Monday, 1 May 2017

Primum non nocere – first do no harm: why we need challenge.

The Latin phrase primum non nocere – in English ‘first do no harm’ - is a principal of medical ethics, sometimes called ‘the principal of non-maleficence’. Healthcare students are taught its fundamental importance during their initial training.

Primum non nocere is thrown into sharp focus by the behaviour of the English surgeon, Ian Paterson, who was convicted last week of seventeen counts of the wounding-with-intent of nine women and one man. He had subjected them to breast surgery which was wholly unnecessary. There is now talk of hundreds of other unknown victims of this man.

Primum non nocere is a principal that also applies to all child protection professionals, whether they be medically qualified or otherwise.  But there have been some notorious occasions on which it has not been followed. In 1991 children were taken into care and adults arrested in response to what turned out to be false allegations of ‘ritual’ or ‘satanic’ sexual abuse on the Orkney island of South Ronaldsay.  After five weeks, during which the parents had no contact with their children, the claims were dismissed by a judge as "completely unfounded".

In 1987 children living in Cleveland, in the North East of England were removed from their homes by social services having been diagnosed, by two paediatricians at a Middlesbrough hospital, as having been sexually abused.  The children were said to show signs of ‘reflex anal dilation’.  So many children were taken into care that there were insufficient foster places for them and some had to be housed in a hospital ward. The validity of the test used to diagnose the children was disputed by other doctors and subsequently an enquiry led by the distinguished judge, Dame Elizabeth Butler-Sloss, concluded that most of the diagnoses were incorrect. As a result, 94 of the 121 children were returned to their homes with no further action.

In 1999, paediatrician Professor Sir Roy Meadow gave expert evidence in the trial of Mrs. Sally Clark, a solicitor accused of murdering her two infant sons, in which he stated that the odds against two cot deaths occurring naturally in the same family were greater than 70 million to 1. Meadow had erroneously assumed that the two events were statistically independent, which they are not. In reality the occurrence of a previous cot death points to the existence of conditions (environmental, genetic etc.) that make the occurrence of a second more, not less, likely. Sally Clark was wrongfully convicted and spent several years in prison before her conviction was quashed in 2003. She died in 2007 having never recovered from the trauma of the deaths of two children, being unjustly convicted of their murder and being separated from her third baby as a consequence of her imprisonment.

There is a common theme connecting these events with the case of the discredited surgeon Ian Paterson. It concerns lack of challenge. For reasons which are not yet clear, Paterson was allowed to continue operating for years even though serious concerns had been expressed about his competence to do so. In a similar way, once the allegations of ‘ritual’ abuse in Orkney were taken seriously, uncritical net-widening ran amok and more and more children were sucked in to what proved to be a moral panic. In Middlesbrough, the apparent scientific basis of the diagnosis made it hard to question the mistaken opinion of the paediatricians involved. In the case of Sally Clark, nobody in the court seems to have been able to challenge an expert witness who had made a basic statistical mistake.

Challenge is one of those words which one minute sounds positive and the next threatening. If I am challenging something or someone, then that is heroic and good. But if someone is challenging me, then that is aggressive and unfair. So, we need to make sure that we get the culture of challenge right.

If we are carrying out tasks which are safety critical – ones in which people might suffer or even die if things go wrong – then challenge is not something which is an unwelcome or painful inconvenience to be avoided at all costs. Rather it is a welcome opportunity to get things right. Everybody, including the most senior manager, who works in a safety critical context needs to be taught not just to expect challenge, but to welcome it. And everybody, including the most junior employee, needs to be taught how to initiate challenge of even the most powerful and distinguished colleagues.

Failing to get challenge right is not just unfortunate. It is downright dangerous. Unchallenged practice is unsafe practice. We all need to realise that, if we are to avoid doing unnecessary harm.