The judge who presided over the public inquiry into the tainted-blood tragedy is sharply criticizing the federal government for failing to create a no-fault system insurance plan for victims of medical errors.
In a rare public comment, Mr. Justice Horace Krever told the Canadian Healthcare Safety Symposium that there is an "urgent need" for a no-fault scheme because the adversarial litigation route is failing patients who suffer harm from medical procedures such as blood transfusion, vaccination, anesthetization and surgery.
"While we must strive to reduce risk, risk cannot be eliminated," Judge Krever told more than 500 safety experts gathered in Calgary.
"We must incorporate that reality into public policy."
An estimated one in every 13 hospital patients suffers from an "adverse event" during their treatment.
A study released last year found that up to 24,000 Canadians die each year as the result of medical errors, making them one of the leading causes of death.
Judge Krever headed the Commission of Inquiry on the Blood System in Canada between 1993 and 1997. His No. 1 recommendation was no-fault insurance and he is obviously still smarting from the lack of action on the issue.
"It is not beyond the ability of us who can send people to Mars to do this," he said. "Obviously there is no great interest in society."
Judge Krever said the fear of pandemic influenza and terror attacks makes a no-fault insurance plan all the more pressing.
While vaccines against influenza and smallpox can protect a lot of people from harm, some will have reactions and there could even be deaths as a result, Judge Krever said, arguing that society has an obligation to compensate citizens for that harm.
"Only the enlightened province of Quebec has no-fault insurance" for people who suffer harm from vaccines, he said in urging other provinces to follow suit.
Judge Krever also lamented the fact that governments take so long to implement sensible public policy.
He noted, for example, that in 1980 he headed an inquiry into the privacy of medical records but it was not until 2004 that the recommendations were implemented, and then only after a number of egregious breaches of privacy.
"Patience may be called for," Judge Krever said of no-fault insurance, "but hopefully not another quarter-century."
An estimated 2,000 Canadians contracted HIV-AIDS from transfusions and blood products and another 20,000 contracted hepatitis C from tainted blood. While governments have set aside more than $1.1-billion for compensation, litigation has been ongoing for more than two decades.
Mr. Justice Murray Sinclair, who headed the Manitoba Pediatric Surgery Inquest into the death of 12 young heart patients in Winnipeg in 1993-94, also had some harsh words for governments for failing to heed his recommendations to improve safety.
In particular, he said there is a need for whistle-blower legislation to encourage health-care workers to expose dangerous situations.
"Ultimately, we need to think about a no-fault system for exposing medical error, one that encourages people to come forward for the good of patients," Judge Sinclair said.
In the Winnipeg debacle, a number of nurses tried to come forward to expose the unqualified surgeon who performed all the deadly surgeries but they were rebuked by management and "clearly would have jeopardized their careers by going public," he said.
Judge Sinclair also told the safety conference that the number of litigations after medical errors has been unsatisfactory and that every effort should be made to avoid problems in the first place.
"Those in charge of the health system have to create a culture that is conducive to preventing errors," and legislative protection of whistle blowers is an essential element for creating such a culture, he said.
CORRECTION
Mr. Justice Horace Krever criticized provincial governments - not the federal government - for failing to implement no-fault insurance programs for victims of medical errors. Due to an editing error, incorrect information was published yesterday.