Whistleblowing and the management culture.

August 5th, 2014

 “For a decade or more, the message has been in the NHS that if you are clinician and speak out for patient safety, you can expect to be discredited, smeared and lose your livelihood. But if you are a manager doing a bad job or hiding the truth, you can often expect a promotion.”  Charlotte Leslie MP.

In other news, Benedict Cumberbatch will star in Hamlet.

Sudden Unobserved Cardiac Death is Probably not Infarction

July 20th, 2014

A universal definition of myocardial infarction is offered at http://eurheartj.oxfordjournals.org/content/28/20/2525.full of which the most important words are “accompanied by”.

Myocardial infarction is a definite diagnosis, and one which can be proved or disproved, but only by technical means which are unlikely to be available to a GP at a sudden death, or arguably by history and observation over a period – which is by definition unavailable in a sudden unobserved death.

Ischaemic heart disease is a cause of death in which one may reasonably believe, based on prior history and manner of death and which is generally assumed to have had a long course, therefore a doctor acquainted with the patient is highly likely to have attended or treated them in their last illness.

The cause of sudden death in IHD is empirically[1] not usually myocardial infarction. It seems likely that either a sudden demand on the heart outstrips the limited coronary blood supply leading to a reduction in output and pressure, and a rapid and quiet feedback spiral giving no cardiac output and prompt death – but not an infarction; or that an area of myocardium rendered ischaemic gives rise to an unrecoverable dysrhythmia with prompt collapse and death. But not infarction.

Cremation certificates require the signatories to be without doubt as to the nature and manner of death. This is beyond “balance of probabilities” but is not a demand for an exact and precise diagnosis.

Being persuaded to give a definite diagnosis of myocardial infarction on a death certificate and cremation form when you not merely cannot be without doubt about it, but are provably unable to have such certainty is unwise, not least because the rejection of the cremation form causes surprise and alarm among the family who may well be your patients.

A repeated statement “I am not in a position to certify a cause of death” may seem unhelpful, but if true is not unreasonable. If the cause is “obvious” to someone else, then let them certify it.

In the case of a patient known to you to have had (a diagnosis of) ischaemic heart disease, and who dropped dead or died in the night without fuss, if you form a clear opinion that the cause of death was ischaemic heart disease and certify this on the relevant forms it seems extremely unlikely that any trouble, disturbance or adverse comment will result. If you have occasion to discuss it with HM Coroner and agreement is reached it seems literally incredible that repercussions would ensue. If of course you do not form such an opinion, see paragraph above.

[1] Doctors in Devon have been persuaded to give MI as the cause of death. A post-mortem has never in my experience shown an MI, and contrarily has excluded an MI in each case. Ischaemic heart disease has been present in all save one. A view that more post-mortem examination should be done than currently in order to improve medical knowledge and be certain of more cause in more cases is a perfectly reasonable view, and merits discussion, however the post-mortems should done at the expense of the State, not the estate of the deceased, and at the request of the attending clinicians not that of the Crematorium Referee.

Exeter Riverside Parkrun

July 18th, 2014

Starts 2nd August 2014.

Photos, when there are some.

The start is near the buoy.

River, with beached buoy

Exeter Cricket Photographs: Coaver Club: Tipton St John vs Sunset

July 17th, 2014

2014-07-16 – 550 images. http://charleswhittonphotography.com/tipton-st-john-v-exeter

Nice evening, entertaining cricket.

Reshuffle Dressing

July 16th, 2014

http://www.newstatesman.com/media-mole/2014/07/new-boys-block-your-guide-kings-downing-street-catwalk The women in the Cabinet, whatever you might think about an Equality Minister whose Christian convictions lead her to oppose equality in marriage, all wore clothes.

censorship ticks on

July 4th, 2014

Seven years ago, Stan O’Neal was ousted as chairman of Merrill Lynch. He had forced the bank to become more shark-like in its behaviour, and succeeded – to the extent that it almost collapsed due to sub-prime loans. “Merrill’s mess” ran a BBC online headline after his departure. “Wave after wave of schadenfreude had been crashing” on his head, it said. Not the most elegant metaphor, perhaps, but a relatively mild verdict, given the circumstances. In the past few weeks, however, someone has complained and Google has emailed the BBC to say that the offending story would be removed from its search engines. The great digital redaction has begun. http://www.telegraph.co.uk/technology/google/10944111/Google-has-become-the-victim-of-digital-censors.html

Via the Torygraph news email.

Not a good thing.

Exeter Cricket: Coaver Club: Westbrick vs Luckham Oaks

June 20th, 2014

18th June 2014 A selection of photographs from the end of the first innings and beginning of the second http://charleswhittonphotography.com/exeter-cricket-westbrick-vs-luckham


Cricket: Westbrick vs Luckham Oaks June 2014 Coaver Club Exeter
Composite image produced in the Gnu Image Manipulating Program (Gimp)
Click image for larger – and larger – image. Ask for a full size one by all means.

Exeter Cricket: Coaver Club Coaver vs Geriatrics

June 19th, 2014

I wandered across the road and took pictures of cricket which are available at http://charleswhittonphotography.com/exeter-cricket-coaver-vs-the

Exeter Geriatrics Cricket Club website

Coaver Club events timetable

Advice to Employers: not General Practice

June 16th, 2014

Whether the amount of variation of sick leave between Devon and the average in England is statistically significant is doubtful, even if it is then in business or social terms it is of little importance. http://www.exeterexpressandecho.co.uk/People-Devon-sick-days-UK-average/story-21242636-detail/story.html?ito=email_newsletter_exeterexpressandecho

What is worth noting is that the advice some employers apparently feel GPs give poorly is of course Occupational Health advice, or Occupational Medicine, and oddly enough this is something that employers should be getting from Occupational Health departments in their businesses or from Occupational Medicine doctors in OH/OM Practices. Not GPs. Now which employers will it be who are complaining that they don’t get the good advice they feel entitled to, free, from doctors who have many other things to do which are either in their specialty, paid for, or both? Perhaps the ones that are too mean to buy Occ. Health services; and who operate the Bradford Score on employees who have odd days off not as a means to pick out who they ought to think about, but as if it were a justification for “disciplinary” action.

That’d be the ones that cause psychological illness in their employees, piss them off and lose effectiveness and willingness, and persuade mildly ill employees to come in and infect their co-workers instead of calling a duvet day.

The Express & Echo is owned by the owners of the Daily Mail, a rag(e) resembling a newspaper in shape, but is in general a local paper and therefore interesting.

Fragment of a Calendar

June 16th, 2014