DOCTOR, HEAL THYSELF

The case of Rodney Ledward, struck off the medical register last week, proves the profession is unable to police itself

IF RODNEY Ledward had not switched off his mobile phone one January night two years ago, details of how he maimed women in a series of bungled operations might never have come to light. The senior consultant gynaecologist from Folkestone, Kent, with a lucrative private practice said to be worth more than pounds 100,000 a year on top of his NHS salary of at least pounds 57,000, might never have been exposed as the incompetent, arrogant, self-serving surgeon who was last week struck off the medical register.

It was the operation on Christine Laverty, a 42-year-old mother of three, on 31 January 1996, that was to prove Mr Ledward's undoing. The inquiry it triggered exposed a pattern of incompetent practice going back seven years, and led directly to the charge of serious professional misconduct found proved by the General Medical Council last week. What remains unexplained, however, is why a surgeon whose errors were so gross that patients almost bled to death, and whose behaviour was so cavalier that colleagues were left to patch up his mistakes, was allowed to continue in practice, unchecked, for so long.

Mrs Laverty was due to have a routine hysterectomy at the private St Saviour's hospital run by BUPA in Hythe, Kent. The operation almost cost her her life. Mr Ledward perforated her bladder and damaged one of her ureters (the tubes linking the kidneys to the bladder) but despite clear evidence of the injuries he had caused - blood in her urine - he stitched her up and left the hospital.

The case might have been put down as one of those unfortunate incidents in which complications arise. But as Mrs Laverty's condition deteriorated, nurses and medical staff made frantic attempts to contact him on his mobile phone - without success. In desperation, they called consultant gynaecologist John Davies, a colleague of Mr Ledward's, who arranged for the emergency transfer of Mrs Laverty to the William Harvey hospital where surgeons spent three hours repairing the damage.

Mr Davies was so appalled by what he found that he called in the William Harvey's medical director, who ordered the suspension of Mr Ledward five days later and set up an inquiry chaired by a QC. That inquiry, which took 10 months, examined 150 operations carried out by the surgeon and found a third had resulted in serious complications; 12 showed evidence of incompetence. Mr Ledward was dismissed without compensation in December 1997 and has not worked since.

THE HOSPITAL was sticking to its line last week that one bad apple does not make the whole barrel rotten. But what is rotten is the system for picking out the bad apples. The hospital insisted it could not have acted against Mr Ledward until there was clear evidence of a pattern. "There is a difference between allegations and evidence," a spokesman said. What patients in Kent and across the country would like to know is whether such evidence is being collected.

The short answer is that it is not. Doctors who qualify as consultants and are admitted to the specialist register held by the General Medical Council may practice for a further 20 or 30 years without another check that they are still up to standard. Detection of incompetence or malpractice thus depends largely on colleagues who will blow the whistle. But whistleblowing is foreign in medicine, which depends heavily on teamwork and patronage.

That was what Dr Stephen Bolsin discovered. He was the anaesthetist at the Bristol Royal Infirmary in the early 1990s who tried to raise the alarm about the length of time being taken to complete heart operations on children and the high death rate. (In paediatric cardiac surgery, speed is essential to ensure a good recovery.) His warnings were ignored, he found his career path blocked and he finally emigrated to start a new life in Australia.

When the facts were finally exposed they led to the longest disciplinary inquiry in British medical history, into what has become known as the Bristol heart surgery disaster. It centred on 53 operations in which 29 babies died and concluded last June with three doctors, surgeons James Wisheart and Janardan Dhasmana and former chief executive John Roylance, found guilty of serious professional misconduct for allowing the operations to continue despite evidence of the high death rate.

That case has proved to be a watershed. It exposed for the first time the absence of clear standards against which doctors can be judged and has triggered a flurry of activity among medical organisations and the Government to remedy what to patients has been a glaring deficiency for years.

This month Frank Dobson, Secretary of State for Health, is due to publish the first league tables of hospital death rates for England, which will allow patients to compare clinical success rates. Although death rates will not be published for individual surgeons, doctors will be required to take part in regular reviews of their work and will be subject to spot checks by the Commission for Health Improvement, a troubleshooting body which will be sent into ailing hospitals to turn them around.

NEW PROFESSIONAL standards are being drawn up by the Academy of the Royal Medical Colleges, which has asked each hospital speciality to supply outcome measures against which the performance of individual doctors can be assessed. For some specialities, such as heart surgery, the measure may be death rates, for others, such as hip replacement surgery, it could be revision rates (the proportion of operations that need repeating in a set period).

The royal colleges are being pressed by the General Medical Council under its reforming president, Sir Donald Irvine, who was instrumental in bringing the case against the Bristol surgeons. Sir Donald is determined to change what he has called the "defensive, protective, inward-looking, culture of medicine". In June, the GMC updated its guide, Maintaining Good Medical Practice, which spells out the duty on doctors to report colleagues who are putting patients at risk. Some 200,000 copies of the guide, which has been described as a whistleblower's charter, were distributed to doctors, hospitals and health authorities. It says that although doctors are expected to "look after and care for" each other, their first duty is to protect patients.

But some senior figures in the profession are dragging their heels. Sir Rodney Sweetnam, president of the Royal College of Surgeons, sought to represent the Bristol case as an isolated incident reflecting "a failure of local auditing procedures", not a symptom of a wider malaise. This was in direct contrast to the GMC's verdict in the case, which listed more than a dozen issues which it said "will have to be addressed by the medical profession", including the need for clearer standards, better training and improved monitoring of performance.

Sir Donald has come under fire from senior colleagues who believe he is pushing through his personal agenda for change too fast. Others fear a backlash. The Medical Defence Union released figures last week showing that 30 doctors had been suspended in the two months since the Bristol inquiry was completed, 10 times the normal average. It warned of a witch- hunt. Professor Tom Treasure of St George's Hospital wrote in the British Medical Journal that he feared a McCarthyite culture. But Stephen Thornton of the NHS Confederation disagrees. People are waking up to the need to report dubious doctors he said. The case of Mr Ledward demonstrates just how urgent that is.

ONE BLUNDER AFTER ANOTHER

1993 Carol Starkie, consultant pathologist at Selly Oak Hospital, Birmingham, took early retirement on health grounds after 300 tissue samples checked for cancers were re-examined. At least two children had chemotherapy unnecessarily.

1995 Nicholas Siddle, consultant gynaecologist at University College Hospital, London, was struck off the medical register after seven women were injured in botched operations.

1996 At least eight women died and 90,000 cervical smears had to be re-examined at Kent and Canterbury hospital. An inquiry found management failings at every level.

1996 James Gough, 38, was struck off after removing part of the stomach and duodenum of a 75-year-old, who died shortly afterwards, which he mistook for the colon.

1997 Twelve women developed breast cancer and two died following delayed diagnosis at the Exeter breast screening centre. A government inquiry said consultant radiologists John Brennan and Graham Urqhart had failed to provide care to the standard expected.

June 1998 Bristol heart surgery disaster. James Wisheart, consultant surgeon, and John Roylance, former chief executive of the Bristol Royal Infirmary, were struck off for allowing operations on babies to continue despite the high death rate. Consultant surgeon Janardan Dhasmana was banned from operating on children for three years and later sacked.

September 1998 Rodney Ledward, consultant gynaecologist at William Harvey Hospital, Kent, was struck off for a series of botched operations over seven years.