Wednesday 18 March 2015

Bart's Health trust - told you so!

I'm reprinting an article from September 2013. As you can see, it wasn't the first time that I'd warned about the scandal at Bart's Health Trust.

It's quite simple; I looked at the extraordinary number of 'never happen' events that were taking place at the trust.

It's not the only measure of what's going wrong at a hospital. It's just one of many.

Two years down the line and Bart's Health trust has been taken into special measures.

It's about time....time for managers and senior health professionals at the trust to resign. We'll see if that happens.

Meanwhile you read it here first, two years ago; 

 

 

Tuesday, 10 September 2013

More questions about Barts health NHS Trust.


O.K.

I’m getting seriously worried about Bart’s Health NHS Trust which is in fact a large grouping of East End Hospitals, swallowed up by inappropriate mergers over the years. This is what I wrote in May of this year after I analysed the ‘Bottom 21’ Trusts for ‘Never Events’, things that should never happen because they are completely preventable:

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’;

Bart’s& The London NHS Trust 8

              Retained foreign object post-operation 4

              Wrong site surgery 2

              Misplaced naso-or oro-gastric tubes 2

Bart’s 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.”

I didn’t believe my eyes, so I left it as a question.

Then I got my answer in The London Standard two months later:

“An inquiry was ordered today at Britain’s biggest health trust in response to the deaths of 28 patients due to medical blunders last year.

 Barts health trust — which runs six London hospitals — was declared at “high risk” of failing patients, with major concerns about delays in cancer care and hundreds of emergency cases readmitted for further treatment.

The inquiry was ordered by England’s new Chief Inspector of Hospitals, Professor Sir Mike Richards, in his first day in the job. It comes after Barts last night said it was calling in financial trouble-shooters to address a £93 million debt.

Sir Mike was alerted by whistle-blowers, patient complaints and key measures indicating the performance at Barts was markedly worse than the national average. This included 10 “never events” — things that should never happen in surgery — involving seven cases where swabs were left inside patients, two cases where the wrong teeth were removed and one where the wrong eye implant was inserted.

 

Barts also admitted 348 serious incidents in 2012/13, including 129 at The Royal London Hospital in Whitechapel, and 105 at Whipps Cross in Leytonstone. Of these, 28 resulted in death.”

 

Now I am really concerned. Yesterday I posted the Freedom of Information responses from 101 NHS Trusts – replies to requests for Information made by the BBC News team about the number of unfilled vacancies at Accident and Emergency departments.

I went back to the figures to find out what has been going on down at Bart’s Health NHS Trust and the answer is……nothing…..nadda….nowt…zilch.

They didn’t provide the information.

So, of course, the only explanation is that the management, after failing to sort out its fairly serious problems has responded by hiding the result of the problems under the carpet. Given the extent of their troubles it would be no surprise to discover that staff are leaving and aren’t replaced and we have a right to know.

Its bad when there are problems, it’s much worse when you cover them up.

What else are they hiding?
Neil Harris
(a don't stop till you drop production)
 
 

Tuesday 3 March 2015

Morecombe Bay NHS Trust, 12 avoidable deaths in maternity.




This is another very long awaited report.

Morecombe Bay Hospital suffered a series of deaths of babies and mothers at its maternity unit – a number far higher than this report accepts.

There followed a similar pattern; denial by the hospital and the professionals involved, the deaths rising to a level where local patients start campaigning, staff move on, there is an investigation and…….everything is fine.

It isn’t.

Furness General Hospital and it’s trust has had problems in a number of areas – for example I’ve catalogued it’s poor record in ‘Never happen Events’.

In this case there seems t have been a climate of incompetence, bullying and a very real cover up.

Preparing answers for everyone to follow at an inquest is the offence of ‘perverting the course of justice; prosecutions should follow.

This report is from ‘The Independent’ newspaper today;

Morecambe Bay hospital report finds 'lethal mix' of failures led to 11 baby deaths

 

The investigation has recommended a national review of NHS maternity services

 

Charlie Cooper

Health Correspondent 

Tuesday 03 March 2015

 

A “lethal mix” of incompetence, cover-up and failure to learn from mistakes led to the preventable deaths of 11 babies and one mother at a rural NHS hospital in Cumbria, a long-awaited report has said.

 

The inquiry into maternity services at Furness General Hospital between 2004 and 2013 found “failures at almost every level”, from the maternity ward to national NHS regulators and the Department of Health, who missed opportunities to investigate a series of serious incidents.

 

The investigation, led by Dr Bill Kirkup, has recommended a national review of NHS maternity services and care for children in rural areas.

 

In total the inquiry uncovered 20 instances of significant or major care failures at Furness General, part of the University Hospitals of Morecambe Bay (UHMB) NHS Foundation Trust. Failures occurred in the run-up to the deaths of 16 babies at or shortly after birth, as well as the deaths of three mothers.

 

Better care could have saved the lives of 11 of the babies and one of the mothers, the report said.

 

Staff on the unit in Barrow-in-Furness lacked essential “skills and knowledge” and working relationships between doctors and midwives were “extremely poor” with a “them and us” mentality that prevented safe working.

 

Midwives failed to keep up with the latest national standards of care and were heavily influenced by a small group of “dominant” midwives who pursued normal childbirth “at any cost”, the report said, leading to avoidable mortality rates that were four times higher than neighbouring hospitals.

 

A “strong group mentality” among midwives known as “the musketeers” hindered investigations into the incidents. The inquiry found “clear evidence of distortion of the truth” in responses to investigation. In preparation for an inquest into one of the incidents, "model answers" to difficult questions were circulated among midwives, the report said.

 

However, the UHMB Trust, as well as regional and national authorities, were slow to investigate and between them missed seven opportunities to intervene in the three years from 2008, when five serious incidents occurred within a short space of time.

 

Proper investigations as far back as 2004 would have raised the alarm, the report said.

 

The report added that without the efforts of bereaved families, the scale of the failings would never have been brought to light.

 

The report makes 44 recommendations for the Trust and for the wider NHS.

 

Investigation chairman Dr Bill Kirkup said: “All healthcare – everywhere – includes the possibility of error. The great majority of NHS staff know this and work hard to avoid it. They should not be blamed or criticised when errors occur despite their efforts.

 

"But in return, all of us who work for the NHS owe the public a duty to be open and honest when things go wrong, most of all to those affected, and to learn from what has happened. This is the contract that was broken in Morecambe Bay.”

 

He added: “There was a disturbing catalogue of missed opportunities, initially and most significantly by the Trust but subsequently involving the North West Strategic Health Authority, the Care Quality Commission, Monitor, the Parliamentary and Health Service Ombudsman and the Department of Health.”

 

The report also recommended that the General Medical Council and the Nursing and Midwifery Council should consider investigating the conduct of those involved in patient care during the incidents investigated.

 

The Trust has undergone changes in management since 2012, and the report said there were now “welcome signs of significant recent improvement” including in maternity services.

Neil Harris

(a don’t stop till you drop production)