Maidstone Hospital – more negligence and poor performance

Maidstone Hospital – medical errors and lack of improvement – the latest update

Since this blog was originally written back in 2014, the position at Maidstone Hospital doesn’t seem to have improved.

The latest review was made by the Care Quality Commission report on the Maidstone and Tunbridge Wells NHS Trust which runs a number of other services including The Tunbridge Wells Hospital at Pembury. The overall conclusion was that the trust still “requires improvement”.

In describing how the trust was run, as you will see below, only the level of care was described as good. All the others either required improvement and its particular damning that the leadership was described as frankly “inadequate”. In particular the report found the following;

  • Safety – Requires improvement
  • Effective – Requires improvement
  • Levels of care – Good
  • Speed of Response –  Requires improvement
  • Leadership – Inadequate

If that wasn’t bad enough, of the 7 individual medical services provided by the Maidstone Hospital Trust,  just one was up to scratch. The report described these services as follows;

  • A and E services (A&E) – Requires improvement
  • End of life care  – Requires improvement
  • Medical care (including older people’s care) – Requires improvement
  • Intensive  care- Inadequate
  • Maternity and gynaecology – Good
  • Outpatients – Requires improvement
  • Services for children & young people -Requires improvement

It really doesn’t make good reading does it.

Recent medical mistakes?

There was the case of Frances Cappuccini, the 30 year old mother of two, who died after giving birth by emergency Caesarean section. Her husband is currently in the process of making a medical negligence claim against the trust.

In 2015, a widow from Aylesford was awarded £177,000 for the death of her husband – after his heart condition Mars missed by Maidstone Hospital in December 2012. The man had earlier been discharged with follow-up and during the subsequent investigation the hospital eventually admitted that he should have been admitted to hospital instead of being sent home.

Here is the original post

Grieving relatives of five patients who died following keyhole surgery have been angered by what they believe is a “cover-up” by hospital authorities. They have demanded to be told the truth about the circumstances leading to the deaths of their loved ones.

Expected legal action for medical negligence

They are now preparing to take legal action against Maidstone and Tunbridge Wells NHS Trust in Kent and have voiced their concern about the failure to reveal the full findings of an external formal investigation by the Royal College of Surgeons.

Three NHS surgeons, based at the trust, have been stopped from carrying out the procedure for upper gastrointestinal cancer but have been allowed to carry on working.

Lawyers are now looking at a further 17 cases involving the surgery that has led to complications or death following botched operations by the consultants.

Despite the ban on carrying out the keyhole operation used on cancer patients, the three surgeons are still continuing with their usual duties and other surgical procedures at the trust’s hospitals alongside their private work.

The scandal is the latest of many in recent times to hit the turbulent NHS trust. The three men have been referred to the General Medical Council (GMC) that is poised to consider whether to investigate their fitness to practice while no disciplinary action has yet been taken against them by the trust.

Controversy also surrounds the motives of the three surgeons in carrying out the keyhole procedure amid claims that it was an attempt to raise their personal professional profiles in what is a highly competitive field.

It is understood that medics who were invited to attend a live broadcast of one such procedure, which resulted in the death of a 51-year-old patient, paid in the region of £900 for tickets to attend the practical seminar.

The relatives of those who died are now in the process of suing for medical negligence and Maidstone and Tunbridge Wells Trust has also referred itself to the Royal College of Surgeons (RCS) after “unexpected” and “potentially avoidable” fatalities after gastrointestinal surgical procedures in 2012 and 2013.

Following an investigation by the RCS it was recommended that the trust cease all “oesophageal and gastric resection operations” until it had addressed its failings.

It issued a warning stating that the surgeons had not demonstrated “sufficient attention to the detail of surgical outcomes or clinical decision-making in respect of keyhole procedures.” The full RCS report on its findings has not yet been revealed by the trust.

It is understood that the report makes reference to an anonymous letter from whistleblowers working for the trust highlighting their serious concerns about “dangerous and unethical practices” in surgery and the frequency of warnings made by staff in the unit over poor standards of care.

Meanwhile patients are now forced to travel to St Thomas’ Hospital, London, while the GI work is suspended at the trust.

Maidstone and Tunbridge Wells NHS Trust defended its position in not releasing the full report following the RCS investigation stating that it was the focus of a continuing review by the GMC and consultants and may involve points of “factual accuracy”.

The trust added that it fully “accepted and implemented” the review’s recommendations and that this meant consultants responsible for the procedure should no longer carry out laparoscopic upper gastrointestinal cancer surgery.

Maidstone Hospital and medical negligence – it’s nothing new

This particular Trust is of course no stranger to controversy. Back in 2007 the Healthcare Commission was strongly critical of the way the Trust handled a nasty outbreak of Clostridium Difficile [or C Difficile as it is usually known] in its hospitals in a period April 2004 to September 2006. The Commission’s report estimated that about 90 patients “definitely or probably” died as a result of the superbug infection, a situation which, the Health Secretary at the time, Alan Johnson, described as “scandalous”.

My concern about medical negligence in Maidstone – it’s really personal

I’m particularly interested in this case. Firstly, I was born and bred in Maidstone – after being born in the old Fant Lane Hospital, I was very well treated in a number of admissions as a child to the old West Kent General Hospital in Marsham Street in the town centre.

What’s more, my father was Secretary of the group of local hospitals back in the 70s – which meant he was responsible for running West Kent and some others – and I’m sure he would have been horrified by the culture of poor standards that seems to have become endemic to the Maidstone Hospital since then. The NHS Trust seems prepared to put up with case after case of medical negligence – and when it comes to medical negligence and Maidstone, that’s a very sore spot with me – as my father, who died back in the 1980s after retiring from the hospital service, did so at Maidstone General Hospital after his own cancer was misdiagnosed for some time by a local GP.

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Patients Accuse Health Watchdog of Siding With the NHS

Over 200 patients and their relatives have accused the health watchdog body of taking the side of the NHS organisations during investigations following another recent National Health Service scandal.

A new report alleges that the Parliamentary and Health Service Ombudsman is “defensive”, “secretive” and often adds to the distress felt by patients and families who have suffered due to actions of the health service.

Inadequate oversight?

The report by the Patients’ Association was put together after requests by NHS patients and their families who were furious about the way they had been treated by the PHSO, which was itself set up to look into complaints about poor service, medical negligence and unfair treatment.

This news comes hot on the heels of parents whose babies died at the failing University Hospitals of Morecambe Bay Foundation Trust calling for the resignation of the Ombudsman over failures in the investigation into the affair and its refusal to admit mistakes.

A recent independent inquiry found that 11 babies and one mother died as a result of lethal failings in the maternity unit at Furness General Hospital, which it described as “seriously dysfunctional”. Parents told the inquiry that the Ombudsman had refused to look into the goings-on at Furness hospital.

The report compiled by the Patients’ Association revealed that:

•    Over 50% of patients thought that the PHSO took sides with whatever organisation it was investigating
•    Almost half felt it was not willing to challenge NHS bodies
•    There was a feeling that the Ombudsman did not investigate complaints in full
•    That the PHSO produced reports which were inaccurate
•    Patients often were made to feel that complaining was a nuisance

Families caught up in the situation in Morecambe Bay said that the independent inquiry into what happened in Furness hospital between 2004 and 2013 further highlighted the failings of the Ombudsman. The inquiry showed up failings at every level from entry level staff in the maternity level right up to people responsible for regulating the Trust which ran the Unit.
Some of the problems uncovered by the enquiry were poor levels of clinical skills, poor working relationships between different employee groups and failures on many occasions to investigate incidents and learn lessons from them.

The inquiry also suggested that midwives conspired to cover up problems after the deaths of babies.

Parents of some of the babies who died claim that the PHSO would not listen to their fears when they first raised concerns about poor standards of care at the hospital.

These findings are however contradicted by a report by Dr Kirkup, who said that midwives had indeed made a “significant and regrettable attempt to conceal” the truth about the death of one infant, and that staff members were able to “distort” the investigation which followed.

In response, the PHSO, said that since it appointed Julie Mellor to lead the organisation in 2012 it had taken steps to make improvements, including upping the number of investigations from hundreds to thousands.

The PHSO also acknowledged that in just over 50% of the cases investigated it was found that the NHS had acted correctly. That’s JUST 50%!!

The PHSO also said that it would look at the Patients’ Association report carefully, and also apologised for not investigating an individual complaint in 2009.

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Surgical Swab Left Inside Patient at Salisbury Hospital

Salisbury District Hospital has always had a pretty good local reputation. In fact our local  Hospital was identified as one of the top hospitals nationwide by a leading national healthcare intelligence organisation, CHKS in 2015. Well done, SDH.

But sadly unnecessary mistakes still occur. In particular, the Wiltshire Clinical Commissioning Group has admitted that a surgical swab was left inside a patient after an operation at Salisbury District Hospital in September 2014 –  a clear example of clinical negligence [often referred to a medical negligence].

The circumstances surrounding this event are being investigated by NHS England. The Wiltshire Commissioning Group will then decide whether the Trust which runs the hospital should be fined. In the interim, the hospital has agreed to implement an action plan as a result of what happened, the patient group Wiltshire Healthwatch has revealed.

Salisbury District Hospital – responsible for a “never-event”

The mistake has been confirmed by hospital bosses at SDH. This sort of incident is termed a “never-event” – a mistake which is so serious that it should never be allowed to happen.

Salisbury NHS Foundation Trust have stated that the mistake was noticed quickly and claim that the patient was not harmed. The patient and their family was told right away and the Trust issued a full apology.

Salisbury NHS Foundation Trust, the body responsible for running the hospital said that the event in question took place in September 2014. It was reported at the first public board meeting after it had happened, in October 2014. The Trust’s December board meeting confirmed the event, and the Trust has investigated the never event fully.

The NHS describes never events as “serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.”
Never events include mistakes such as performing surgery on the wrong part of the body or leaving foreign objects inside a patient after an operation.

Despite enjoying a good reputation locally, this is certainly not the only example of high profile clinical negligence at SDH. In another event at Salisbury Hospital back in 2013, surgeons removed the wrong testicle from a patient suffering from cancer.

“Never-events” – remarkably more common than you might imagine

Jeremy Hunt, the Health Secretary, has been on a crusade against never events for some time, stating that they simply should never happen.

An earlier BBC investigation discovered that over 750 patients had been victims of these never events in English hospitals between 2009 and 2012. NHS England has accepted that the numbers of never events are too high, and have taken steps to improve patient safety.

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What’s more our clinical negligence team is made up of specialist solicitors only [one of whom is also an experienced fully qualified nurse]. So your medical compensation claim won’t be run by an unqualified youngster at a remote call centre.

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Lincoln Hospital-Record £15m Compensation Could Be Awarded to Disabled Boy

A boy aged 12 who was left profoundly disabled after he was starved of oxygen at birth is in line to receive almost £15 million in medical negligence compensation from the NHS.

A High Court Judge stated that there was agreement that the birth of James Robshaw at Lincoln County Hospital in December 2002 had been “negligently mishandled”. James is facing a lifetime of round the clock care after being left with cerebral palsy, and needs the compensation claim pay out to support him throughout the rest of his life.

The Court has not yet settled on the final figure of compensation to be awarded to James, but it is expected to be around £14.6 million. This makes it one of the highest pay outs ever for NHS negligence compensation yet in the British court system.

The Judge praised James’ mother Suzanne for the way she had cared for her son, and described him as a “very active, quite exceptional, young man”.

During the case the court heard that avoidable problems during James’ delivery had resulted in cerebral policy which affects all four of his limbs. He can only communicate with an eye-controlled computer.

Lawyers for the family argued that James’ oxygen starvation during delivery was as a consequence of the medical staff’s failure to pick up on abnormal changes during the final stages of labour.

His mother sued the United Lincolnshire Hospitals NHS Trust on her son’s behalf. The Trust admitted being negligent and admitted liability for compensating him for his injuries.
The 11 day hearing at the High Court in London saw the lawyers arguing over the level of compensation which should be paid to James.

The Judge rules on the main issues in the case, and then asked the lawyers to consider the sums payable out of court.

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Medical Negligence and Surgery for Varicose Veins

Do you think that you might have been a victim of medical negligence during a varicose vein procedure? If so, what are your legal entitlements and what options are there?

What is a Varicose Vein?

A varicose vein is a medical condition caused by a vein becoming weaker. This allows blood to flow back up the vein and can cause a build-up of blood. Our body’s muscle and blood system usually makes sure that blood flows round our body in one way only, but a weakness in the vein stops this happening. Not all cases of varicose veins need surgery, but if a patient starts to experience other complications such as swelling, pain, ulcers or discomfort, an operation may be recommended.

The leg is the most common part of the body in which to find varicose veins. The veins may appear swollen, discoloured, twisted and distended. Suffering from varicose veins can also lead to swollen feet or ankles, or cramps in the muscles. Prompt treatment of varicose veins is required as leaving them untreated can be detrimental to the health of you or a loved one.

Surgery for Varicose Veins

Having an operation to treat varicose veins is common, and in most cases will be relatively uncomplicated. However, occasionally errors can be made during an operation which can have a serious impact on the patient’s health. If the mistakes made are serious enough to be classed as medical negligence, then the patient may not only be claim for compensation, but also for the costs of any corrective surgery which might be needed.

What Constitutes Medical Negligence in Varicose Vein Surgery?

Any surgery which does not come up to acceptable standards can be classed as medical negligence. Some of the more common complications of surgery for varicose veins include damage to the veins themselves or nerve damage in the immediate area, which causes problems with walking after the surgery. If this has happened to you, or a loved one, then it is vital that you get specialist legal advice as soon as you can. Further surgery might be needed to repair damage to the vessels or nerves, and you may be eligible to claim compensation for medical negligence.

Other Surgical Errors and Varicose Veins

Not all cases of varicose veins need surgical treatment, only those which are causing the patient pain or discomfort. Sometimes though further treatment is recommended to deal with any complications, or for cosmetic reasons. Surgeons have to act with due diligence and the required skill when operating on varicose veins and if this does not happen, the following errors may occur:

  • Serious or permanent damage to nerves
  • Excessive scarring
  • Delays in treating post-operative infections

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Infections After Knee Surgery – Medical Negligence?

Developing an infection after an operation on your knee can potentially be extremely serious. Consequences can range from fever and pain through to organ failure or even amputation. Doctors and nurses should do everything they can to stop this from happening, and quickly spot and give treatment if an infection does occur. If they fail to do this, their actions could mount to medical negligence and you may be entitled to claim compensation.

How Infections Occur After Knee Surgery

Any surgical procedure carries a risk of infection, and knee surgery is no different. There are several different ways in which an infection could develop. Sometimes, a patient already has an infection before the operation which only becomes obvious after the procedure is carried out. It is more common though for a patient to pick up an infection from the hospital, either passed direct from a member of the hospital staff who themselves has an infection, or from equipment which has not been sterilised properly.

There is an extra risk with surgery on the knee as this type of surgery involves significant tissue damage and increases the chance of an infection getting into the body.

Symptoms of Infection After Surgery

People who are suffering from an infection after having their knee operated on might experience some or all of the following symptoms:

•    Discomfort
•    Stiffness in the knee
•    Fever and/or feeling alternately hot and cold
•    The knee might feel warm to the touch or look red

If the infection is left untreated, the patient may start to experience more severe symptoms such as:

•    Breathing difficulties
•    Liver and kidney function problems
•    Visible pus at the site of the operation scar

Treating Infection After A Knee Operation

It is essential that any infection after a knee surgery operation is picked up as soon as possible. This is because the patient’s condition will deteriorate as the infection spreads, and their recovery time will be increased significantly.

Medical professionals should be able to diagnose infection using a mixture of visual, clinical and laboratory tests. A patient with redness, fever or warmth around the site of the wound should be investigated urgently. The condition can then be confirmed using a simple blood test which will show any infection.

No time should be lost in treating any infection once it has been diagnosed, and the type of treatment will depend on the sort of bacteria which are causing the infection. The most common type of treatment is with antibiotics, and the knee will have to be cleaned out regularly. In a few cases, antibiotics on their own are not enough, and the patient will have to undergo another operation. This is only the case when the in infection is severe enough to need the affected area removed. This operation is known as surgical debridement.

Medical Negligence and Knee Infections

Infections which are caught quickly are much easier to treat. An infection which is left for longer can have a serious impact on the patient’s condition, and as well as meaning an extended recovery period, it can even cancel out the benefits of having the surgery at all.

Medical professionals who don’t prevent, diagnose or treat a knee infection after a surgical procedure might well be guilty of medical negligence. Furthermore, if it can be shown that the infection was passed on negligently (for example from equipment which was not sterile), then this could also be grounds for a claim. Compensation can be claimed for pain and suffering caused by the infection, as well as any financial losses which have been incurred, such as the cost of further medical procedures or loss of earnings.

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Delays Affect 3,000 Patients Who Fall Seriously Ill on Weekend

3,000 heart attack and stroke patients who fall ill at the weekend experience serious delays due to the NHS’s failure to provide a full and properly staffed seven day service.

A new report suggests that 3,000 people who suffer a stroke or heart attack every year are experiencing delays in being admitted to hospital because the National Health Service is not providing an adequate round the clock service.

Senior medics have warned that patients might be dying because they cannot get access to see a GP, or because out of hours provision is not picking up on emergency cases who should be directed to A&E.

A new study of data from the NHS shows a sharp decline in the number of people admitted into hospital as an emergency case on Saturday or Sunday, and an even larger drop in the number of patients sent to hospital by a GP.

According to the figures, 3,144 patients every year who are suffering from a stroke or heart attack do not have their case identified as a medical emergency, and as a consequence experience a delay of at least 24 hours before being admitted to hospital.

Don’t fall ill at night time

President of the Royal College of Emergency Medicine, Dr Cliff Mann, said that the NHS’s failure to provide true seven day emergency services means that patients get a “two-tier” service. People falling ill at night may experience a skeleton service, and mortality rates are as a consequence higher.

Patients who develop acute symptoms of stroke or heart attack are likely to go straight to A&E whatever the time of week, but those who have milder symptoms could be faced with potentially fatal delays because of problems seeing a GP over the weekend, according to Dr Mann. Previous studies have also proven that death rates in hospitals are much higher over the weekend.

NHS Medical Director, Sir Bruce Keogh, has previous expressed the desire that the NHS offer routine services on every day of the week, and should be “patient-centred, compassionate and convenient”.

The debate about how this level of care should be funded is still contentious, and there has been a breakdown in negotiations between the NHS and the British Medical Association about how much doctors should be paid to work over the weekends.

These new figures, from information analysis company CHKS, shows that the number of patients being admitted as emergencies falls by 20% over a weekend. On an average week day there are 14,582 patients admitted to hospital as an emergency, falling to 11,623 on a weekend.

These figures suggest that in total, 1,514 patients having a heart attack and 1,630 having a stroke on a Saturday or Sunday are not going into hospital until the start of the following working week.

However, the numbers of people turning up at A&E departments is fairly constant through the week, which suggests that the number of people falling ill each day is broadly similar.

Problems with urgent weekend GP appointments

Patients who need urgent care find it difficult to see a GP over the weekend according to experts, and others just assume it will be too difficult to get to see a family doctor. Another group try to “hang on” and see their own GP after the weekend.

The figures could also mean that GPs working at an out of hours service at the weekend or in the evening are less likely to refer patients on to hospital. The figures also showed that for 24 out of 25 of the most common emergencies, patients were far more likely to be sent straight to hospital during the week than on a weekend.

The only exception to these figures was admission after an open head wound, which experts believe are more likely to be relate to fights and accidents experienced after drinking on a Friday or Saturday evening.

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Norfolk and Suffolk NHS Foundation Trust PLaced In Special Measures

Norfolk and Suffolk NHS Foundation Trust has now been placed into special measures. It is the first mental health trust in England and Wales to receive this drastic treatment.

A recent inspection of the Trust, which runs various healthcare services and hospitals in East Anglia, detected a number of serious problems resulting in an overall “inadequate” rating

The inspection by the CQC (Care Quality Commission) led the Chief Inspector of Hospitals to recommend it be placed into special measures. The inspection in question took place in October of 2014. CQC inspectors looked at the Trust overall and at individual services, and rate them on a four point scale of outstanding, good, requires improvement or inadequate.

The Trust provides learning disability services and mental health care to a large swathe of Suffolk and Norfolk and was found to be in need of significant improvements to ensure that it was providing its patients with care which was effective, safe, well managed and responsive to the needs of patients.

CQC concerns regarding the Norfolk and Suffolk Trust were passed to Monitor – the official body responsible for health services across England – which has now made the special measures decision.

“Inadequate” services “requiring improvement”

Norfolk and Suffolk NHS Foundation Trust was rated “inadequate” when inspectors looked at whether services were properly managed and safe, and “requiring improvement” for services being effective and responsive. The CQC rated the Trust as “inadequate” overall.

During the inspection the CQC found that across many areas of the Trust staff morale was exceptionally low, and there were concerns raised about the lack of support given to staff by senior management.

The CQC also found examples of unsafe environments which did not allow patient dignity, not enough staff on duty to meet the needs of patients, poor management of medication and issues around practices concerning seclusion and restraint.

The CQC demanded that the Trust take action to identify and remove ligature risks, and to make alternative arrangements where staff cannot easily see patients. The CQC’s Deputy Chief Inspector of Hospitals, Dr Paul Lelliott, said that a number of serious problems were identified during the CQC inspection.

Dr Lelliott said that the CQC was concerned about both the quality and safety of care found in some of the Trust’s services. He also stated that the CQC were worried by the low levels of morale expressed by many of the staff who had been spoken to, who expressed the opinion that they were not being heard by senior Trust management.

CQC inspectors did identify some positives from the inspection, and found good examples of working practices across disciplines from staff in the child and adolescent community teams.

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Almost 25% of NHS Budget Earmarked for Compensation Payouts

Recent figures show that the NHS has set aside almost a quarter of its entire budget as a contingency fund to cover medical negligence claims against it. It is now expected that Jeremy Hunt, the coalition government’s Secretary of State for Health, will announce plans to fine hospitals which try to cover up medical errors.

The figures indicate that the NHS Litigation Authority – the body responsible for dealing with legal action against the NHS – has set aside just over £26 billion to cover liabilities both now and in the future. This represents almost a quarter of the annual NHS budget, which stands at £113 billion.

In 2014 alone, over £1.3 billion was paid out to people who had made medical negligence claims for compensation.

Hospitals to be fined up to £100 K for lack of honesty

Jeremy Hunt’s plans to fine hospitals who cover up mistakes may result in fines of up to £100,000 where it can be shown that hospitals have not been open and honest about their negligence cases.

On the face of it, this initiative should be welcomed, as long as the government is serious about it, and will follow through on the threat of fining hospitals who have covered up errors. An important part of improving patient care is surely being open, and willing to learn from mistakes. The government does seem to be committed to sending out a very clear message that covering up medical mistakes is not acceptable.

The government cannot be criticised for wanting to reduce avoidable deaths in the NHS and to make it easier for whistleblowers who flag up care failings. The overwhelming majority of people working in the NHS do what is a very demanding job to the very best of their ability – and each and every one of us is grateful for what they do.

It is shocking though to learn that an estimated thousand patients every month are dying because of NHS employees mistakes. The prime example of this which hit the headlines was the notorious Mid Staffordshire NHS Trust where vulnerable patients were left without food or drink, or left lying in soiled bedding. The problems at Mid Staffs stemmed partly from the culture within the hospital, meaning the poor standards were thought of as normal by the staff, and anyone who did try to speak out was bullied.

Is enough being done to support NHS whistleblowers?

But are the government really going far enough to protect NHS whistleblowers as recommended by Sir Robert Francis’s report? A senior official in the Care Quality Commission (CQC) thinks not. Amanda Pollard handed in her resignation after raising concerns that the CQC would not be able to pick up “another Stafford” and said that the recommendations in Sir Robert’s report would have done little to give her protection.
Mrs Pollard said that the implementation of the recommendations in Sir Robert’s report depended solely on the goodwill of NHS Trusts and other official bodies.

Is the NHS really ready to change?

It’s all very well to say that the NHS culture has to be more open, but for the culture to change, the NHS has to want to be more open. Can we really believe that the NHS is ready to completely change its ways and admit that sometimes its employees can make errors.

The story about the levels of spending on medical negligence comes hot on the heels of previous revelations that NHS spending on public relations is up more than a quarter in a single year, just at the time when hospitals are going through a period of deep crisis. Figures show that spending on PR is predicted to reach almost £12.1 million in the current financial year, compared to a 2013/14 figure of £9.5 million.

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Ombudsman Brands NHS Complaints Process “Appalling”

A damning review has concluded that patients who complain about their treatment in NHS hospital are being badly let down by “appalling” investigations.

A report by the Parliamentary and Health Service Ombudsman (PHSO) found that over a third of investigations carried out into avoidable injury or deaths in hospitals were “inadequate”.

Concerns from patient groups

Dr Katherine Rake, who heads up the patients’ group Healthwatch England, has called for the NHS complaints system to be completely overhauled in the light of the report’s findings. Dr Rake said that the findings released by the Health Ombudsman were “worrying, but sadly not surprising”.

Some of the families who were spoken to during the review spoke of feeling belittled or misled by hospital staff. They also said staff wouldn’t give them straight answers, or listen to their worries. Patient campaigning groups condemned the review findings as “worrying”, and said that they suggest that the NHS is not learning the lessons of hospital scandals.

Thousands fail to follow up NHS complaints

Research carried out by the PHSO indicates that many thousands of people are being failed by the NHS every year, yet fail to report it because they believe that making a formal complaint will make no difference.

Healthwatch England led calls for a total overhaul of the complaints system. Dr Rake called for a system which makes sure that every incident is fully investigated and that the lessons are learned each time. She also called for those affected to be treated with dignity and respect.

The Ombudsman looked into 150 complaints concerning situations where patients had suffered avoidable harm or had died because of failures in care standards.These could be down to medical negligence or genuine accidents.

The investigation found that 28 out of the 150 cases should have been designated as a Serious Untoward Incident (SUI). This designation allows doctors to learn from previous incidents and avoid similar mistakes in the future. In the overwhelming majority of these cases (71%), the hospital concerned did not label the incident as an SUI.

Julie Mellor, the Parliamentary and Health Service Ombudsman said that the quality of NHS investigations varied significantly. She also said that investigations were not carried out when they should have been, and even when investigations were carried out, they did not get to the root cause of any failings.

It is clear from these figures that the NHS has to do something to improve the quality of investigations, but also needs to be clearer about when an investigation is necessary.

One of the cases highlighted by the report concerned a 77 year old man who was admitted to hospital. Once on a ward his condition got rapidly worse, and he died two days later from a serious infection.

The patient’s daughter, who was unhappy with care standards, complained to the Head of Nursing. She investigated, but did not speak to any of the clinical staff involved. The Ombudsman investigated the case and found that doctors and nurses had not realised just how ill their patient was. The Ombudsman’s report stated that it was unable to say whether the death could have been avoided, but identified many missed opportunities for better chances of recovery and more timely interventions.

A major review is underway into the entire NHS complaints procedure and these are just interim findings. A full review and related report will be released at a later date.

A full review into the complaints process was announced in the wake of the Francis Review, which looked into the scandal at the Mid Staffs Hospital, in which at least 1200 patients are thought to have died because of poor care standards.

A spokesperson for the Ombudsman said that the final report would demonstrate that the quality of NHS investigations into complaints regarding avoidable harm vary in quality, and more often than not are “appalling”.

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