"Your Eyes Don't See What Your Mind Can’t Think"

The media are quick to highlight medical problems that occur in a celebrity, or if the patient happened to die from child abuse. As a doctor it is very difficult to highlight existing problems because doctors who come forward to raise concerns are either gagged or prevented from taking legal action by subjecting them to prolonged investigations.

Doctors who criticise staff, nurses or management to defend patient care often find themselves facing serious allegations or unsubstantiated claims resulting in prolonged investigations.

Most doctors we spoke to are aware of what is going on, but are helpless and are suffering in silence. Managers know doctors will find it very distressing to breach patient confidentiality to help defend themselves and so are exploiting this weakness.

The cases I have highlighted here are true stories that have made me feel sad as the lives of innocent patients who trusted doctors are made to made to suffer.

No patient visits a surgery, A&E or a walk-in-clinics to consult a doctor must be advised or treated by a nurse using a protocol or guidelines. Unfortunately, the system in UK does not allow them to access doctors, and the receptionist refers them to a nurse rather than the doctor.

I would label the errors I listed as "Negligent" because a good doctor with the knowledge and training would have diagnosed, treated and prevented complications and alleviated pain and suffering early.

These cases clearly demonstrate how lack of knowledge and formal medical training can result in errors that produce short-term or long-term complications. This is what doctors call “Medical Ethics” because it makes us feel very uncomfortable and sad.

I have listed only few of the cases (which I have documents to prove) that occurred in a nurse-led surgeries or walk-in-clinics. After I stopped working in hospitals the trauma I experienced, not because I was subjected to complaints or the disciplinary enquiry, but thinking of my patients whose lives had been affected by the provision of sub-standard care. The sad thing about this is that they do not know their illness or suffering was because of wrongdoings and poor care offered by the NHS.


The trauma and the sadness of seeing so many lives affected by poor care offered by nurses supported by incompetent doctors. The only way they could defend their actions would be to say they followed the protocol.

If offering healthcare advice and treatment was easy and straightforward, then we would not need doctors. Patients could use this protocol, refer British National Pharmacopeia (BNF) and self-medicate or treat themselves.

Knowing and practicing medicine in acute and critical care for almost 25 years and helping very sick people (children) to survive, it was hard to observe how many mistakes occur every day in the NHS, yet people are made to believe this is the best system in the world.

“Please do not offer free poor quality healthcare service to fellow human beings if you can only afford to offer a service that harms them”

Dry Skin Diagnosed as Eczema

A rash was not getting better. The nurse prescribed steroids because the protocol said so.

As the initial diagnosis was wrong, fungal infections, scabies and bacterial infections like Multi-Resistant Staphylococcus Aureus (MRSA) spread like wild fire often being contagious.

This will become potentially major problem in the future because of antibiotic-resistant bacteria like MRSA. It is hard for doctors to diagnose this infection because so how can we expect a nurse or chemist to know?

A steroid is not a simple cream; this drug is used only to suppress the symptom and often has serious long-term effects that can make you suffer as you get older.

NB: These are only few simple cases I collected in three months but have more that I would publish.



Tiredness Does Not Mean you are Anaemic

A girl aged twelve years presented a history of tiredness. Her haemoglobin in the blood test was low and so, based on protocol, she was treated with iron tablets.

When the treatment did not make the girl better, the doctors and nurses did not stop to think why. They did not clinically examine her, but continued the treatment for two years.

I saw her when she was 14 years old because she developed acute tummy pain. When I went through the notes I noticed the mistake and so clinically examined her. She had a huge mass in her tummy, which turned out to be kidney.

The father of this girl asked me why the doctors and nurses who saw his daughter did not clinically examine her. I could not answer the question and suggested he contact the practice manger but he did not.

This girl has now lost one kidney and is on treatment for high blood pressure. This complication that could have been prevented and so is termed: "Negligent".

Girl With Hairy Legs, Cheek and Chest

A twenty-three-year-old medical student was worried about spots on her face. As she entered she spoke with a husky voice (masculine), was shaking and looked anxious.

After going through the notes and listening to her story, I felt she had a thyroid problem and so requested her to undress for me to examine her chest (the mother was in the room).

I was shocked to see excessive hair on her chest, cheek and legs (shaven) and so I referred her to see a specialist.

This girl made a complaint against me, saying she found it uncomfortable when I requested her to remove her blouse to examine her chest, because she had been examined on numerous in the surgery by doctors and nurses with her clothes on.

This girl developed excessive hair growth that required shaving because doctors or nurses had failed to examine her chest as expected and so failed to identify her problem early and so she was referred to a speech therapist rather than an endocrinologist.

PS: The nurse who was in charge of conducting the enquiry to see if I was fit to practise did not know what I meant by
“hirsutism”.

Tummy Pain and Vomiting Treated as Gastritis


A nurse and a doctor saw a 55-year-old lady who had tummy pain and was vomiting. She was diagnosed as having gastritis and prescribed anti-sickness pills without asking about or examining her tummy.

I saw her with the same complaint a few weeks later and was surprised to hear the pain was lower down and so asked her about sex and contraceptive. She denied getting pregnant but I insisted on a pregnancy test, which was positive.

This lady (a strict Muslim) was very distressed as her pregnancy had advanced and found it hard to think of termination.

Girl Presented with Vomiting and Tiredness


A 24-year-old lady had a flu-like illness and was treated with paracetamol for two weeks. The blood test suggested liver problem. The doctor who saw the result accused her of abusing paracetamol.

She came to see me because she was not getting better and was distressed because the doctor blamed her for her illness. The first thing I noticed was that she was jaundiced and so asked her about the colour of her stool and recent travelling she had done. I diagnosed hepatitis.

This lady was surprised because she had told the doctor and nurses about her white coloured stool. They had not diagnosed jaundice and so advised paracetamol (not to be taken when you have liver problem).

Healthcare Protection Agency contacted me and advised me to offer a hepatitis vaccination to people in contact (family and friends). They said the risk of spreading this infection was high as she had not been abroad.

This lady was made to come to the surgery three times, which put other patients’ lives at risk.

Sore Throat in a Dying Lady Treated with Banjul

A 54-year-old lady with an inoperable brain tumor developed a sore throat. She could not eat or drink. The doctors and nurses treated her with Bonjella (used to numb gums in babies during teething).

She developed Disseminated Intra Vascular Coagulation (DIC) side effect of treatment. The nurse (on call for emergency) visited this patient at home and reassured her that her blood test was normal. I was surprised to note that a nurse who did not know what DIC means had been allowed to prescribed Bonjella and reassure patients.

Steroids make patients very hungry; knowing this I felt bad because she was practically living on 21 tubes of Bonjella every day for two weeks. She died a few days after I referred her to hospital to get total parenteral nutrition.

I spoke to this ladies daughter recently and told her how I can never forget her mother because of what happened .This lady was not aware and felt sad. She has offered her support

Nurse Diagnosed "White Collar Hypertension" – Patient Admitted in Intensive Care Unit (ITU

A nurse in the surgery saw a young lady with multiple problems. She noticed high blood pressure but had not discussed with doctor or given any treatment.

The nurse documented this in the notes as "White Collar Hypertension” and asked her to return the following week.

This young lady collapsed at home and was admitted in ITU and was said to have had kidney failure.

Child Developed Spasticity

A child with a high pitched cry was said to be very irritable. I noticed this child had a severely blocked nose and so was irritable. A child younger than a year does not know how to breathe through its mouth and so the supply of oxygen to brain can be reduced resulting in spasticity.

I used a mild steroid (Budesonide) via volumetric to see if I could help open the blocked nostrils.

The nurse who saw him a couple days later stopped this treatment without asking me and raised concerns that I had used a treatment not recommended in BNF

It is unethical (Tokyo Declaration) to stop treatment (not knowing anything about this drug) recommended by a doctor who has the knowledge and experience to prescribe to alleviate pain and suffering. Her action has resulted in spasticity (hypertonia and difficulty to walk) and developmental delay.

Obese Patient with Urine Retention Suffering Pain

The bladder of a patient was not drained due to fear of damaging his prostrate. I was contacted a fortnight later (I had been on holiday). The nurse practitioner had not appointed a locum doctor and so the district nurse waited for me to return from holiday to discuss.

When I asked her why she did not consider using a smaller tube (nasogastric tube) she thought it was unethical. She did not think it was unethical to allow a patient to stay at home in pain due to discomfort for fortnight before getting a doctor to review.

Rash in Neck of a Man Aged 20 Treated As Shingles


A 20-year-old youth was seen, diagnosed and treated as having shingles in the local walk-in clinic.

He walked into surgery a week later looked well, but demanded an emergency appointment, didn’t want to go home and returned that evening saying he was very unwell.

The receptionist could not offer an appointment, but looked at the MAYA card. She asked him for three symptoms (all RED) and so rushed him to see me. I diagnosed septic shock and admitted him to my consultation room and he asked if I would see him, and so I did and referred him to a hospital.

This young man had staphylococcus infection (Impetigo), which was not diagnosed or treated, resulting in septicemia.


Girl Aged 12 years with Fresh Bloodstain in Panties.

The girl was well and not had periods. She was seen by a nurse and treated as having a urine infection without examination.

She did not have any symptoms suggesting infection and her urine test was normal.

The girl was seen twice with the same problem but nurse and doctor had not clinically examined her. Both had missed sexual abuse and traumatic injury.

Child Now Looks Like a Toad

A child age three months was brought to see me with a history of vomiting, rash and excessive crying. I noticed the head was small because the sutures were closed. After explaining all about small head and the child needing a scan I referred the child to the hospital.

Hospital consultants diagnosed this as milk allergy and continued to treat this with alternative milk. Patients believe doctors in the hospital know better and so avoided a return to the GP.

Six to eight months later the child was brought to see me by the mother saying the child is not still well. By that time the child looked odd, so I referred him to another consultant but no change in treatment.

The child was referred to Great Ormond Hospital by the pediatrician to investigate for food allergy. A neurologist during his rounds noticed this child and took over the care and diagnosed “Craniostenosis” (closed sutures in skull) and operated.

Now the child is slowly progressing but looks like a Toad with eyes popping out of his skull.

Diagnosing Otitis Media

Ear infection is one of the most common reasons for prescribing antibiotics in the UK. Doctors and nurses have been prescribing without properly examining the ears. "Red ear" does not mean you have "infection" because ears drum can look red after you sneeze or a baby cries out loud.

Penicillin, often prescribed as advised in the protocol, does not enter the pus behind the ear. Using 250 mg of poorly absorbing Penicillin V in an adult can cause more harm than good. We know a low dose of antibiotics stops bacteria multiplying but does not kill them.

Amoxicillin was invented to help us get good blood levels that kill bacteria (if you need to kill an elephant use a double barrel gun, not a matchstick).

If you have infection in the ear, the drum gets hot (inflamed) and so the wax often melts away.

Danger of Cavernous Sinus Thrombosis

A child treated with Penicillin and Vaseline resulted in a blocked nose and septicemia.

Infection in this area must always be treated early because the infection can quickly enter the brain that can result in "Cavernous Sinus Thrombosis" and death.

This infection was caused by staphylococcus which is very resistant to Penicillin. The protocol does recommend the treatment advised by the nurse but she was not aware of the complication.

Increasing Anxiety of Patients

Nurses who are not trained to differentiate common from potentially serious conditions often rush patients to hospital.

Fortunately these were not serious but made patients and their family very anxious.

We must avoid inflicting anxiety by making wrong diagnoses that are potentially serious because patients will find it harder to cope with stress than the illness. A doctor’s duty is “Do No Harm”.

I have seen numerous patients who were made to suffer because the nurses are not trained to clinically differentiate rashes. This not only results in delay and can impart psychological trauma and anxiety which is unethical

“Your Eyes Don’t See What Your Mind Can’t Think”

I am planning to publish these stories to help doctors and nurses learn how mistakes occur. We must warn patients that healthcare advice and treatment offered in the NHS may not necessarily be the doctor’s fault, but because the system does not allow them to offer diagnosis and treatment based on their knowledge and training. If they rebel against this system, they are castigated.

Doctor’s Dilemma

Patients demanding investigations, treatment or referral are often abusive to the doctor if their demands are not met. They will often complain to others that the doctor is bad or spread malicious rumors.

The staff often uses this; nurses or managers blame the doctors, or investigate if the authorities find the doctors threaten the institution. As doctors it will be difficult to defend ourselves as we work independently with no witness.

Offering healthcare advice is based on mutual trust. Unfortunately it has become very difficult to work as a doctor in the UK because we do not have the protection and so it is not safe.

People in power have made patients believe they must be treated as “clients” and not as “patients” without thinking of the consequences. A client can go to a shop and demand what he/she needs. If the demand is not met he/she can go to another shop and buy what she/he needs there instead.

In healthcare we cannot afford to satisfy the patient because doctors are governed by the ethical duty to “Do No Harm”, so will not be in a position to satisfy demands and so are subjecting him or herself to hardship.

How can a doctor satisfy a drug abuser who demands prescription knowing it is harmful to his well-being?

“To prescribe it is unethical, but if we don’t the patient is likely to complain that the doctor was rude and abusive.”

This is a true scenario that I have been through and one that I do not wish to hear or see happen to any doctor who works under an illusion that he/she will be protected by the very institutions that claim to defend patient care and defend the medical profession.

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“Prevention Is Better Than Cure”