Professor Sir Bruce Keogh, NHS England Medical Director, has published a major report today which worryingly confirms that the tragic events at Mid Staffordshire were sadly not isolated.
The review was requested by the Government following the outcome of the Francis report into Mid Staffordshire and focused on reviews into other hospitals with worrying mortality rates. 14 hospitals were identified as having mortality rates higher than normally expected.
The trusts that were reviewed included three North West trusts including Tameside Hospital NHS Foundation Trust, East Lancashire NHS Trust and Blackpool Teaching Hospitals NHS Trust.
11 out of the 14 hospitals that were reviewed have now been placed in special measures for fundamental breaches of care, including Tameside Hospital and East Lancashire NHS Trust. All 14 have been placed on notice to fulfil all of the recommendations made within the review and they will all be subject to a further inspection within 12 months.
In Tameside Hospital NHS Foundation Trust, the panel found that there were a number of areas of concern identified, including a culture of accepting sub-optimal care, which needed urgent action to address. Patients spoke of being left on unmonitored trolleys for excessive periods and a general culture of “accepting sub-optimal care”.
- Further, the experience of patients in the emergency and acute medical pathway was often poor. This was found to be due to;
- Concerns with infection control practice in an area of the hospital that was identified as needing immediate action
- Insufficient senior clinical cover, particularly out of hours;
- Lack of timely investigations and poor management of deteriorating patients;
- Inappropriate use of escalation areas and poor bed management;
- No clear evidence that the Trust was listening to patients or their families or staff to improve the quality of the patients’ experience;
- Quality and performance management information needs significant improvements to enable the Board to scrutinise and gain assurance on quality improvements.
In East Lancashire NHS Trust, the panel found there was concern over staffing levels and high mortality rates at weekends. In addition:
- A high level of still born babies in March 2013 but this had not been escalated to the Board or investigated;
- Concern over the appropriateness of location of close observation beds in the Delivery Care Centre in the maternity unit;
- Quality governance processes were not cohesive and failed to use information effectively to improve quality of care;
- Quality governance processes were not providing the expected level of assurance to the Board and the escalation to the Board of risks and clinical issues is inconsistent;
- Managing high patient levels, particularly in A&E, and understanding and addressing the issues causing high readmission rates of patients treated in the Trust’s hospitals;
- Trust’s complaints process was poor and lacking a compassionate approach.
There was also concern that the staffing levels were low compared with the national standards, particularly in A&E and midwifery staff.
Although Blackpool Teaching Hospitals NHS Trust has not been placed on special measures, the panel found:
- Equipment safety checks were not being consistently undertaken, particularly on elderly wards;
- Nursing staff levels were not always sufficient, particularly on elderly care wards;
- The incident review system is unreliable in terms of reporting and classification of serious incidents, multi-disciplinary investigation and dissemination of findings;
- Infection control policy was not being implemented consistently.
The hospitals that are in special measures will be required to implement the recommendations made by the Keogh review and will have the assistance of external teams to help them comply. They will be monitored, including the quality of leadership at each hospital and if they are unable to lead the improvements then it could lead to removal of any of the senior managers. Finally, each of the 11 hospitals will be partnered with high-performing NHS organisations to provide mentorship and guidance in improving the quality and safety of care.
Those hospitals which aren’t in special measures will still be expected to implement the recommendations made but the findings of the panel were such that they were confident that the leadership teams in place at these trusts can deliver the recommendations.
This is not the end of the review by any means. Professor Sir Bruce Keogh announced to Parliament today that: “We have today begun a journey to change this culture. Those 14 failing hospital trusts are not the end of the story. Where there are other examples of unacceptable care we will find them and we will root them out.
“Under the new rigorous inspection regime led by the Chief Inspector of Hospitals, if a hospital is not performing as it should, the public will be told. If the hospital is failing, it will be put into special measures with a limited period of time to sort out its problems. And there will be accountability too: failure in the NHS should never be a consequence free zone.”
Judith Thomas-Whittingham, partner and head of the Clinical Negligence department at leading North West law firm Stephensons Solicitors LLP, said: “I have read the review which has been published today and I am very concerned regarding the content which criticises the care at 14 trusts, almost a quarter of which are based within our region and servicing our friends and families.
“I support patients and their families on a daily basis who have been let down by the NHS and they will no doubt be angered by the outcome of the report. Bereavement is very difficult to deal with in any circumstance but to learn that the death of a loved one need not have occurred is incredibly hard to process and come to terms with and a lot of my clients require psychological treatment to help them.
“Lessons need to be learned and action urgently taken. At all 14 hospitals reviewed, the panel found that there were inadequate staffing levels of differing levels. At one hospital, the staff were expected to work shifts 12 days in a row without a rest day. Mistakes can and will happen but inadequate staffing levels will only lead, in my opinion, to more needless deaths and never events.
“I am pleased to hear that there will be accountability and the public will be told. There are too many incidents of issues being covered up. A large proportion of my clients instruct solicitors as they are left in the dark as to what may have gone wrong and so they feel that they have no choice other than to seek legal advice to get answers and apologies, if appropriate.”
Stephensons’ Clinical Negligence department is one of the largest in the region. The team advises members of the public who have suffered negligence at the hands of medical professionals, including GPs, surgeons, beauty therapists, dentists and other practitioners. They assist individuals in recovering compensation for injuries and financial losses they have suffered as a result of negligence.
ENDS
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Media information Lianne Tracey
Stephensons Solicitors LLP
Tel: 01616 966 229
Email: lct@stephensons.co.uk