Memorandum by Cure the NHS (PS 101)
PATIENT SAFETY: THE LESSONS OF MID-STAFFORDSHIRE
EXECUTIVE SUMMARY
In October 2007, I spent eight weeks caring
for my mother and others on Ward 11 in Stafford Hospital. What
I witnessed was the most dreadful thing I have ever experienced
and I am now left with many unanswered questions and so too is
this community. In December 2007 I launched Cure the NHS so that
I could campaign with other relatives in a similar position. We
are still campaigning.
The Healthcare Commission's report of March 2009
has provided some explanations of what went wrong but signally
failed to answer the question WHY? Every day since the publication
of the report more relatives bring continuing accounts of the
dreadful standards of care at Stafford Hospital and harrowing
stories of the deaths of their loved ones.
We do not believe that people outside this community
understand the actual extent of the problem here in Stafford.
We believe that extends to the Health Secretary, himself, his
ministers, the chief Executive of the NHS, and the Executive Chairman
of Monitor. The Health Secretary has noted the lack of "whistleblowing";
but the reality is that "whistleblowers" have been,
and continue to be vigorously suppressed by the hospital.
The "culture" within the hospital
was distorted and non executive directors and governors far from
challenging the chairman and chief executive over the poor standards
of treatment and care praised them to the sky. Even the chief
executive of the Royal College of Nursing, after a visit soon
after the start of the Healthcare Commission's investigation,
wrote to a local newspaper in glowing terms about the chairman,
chief executive, and director of nursing, all subsequently heavily
criticised by the Healthcare Commission.
We believe it was a systemic failure across
the West Midlands NHS which caused the failures at Stafford. The
NHS even today has no modern patient safety and quality "system"
to preclude such failures so the responsibility for them must
extend to the Department of Health, the Health Secretary, his
ministers, and the executive of the NHS and Monitor.
Only a systematic inquiry, that is a full public
inquiry under the 2005 Act can answer these questions. Please
tell the Health Secretary that he must order such an inquiry now.
1. OUR EVIDENCE
1.1 Cure the NHS welcomes the opportunity
to make submissions to the Health Committee's inquiry on patient
safety at Mid Staffordshire NHS Foundation Trust.
1.2 Because of the Committee's limit on the length
of this submission, and because we have not been invited to give
oral evidence, we ask you to understand that this document represents
a very short summary of our views on this vital subject.
1.3 A full Public Inquiry under the 2005
Act is essential to answer the very many questions that remain
unanswered by those already carried out.
1.4 In October 2007, I spent eight weeks
caring for my mother and others on Ward 11 in Stafford hospital.
What I witnessed was the most dreadful thing I have ever experienced
and I am now left with many unanswered questions and so too is
this community.
1.5 Today and everyday since the Healthcare
Commission (HC) report was published, I sit and listen to another
relative who has lost a loved one, another tragic death. We all
seem to have lost under similar circumstances, where we are now
left thinking either they shouldn't have died, or they shouldn't
have died the way they did. When you lose someone in this way
it is something that you never get over, because you feel it was
avoidable. We all seem to have tried to alert the people who could
have helped us but it seemed no one wanted to listen.
1.6 I do not believe that people outside
this community understand the actual extent of the problem here
in Stafford. We have lost so many people under dreadful circumstances,
some have lived but are still suffering, failed by the very people
we put our trust in to care.
1.7 The amount of people who have made contact
with the group has been absolutely overwhelming. I am sure that
there are many more but the only way of contacting these people
is through the media, some do not have contact with the media.
1.8 The independent casenote review will
not be a true reflection of the extent of the problem. I myself
and I know many others would not want contact ever again with
the hospital. Although it is claimed to be independent we firstly
have to contact the hospital or the Primary Care Trust to register.
Then we will be invited to meet with an independent doctor to
discuss the case notes. Many people from this community want nothing
more to do with the hospital, we have dreadful memories of the
sufferings of our loved ones. What about those who have died who
have no one to request a review there must be many? Other relatives,
elderly themselves are in no position to request a review. Again
the only way of knowing about the reviews is through the media,
many people will not even notice they are on offer.
1.9 Cure the NHS has tried to stop further
deaths and improve patient care but it has proved to be very difficult.
We first tried to expose the horrors we witnessed and our loved
ones suffered to those in the system that should be there to listen
and scrutinise.
1.10 In January 2008, we contacted the Secretary
of State, Alan Johnson, David Kidney MP, Tony Wright MP, Bill
Cash MP. We wrote and told them, that patients were being denied
their basic human rights. Their advice was to talk to the hospital
management and the board of Governors.
1.11 We did, by this time we had around
50 grieving relatives who addressed a Council of Governors meeting.
We told them how our relatives had died, suffering with a total
lack of dignity, some screaming out in pain as they died. They
listened, but did nothing in fact our accounts of our loved ones
dreadful deaths were not even included in the minutes from that
meeting.
1.12 In the same month we told the Stafford
Overview and Scrutiny Committee of our concerns, despite receiving
a letter from their solicitor's department, warning us not to
contact them with individual concerns. We persisted and told them
we felt it was systemic failings within the hospital with vulnerable
and elderly members of this community suffering. During the eight
weeks I cared for my mother I had to feed vulnerable patients
as there was no one else to feed them. I saw confused patients,
physically and verbally abused daily. Patients continually fell
and no one was around to help them, staff didn't seem to understand
risk and how to manage it. The Overview and Scrutiny Committee
spoke to the hospital management who told them everything was
fine, they believed them and did no more.
1.13 We contacted the Healthcare Commission
in February 2008, we alerted them to the third world conditions
within the hospital. We set out 69 points that we had all witnessed
and our loved ones had suffered. Although we believe the Healthcare
Commission provided the evidence to expose many of the hospitals
failing we feel somewhat let down by their intervention to date.
We question why, when they inspected the A & E department
of the hospital in May 2008 and found it in such an unsafe condition,
no immediate intervention was taken. I know that during the HC
intervention from March to October 2008, we lost many more members
of this community unnecessary, as their family have since contacted
me.
1.14 Furthermore it seems that the Healthcare
Commission recommendations for the hospital over the last year
have not been implemented in full and in October 2008 they still
had concerns when they had finished their investigation. Even
after Professor George Alberti had reviewed the hospital there
remained a lack of suitable numbers of staff and vital equipment
still hadn't been purchased. Why wasn't something more done when
the hospital appeared to be dragging its feet over improvements?
Why were they allowed to delay putting safe systems in place when
they had been told to do so.?
1.15 Ironically too in February 2008, the
hospital was awarded foundation trust status by Monitor. This
community wants to know how this status was awarded while patients
inside were being denied their basic human rights. How could such
a status be awarded whilst conditions inside were appalling?
1.16 Cure the NHS continued to hear from
more grieving relatives and in May 2008, we contacted the Primary
Care Trust with our concerns. They said they wanted to help but
like others didn't, their advice was for us to speak to the hospital
management. We told them we had but they told us to speak to them
again. We contacted the Local Management Committee who also advised
us to speak to the hospital management. We contacted the Local
Involvement Network, they too could offer us nothing to stop the
abuse we had witnessed. In fact they were hostile toward us telling
us to bring evidence to support our claims of neglect.
1.17 It seems everyone we spoke to wanted
us to speak to the management of the hospital, they all seemed
to hold the management in high regards and told us what a good
job they were doing. They tried to tell us that things had improved
a new action plan had been put in place and the hospital was meeting
the targets. What we had witnessed would never happen again, we
tried to tell them it still was, but no one wanted to hear and
no one would listen.
1.18 We began to feel that we were getting
nowhere, people were still contacting me telling us of the same
dreadful conditions we had seen and yet those that could help
stop the abuse were telling us that things had improved. At this
point it seemed that everyone who could do something didn't, it
appeared they did the very opposite.
1.19 Our MP David Kidney, spent time in
the hospital doing a work experience, telling the local press
that everything was fine at the hospital. His only recommendation
was to promote more recycling within the Hospital.
1.20 Peter Carter, Chief Executive of the
Royal College of Nursing spent a day at the hospital and applauded
the staff and management, he even made a point of writing to our
local paper informing the community that we should be proud of
the hospital.
1.21 The chair of the Local Management Committee
and the RCN local representative did the same, they went as far
as saying that the hospital had adequate staffing levels and the
right skill mix, all nonsense but why? It may have led to us losing
even more members of this community which we have over the last
year. More deaths where questions are left unanswered, some relatives
still don't know where their relatives died. Suspiciously the
files have gone missing, others have died covered in bruises,
with no explanation. We are all left with something that concerns
us and the complaints procedure hasn't helped to tell us what
has happened.
1.22 The complaints procedure appears to
of worked against us too, we suspect the tactic has been to wear
us all down and hope we will go away.
1.23 We cannot because this hospital has
destroyed many proud members of this community under cruel circumstances
and we want to know why. We have been told that a Public Inquiry
under the 2005 Act would hamper the hospital moving forward. Simple
changes to improve care can and should be introduced very quickly,
but we do not feel that the hospital can truly move forward with
so many questions left unanswered. The very staff who have been
part of this appalling standard of care are still employed within
the hospital. The staff themselves, want a public inquiry, they
want the truth to be exposed themselves. Only recently the managers
have hidden more deaths from Clostridium Difficile, they appear
to be incapable of moving forward. Families continue to contact
us and tell us that their relatives are still not having their
basic needs met. Patients are still suffering harm and South Staffordshire
Primary Care Trust remain concerned as complains have increased
and serious untoward incidents remains high.
1.24 Another reason we have been given is
the cost, we do not find this reason acceptable. We believe unless
the truth is told and bad practice exposed it will resurface once
again and in fact the hospital will never have the opportunity
to move forward. In the long term the cost would be higher because
the hospital will always be plagued with problems, as it has.
The cost would be reduced as a public inquiry could build on the
work done by the Healthcare Commission report.
1.25 As members of society we should all
want to know what has happened, how could so many people die in
such awful circumstances? We don't even know how many people died
which we believe as a community we have a right to know. Most
of these people were elderly or vulnerable with many not having
anyone to speak up for them.
1.26 We want to know why so many people
stood by and let this happen. Within the hospital we found some
fantastic staff, but we also found some dreadful ones. We want
to know why, why were some so cruel towards our loved ones? We
want the bad practice exposed.
1.27 We want to know why those who should
have been scrutinising the hospital didn't, despite us telling
them there were serious problems. Why did they appear to conspire
against us and tell this community that everything at the hospital
was fine, in fact it was excellent. Why did some local press support
them and try to discredit our accounts?
1.28 Everything was pointing to problems
over a number of years, Healthcare Commission inspections, patient
surveys, staff surveys and yet nothing was done. Surely this in
itself deserves further investigation, why did no one do nothing
apart from supporting the management?
1.29 We are still being approached by families
who have relatives in the hospital now, still suffering. This
is wrong and we are asking you to help to expose the systemic
failings by recommending a full public inquiry where people are
compelled to give evidence. We believe only then can this community
move forward and help to build a hospital to be proud of.
1.30 The Health Secretary claimed the failings
at Stafford Hospital were attributable just to the failings of
local management. The Chief Executive and Chair have been allowed
to resign, no other senior executives and managers have been held
to account in any way? Does the massive array of criticism in
the Healthcare Commission report mean nothing for those continuing
to run Stafford Hospital every day?
1.31 We believe the Health Secretary is
wrong, Stafford Hospital is not an isolated case. We now have
contact with other groups experiencing similar problems; Warrington,
Tameside, Norwich and Birmingham, all with high mortality figures.
2. SOME FURTHER
ISSUES FOR
YOUR ATTENTION
2.1 Cure the NHSOur AnalysisWe
will be shortly be publishing an extended version of the views
above and commentary on the following:
2.2 Review by Professor Sir George AlbertiThe
remit clearly excluded any analysis of the "why". Professor
Alberti was later interviewed on BBC Radio Stoke and asked if
he would feel safe being admitted to the hospital, he said he
would for something minor like a broken leg, but for more serious
conditions would want to go to regional centres; so are patients
for these more serious conditions being treated at Stafford Hospital
now?
2.3 Review by Dr David Colin-ThoméWe
believe that his investigation was sketchy, covered much of the
ground already covered by the Healthcare Commission, but in no
greater depth, and was in no way systematic and reached no significant
conclusions.
2.4 Independent Casenote ReviewSet
up by the hospital. It is not independent. The hospital's own
board papers demonstrate very clearly that they are managing the
process; they should not be involved at all in any part of it.
2.5 Patient and Public InvolvementIt
was this Government which twice closed down channels for patient
and public involvement, the short history of the Local Involvement
Networks in Staffordshire is little short of farcical.
2.6 The Role Of The CoronerWas
is correct that he would not assist the Healthcare Commission?
If not, why not?
2.7 The Royal Colleges and UnionsDid
none of them receive any alerts from their members? Did they not
spot the alerts from Dr Foster?
2.8 The RegulatorsWere none
of the regulatory bodies contacted by members of the public complaining
about registered professionals?
2.9 Tony Wright MP's InquiryDr
Tony Wright, MP for Cannock Chase has suggested an inquiry in
public, a lessons to be learnt from Stafford inquiry which does
not replicate what the Healthcare Commission inquiry has done,
but pulls all the lessons together for the NHS. Since it would
have no statutory powers, key witnesses would simply not appear
and it would not and could not produce any meaningful results.
2.10 Royal College of NursingDr
Peter Carter has suggested a public inquiry but in camera. This
would be equally meaningless. The truth needs to be heard in public.
2.10.1 Claims at the recent RCN conference that
the RCN representatives raised concerns are in direct contradiction
to their chief executive's letter to the Stafford press in May
2008 and should be questioned carefully by the members of your
Committee.
2.11 Culture Of ChallengeWhy
did so many people not challenge the hospital on its poor standards
of care? Non-executive directors of all NHS bodies, councillors,
GPs, governors of the foundation trust, members of the PPI Forum
and the Local Involvement Network?
2.12 Ideas for ChangeCure
the NHS put four key suggestions to the Health Secretary's team
in early April:
2.12.1 a simple mechanism to ensure that all other
hospitals are "safe";
2.12.2 the outline of a modern system of patient
safety and quality of care based on the fundamental principle
for all the NHS that there should be "zero untoward incidents"
and "excess" deaths. Currently there seems to be an
acceptance of errors and excess deaths as inevitable; they are
not;
2.12.3 "turning the NHS the right way up again"
so that the enormous burden of managerialism is lifted from front
line carers so that they, once again, can lead the delivery of
high quality care;
2.12.4 bringing all the standards-setting, licensing,
and regulatory bodies under one roof with just the investigatory
arm separate. The model of civil aviation is instructive; and
2.12.5 turning the National Quality Board from its
search for early warning signs of failure to eliminating failures
in the first place. This latter concept has been common in many
sectors for very many years.
2.13 Targets do More Harm Than GoodThe
Stafford Hospital failure should destroy for ever anyone's belief
that "targets" are the way to give the best to patients.
The fact that the government still clings to them demonstrates
that they do not understand what organisations need to do to deliver
consistent levels of quality. They must be replaced by measures
of treatment and care quality derived from the treatment and care
themselves. This is so straightforward.
2.14 Annual Healthcheck DeclarationHas
this method of "self-assessment" not been seriously
discredited by the failures at Stafford Hospital?
2.15 Stafford Hospital's "Transformation
Plan"Stafford Hospital's transformation plan was
recently published. We asked to be involved in its development
but we were not given that opportunity. The plan is written completely
in "management speak" has far too initiatives. It is
anyway a rehash of similar programmes which the hospital itself
and others have produced over time. What happened to the action
plan drawn up in 2008 by South Staffordshire Primary Care Trust?
2.16 Chaos in the West Midlands NHSIn
the year between Summer 2005 and Summer 2006 there was chaos in
the West Midlands NHS as the primary care trusts and strategic
health authorities were reorganised under the leadership of the
current Chief Executive of NHS. The board minutes of the time
demonstrate it very clearly.
2.17 Financial Chaos TooThat same
period was accompanied by a rapidly growing deficit in many parts
of the NHS. Stafford Hospital had a deficit and cut staff numbers
to reduce it.
2.18 The Care Quality CommissionThe
chairman of the new Care Quality Commission is reported as saying
that the Healthcare Commission's investigation into Stafford Hospital
was a blunt instrument and would not be used again, is that correct?
What approach would be taken now?
2.19 WhistleblowingThere has
been a great deal of talk of "whistleblowers" or rather
the lack of them at Stafford Hospital. The reality is that they
have been and continue to be firmly suppressed by the hospital
management.
2.20 Does This Extend Across The NHS?
Of course it does. Look at the serious investigations carried
out by the Healthcare Commission in its short life. As this is
written we read of major chaos in A and E departments across the
country. Cure the NHS has been contacted by people from a number
of other places. Performance will be like most other things in
human affairs, "distributed" roughly in the shape of
the "bell" curve, the "normal" or "Gauss"
distribution. Stafford Hospital is probably at the very end of
the tail of the poor performers but the big question is, how many
more poor performers have been missed?
2.20.1 The difficulty and the challenge for the
Department of Health and the NHS is that they have no mechanism
for finding out; they have not developed and implemented modern
patient safety and quality systems to guarantee high quality care
for all for every minute of every day of every patient's stay;
systems designed and implemented by frontline hospital carers
with the help of patients. We are all patients and potential patients.
2.21 Excess DeathsWhy do we
tolerate "excess" deaths?
1 June 2009
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