Financial priorities led to ‘appalling’ care

The Healthcare Commission (now replaced by the Care Quality Commission) recently published an investigation report criticising Mid Staffordshire NHS Foundation Trust for significant failings in emergency healthcare, leadership and management. Problems identified by the Commission included low staffing levels, inadequate nursing, lack of equipment, lack of leadership, poor training and ineffective systems for identifying when things went wrong. Receptionists who were not qualified to do so carried out initial checks on patients arriving in A&E, heart monitors were turned off on the emergency assessment unit (EAU) because nurses did not know how to use them, there were not enough nurses to provide proper care to patients on wards, and the board did not routinely discuss the quality of care. The investigation found that these problems put patients at serious risks that undoubtedly resulted in poor outcomes for patients. Sir Ian Kennedy, the Commission’s chairman, said: “This is a story of appalling standards of care and chaotic systems for looking after patients. There were inadequacies at almost every stage in the care of emergency patients. There is no doubt that patients will have suffered and some of them will have died as a result. “The investigation found there were too few doctors and nurses, vital equipment was not available when needed, patients did not receive the care they         deserved, and the Trust had no systems in place to spot when things were going wrong.” The Commission launched its investigation at the Trust in March 2008 in response to concerns from local people and when it became clear that the Trust stood out statistically in terms of the high death rates of patients admitted as emergencies. As part of the investigation, the Commission’s investigation team, including senior NHS managers and clinical experts, conducted five visits to observe wards and clinical care. The team also interviewed over 300 people, including current and former employees at the Trust, patients and their relatives. There was an unprecedented response from patients and relatives. The Commission also analysed more than 1,000 documents and over 30 sets of case notes of patients who died.

Summary of findings

The investigation found that the triage of patients in A&E by receptionists, resulted in poor care for patients and, in one instance, an individual with an open fracture of the elbow waited for over four hours covered in blood with no pain relief. In addition, there were too few consultants in A&E to provide adequate on-call cover and junior doctors were not adequately supervised. Between March and May 2008, for example, there was only one consultant in A&E. The Trust had two clinical decision units (CDUs) which staff said were used as “dumping grounds” to avoid breaching the four hour target for being treated in A&E, one of which was not allocated any staff. Patients who were unwell were placed in the smaller CDU without a dedicated nurse to care for them. The Commission pointed out that patients should not be admitted to CDUs for any longer than 24 hours, after which time a decision should be taken about the best course of treatment or to discharge. Some patients were in the CDUs for three days or more. The smaller CDU was closed by September 2008. A review of staffing levels in A&E in 2007/08 found the Trust was short of 120 nurses – 17 were needed in A&E, 30 were needed in the surgical division and 77 on the medical wards. Moreover, nurses, particularly in the EAU, did not have enough training. Some had not been trained to read cardiac monitors, for example, which were also sometimes turned off. Patients did not always get the correct medication, while some nurses did not know how to use the intravenous (IV) pumps correctly. This meant that patients did not receive the right dose of IV fluids and medicine at the correct rate. Of particular concern was the fact that nurses were not always able to identify when patients were deteriorating after an operation, by monitoring vital signs. Due to nurse shortages, call buttons were not always answered when patients were in pain or needed the toilet, particularly on medical wards. Some relatives claimed patients were left,  sometimes for hours, in wet or soiled sheets, putting them at increased risk of infection. Patients at risk of developing pressure sores did not get appropriate care. In one ward, 55% of patients were found to have pressure sores when only 10% had sores on arrival. Delays in operations were commonplace, especially for trauma patients at weekends. There was no system in place to give priority to cases for emergency surgery at weekends. This meant that trauma cases, such as patients with a fractured neck of femur, were often delayed to give priority to general surgical or obstetric emergencies. Sometimes a patient’s operation might be cancelled four days in a row, and they would receive “nil by mouth” for most of the day, four days running. There was often no experienced surgeon routinely in the hospital after 9 pm at night and often only one foundation year one doctor (the most recently qualified) would be responsible for covering all the surgical patients. The resident surgical officer was often quite inexperienced and was responsible for admitting up to 20 patients a night. These surgical officers might also be required to go to theatre or be called to A&E. The Trust also had poor systems for the prevention of deep vein thrombosis, following surgery. An audit conducted between January and March 2008 found that only 10% of the relevant patients in Cannock Hospital and 30% at Stafford Hospital were given the drug in line with the protocol of best practice. Essential equipment was not always available or working. For example, there was no non-invasive ventilation on the respiratory ward to help to support breathing in patients with lung disease. In February 2008, there was no or only limited portable suction available to patients who had suffered a cardiac arrest, yet suction is important in clearing airways. The Trust also had no effective system for monitoring outcomes for patients and therefore failed to identify, or understand, what might be the cause of the higher than expected death rates among patients admitted as emergencies. Furthermore, it was poor at identifying, reporting and investigating serious untoward incidents. An analysis of the Trust’s board meetings from April 2005 to 2008 found discussions were dominated by finance, targets and achieving Foundation Trust status, while there was little evidence that poor standards of nursing care were identified and discussed. The investigation found that poor results of surveys of inpatients or staff were not discussed publically, while a doubling of the rate of C. difficile infection in the early months of 2006 was not released to the board or the public. The investigation also found that in 2006/07 the Trust set itself a target of saving £10 million. This equated to about 8% of turnover. To achieve this, over 150 posts were lost, including nurses. This was in a Trust that already had comparatively low levels of staff.