Patient Safety - Health Committee Contents


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 NHS—Our Analysis—We will be shortly be publishing an extended version of the views above and commentary on the following:

2.2  Review by Professor Sir George Alberti—The 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-Thomé—We 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 Review—Set 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 Involvement—It 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 Coroner—Was is correct that he would not assist the Healthcare Commission? If not, why not?

  2.7  The Royal Colleges and Unions—Did none of them receive any alerts from their members? Did they not spot the alerts from Dr Foster?

  2.8  The Regulators—Were none of the regulatory bodies contacted by members of the public complaining about registered professionals?

  2.9  Tony Wright MP's Inquiry—Dr 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 Nursing—Dr 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 Challenge—Why 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 Change—Cure 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 Good—The 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 Declaration—Has 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 NHS—In 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 Too—That 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 Commission—The 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  Whistleblowing—There 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 Deaths—Why do we tolerate "excess" deaths?

1 June 2009





 
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