There are as many ways of comparing patient outcomes as there
are procedures (almost), it’s becoming an industry. If that’s an exaggeration,
fixing the figures certainly is a well paid occupation.
I’ve Blogged a lot about mortality rates, and the attempts to
alter coding (the bad guys call it ‘gaming’ the codes) to make a hospital look
better than it is and to avoid spending money to make it better. It’s a
management thing…. it’s all on my other Blog;
However I have to commend NHS England for collecting figures
on the ‘never happen’ events, its important information for anyone wanting to
improve the NHS.
They aren’t/weren’t public until BBC News obtained them –
it’s what used to be called a ‘scoop’. I
republished them yesterday to make it easier for people to make use of them and
to publicise them but all credit to the BBC.
I’m worried that hospitals will be doing everything they can
to minimise the reporting of those disasters, but in the meantime I hope that
NHS England is now going to do something with the figures, which they would rather
have kept hidden.
As I don’t actually think NHS England is going to do anything – I have. I’ve compiled my ‘Bottom 21’; an
alternative to the hit parade, it’s my sh#t parade of failing hospitals.
I chose 21 to be on the safe side because, as you’ll see
later, it may in fact only be a ‘Bottom 20’.
Don’t get me wrong, anyone can make a mistake – I often do-
but these are the mistakes that shouldn’t happen. It’s not just that patients
are dying, that happens when you try to save lives. There are procedures to avoid ‘never events’
and they shouldn’t be missed.
It starts with 8 hospitals all of whom had 8 ‘never events’
in the last four years. There isn’t much else to say – 2 a year is too many.
Barts and the London Hospital
Cambridge University
Croydon
Heart of England
Sandwell and West Birmingham
Shrewsbury and Telford
St. Georges
Princess Alexandra
Then there are the nasty nines;
Chelsea and
Westminster and Gloucestershire.
Followed by the ‘tottering tens’;
Hull and East Yorks, James Paget, Royal Free and the Royal
Wolverhampton.
At 11 ‘never events’ are Barts, Mid Essex and Imperial College. I think we are
getting in real danger ground here; Barts and Imperial both have really good
reputations and need to take a long, hard look at how they are working. Mid
Essex is currently in pole position for me as it includes operating on the
wrong person in its role of shame. That has to be the worst mistake you can
make – it’s why we all wear bracelets in hospital. Have you never heard of
Barcodes and scanners? It’s 2013.
At 12 ‘never happen’ incidents is United Lincolnshire – if I
am not mistaken this ‘Trust’ is already under investigation for abnormally high
death rates, although as the 14 Trusts being looked at have not been publicly
identified, I can’t be sure.
There is no unlucky 13, but at 14 ‘never happen’ incidents is
Plymouth and at 15 are Guys and St Thomas’s Trust – who should be ashamed of
themselves – two great and much loved London hospitals.
I would have said that the dishonour of being worst in the
land goes to Nottingham University Hospital with a staggering 17, more than 4 disgraceful
incidents a year but I fear it isn’t.
Before there is a chorus of complaints – that my bottom 21
doesn’t take account of how busy hospitals are, the number of procedures, the level
of complexity? Forget it – these are the events that should never happen. Ordinary
mistakes are something different – there will be a percentage of them for any
given number of procedures. There shouldn’t be any of these.
My own ‘Lantern Rouge’ (that’s the Tour de France prize for
finishing last) is because I’ve picked out the two separate entries for
‘Bart’s’;
Barts & The London NHS Trust 8
Retained foreign object post-operation
4
Wrong
site surgery 2
Misplaced
naso-or oro-gastric tubes 2
Barts Health NHS Trust 11
Retained
foreign object post-operation 4
Wrong
site surgery 3
Misplaced naso-or oro-gastric tubes 2
Wrong
implant/prosthesis 1
Air
Embolism 1
and I did so because Barts Health was formed on 1 April 2012
by the merger of Barts and the London NHS Trust, Newham University Hospital NHS
Trust and Whipps Cross University Hospital NHS Trust.
For starters that means that St Bartholomew’s may have had its
figures split in two and actually had 19 ‘never happen’ incidents over that
four year period which is seriously worrying. Even more worrying is that the
newly combined Trust – the four hospitals together- seems to have had 11
incidents in just under a year (2012/13).
If you want to get really frightened, add up the number of
incidents over the four hospitals for those four years – it’s a total of 27. Or
is there duplication in these figures? Have they tried to separate the new from
the old, producing double counting? I hope so – mind you where the NHS is
concerned the problem is usually undercounting problems.
Either way, it’s not what I would call a centre of
excellence.
So if Barts it isn’t being investigated right now, it’s time
it was.
Neil Harris
(a don’t stop till you drop production)
No comments:
Post a Comment