SOCIETY TODAY

Medicine

Who indeed, is to blame?

John Linklater

A sick baby died without receiving medical attention, three days after his parents had asked, in vain, for an urgent home visit from their • general practitioner, reported John Gordon, in his centre-page column in the Sunday Express on Sep tember 30. The columnist then implied that the doctor was dishonourably avoiding direct responsibility for the death because his "receptionist was medically untrained." He pointedly asked "Who is to blame?"

Like all those who read the article, I was enraged. If these facts were true, I would have that doctor publicly disgraced to show how abhorrent his action was to his colleagues in the medical profession. He would be struck off the register.

The practice was easily identified from the report which gave its address in York, where a number of well-informed persons confirmed each other to say that the facts, as reported by John Gordon, are in flat contradiction to the facts as known to them.

I found that Andrew Hawkridge, the baby who died, was born on about August 12. A doctor, from the group practice referred to in the Sunday Express, visited him at home, as a routine measure, on five separate occasions during the first two weeks of his life. He was normal and well.

On Thursday, August 30, some two days after the last visit and "about half an hour after the last doctor had left surgery, the baby's twenty-year-old father telephoned, and brusquely demanded a home visit. The receptionist asked for further details in order to help the doctor to assess the urgency of the visit. "That's none of your business, you send the doctor round," replied the father, who would not discuss it further, and rang off without leaving his name. About an hour later, the baby's mother telephoned. This call was taken by the senior night-duty receptionist, who also replied "Yes, of course. How urgent is it, and what seems to be wrong with the baby?" "You can stuff your bloody practice," replied the child's mother, and also rang off.

At about ten o'clock on the following morning, the tirading mother registered the baby with another nearby practice in the town, where the baby was carefully examined by a lady general practitioner. She remembers this examination clearly. She could find nothing wrong. The baby was said to be Ivomiting, but looked bonny: it had gained two pounds in weight since birth.

To be on the safe side, however, she telephoned the group practice to find out whether there was anything unusual in the medical records. All the entries were strictly normal. The group practice thus knew that the infant had come under the care of another doctor, and that no further action was possible.

The baby was seen twice, thereafter, by the same lady doctor, who found no reason to alter her diagnosis of a slight mismanagement and feeding problem. Her last consultation was on Saturday, September 1.

The baby was found moribund in its pram, downstairs, when the parents woke on the following morning at about nine o'clock.

This sudden, totally unpredictable and unexpected infant death is well known medically. It is known as cot death and is accepted by the Registrar-General as a diagnosis, by exclusion, and a sole and sufficient cause of death. It used formerly to cast suspicion against the parents for neglect or, even, for deliberately suffocating their child in a brutal fit of bad temper.

The reason for this suspicion is that the only abnormal postmortem finding in cot death, is that the internal organs are covered with minute red spots, caused by the bursting of small blood vessels as a terminal event. These spots are known as petecchial haemorrhages, and they are also always found after suffocation or strangulation.

The post-mortem examination of baby Andrew confirmed the evidence of his lady general practitioner, in that all tissues and organs were healthy and normal except for the presence of petecchial haemorrhages. There was no infection, nor other disease,' and only trivial vomitus in the trachea. The consultant pathologist at the inquest gave cot death as his firm, and only, diagnosis.

The death of the baby was, thus, a tragic act of fate, and was anyway not connected with the original group practice, or with the doctors in it, and the medically untrained receptionists had no connection with it either.

At the inquest, a curious event took place. The coroner was young and newly appointed and not medically qualified. He queried the widespread presence of the petecchial haemorrhages, and ap peared to believe that they were evidence of some untreated illness of longer duration. He did not ac cept the explanation, and gave an open verdict. It is, perhaps, as the result of this, that the dead baby's parents, who did not understand the petecchial haemorrhages either, have been ventilating their grievance on the media. They still seem to be convinced that thp original group practice was, in some obscure way, responsible for the tragedy.

One cannot help feeling that if the coroner had discussed cot death with his cousin, who is one of the uninvolved general practitioners in the town, he would have been better informed. Much harm might have been avoided.

Another aspect of this affair also serves to illustrate, only two poignantly, an argument developed in this column on September 29, when I showed that the Government itself is chiefly to blame for many of the problems that beset the general practitioner today. By advertising, for example, the totally free, instant access, as of right, to the family doctor, on the 'no home should be without one' basis, the Government creates an incredibly difficult and totally unnecessary public relations problem.

Unthinking people, who actually take the Government at its word, must feel cheated of their promised instant doctor when they are asked by a receptionist for further details of the complaint, instead of getting instant satisfaction. They therefore give a surly reply. How much more surly will the public be, next year, when they observe more money spent on bigger, and yet more understaffed hospitals, and huge office blocks to house the elephantine bureaucracy of highly paid lay administrators who will be directing yet fewer and fewer instant doctors to do the actual, everincreasing work? We may then think ourselves fortunate indeed, if they merely express their resentment by telling us to stuff ourselves.

John Linklater MBE is an exArmy officer who became a doctor and is in general practice.