the NHS Management Training Scheme and has worked in the NHS, parliament and government. Before coming to Barts Health, Ralph was previously director of strategy at the NHS Trust Development Authority.
“Ralph has led on a number of key strategic priorities during his time at the Trust, including the successful launch of the East and South East London Pathology Partnership, the ongoing Whipps Cross Redevelopment and our life sciences programme,” Alwen Williams, group chief executive, said when he was originally appointed for this role
“I have every faith that he will take on this role with the upmost professionalism, compassion and diligence”. These nice rhetoric has not been lived up to on this occasion.
Mr Coulbeck should have conducted a comprehensive investigation and ensured disciplinary action of some kind for the failure to ensure Mr Tariq was attended to it, once the entire situation was brought to his attention. His failure to do so in our view makes him not fir for the top position.
A CQC spokesperson said, “We are aware of this case and have followed up with the trust directly to understand the circumstances surrounding Mr Tariq’s death and any need for action on our part. The trust shared details of their serious investigation report and evidence of the steps being taken to ensure learning from the case was captured and acted on.
“We are in regular contact with the trust, and continue to monitor its services closely to ensure patients are receiving safe care.”
“If we identify concerns that patients at risk of harm, we will take regulatory action and should anyone have any concerns about care or treatment at the trust we would encourage them to contact us directly.”
A statement from the General Medical Council to The Eye Of Media.Com read: ”In terms of the GMC’s remit, when a serious concern is raised about a doctor’s ability to practise safely or the way they do their job, we will assess whether an investigation is needed.
While we are unable to comment on specific cases unless they proceed to a tribunal hearing, we do investigate all concerns raised with us, and fully consider all relevant evidence before making a decision on each individual complaint”.
The GMC has been urged to pursue an investigation of the full details of this case for the sake of accountability and transparency.
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