Friday 11 December 2015

The Parliamentary Ombudsman condemns the NHS failure to investigate deaths properly.



This Guardian article highlights a report by The Parliamentary Ombudsman. However I would point out that my own complaint to her was dealt with very unsatisfactorily.

The Patients Association has recommended against complaining to The Ombudsman due to the ineffectiveness of her organisation.

  
The Guardian
Three out of four investigations by hospitals into complaints that patients suffered avoidable injury or death fail to identify serious failings in care, leaving distraught families in the dark, the NHS ombudsman has warned.

Inquiries by hospital staff are so often inadequate that many complainants seeking to understand what went wrong are met with “a wall of silence from the NHS”, according to Dame Julie Mellor.
Mellor, the parliamentary and health service ombudsman, has demanded an urgent overhaul of how hospitals examine serious complaints made against them, in which mistakes allegedly led to patients being harmed or even killed.
Her review of the quality of internal hospital investigations uncovered a series of major weaknesses. In 73% of cases in which she found evidence of clear failings, the NHS hospitals trust concerned had concluded that no failings occurred.
“Parents and families are being met with a wall of silence from the NHS when they seek answers as to why their loved one died or was harmed,” said Mellor.
“Our review found that NHS investigations into complaints about avoidable death and harm are simply not good enough. They are not consistent, reliable or transparent, which means that too many people are being forced to bring their complaint to us to get it resolved.”

In just over half (52%) of the cases she examined, the investigation had been led by a doctor who was not independent of the events complained about.

For example, when a baby girl was left with brain damage after a blood transfusion went wrong, the hospital appointed a close colleague of the paediatrician at the centre of the complaint to investigate. The girl’s family had to wait three years before learning what mistakes had been made.

Hospitals also failed to categorise 20 out of 28 cases of avoidable harm examined as serious incidents, which meant they were not properly investigated.
Mellor said hospitals’ inquiries into serious injuries or deaths too often fail to gather enough evidence, are inconsistent in how they look for proof of errors, and do not look closely enough at material to see what went wrong and why.

Almost a fifth (19%) of inquiries did not gather important evidence such as the patient’s medical records, statements and interviews, Mellor found.

In investigations that found there had been failings, more than a third (36%) failed to get to the bottom of why they had occurred, even though 91% of complaints managers said they were confident they could find out what happened.

Hospital bosses admitted that too many investigations are substandard.
“We know we don’t always get this right and it’s crucial that we learn and improve every time,” said Rob Webster, the NHS Confederation chief executive.
“The Care Quality Commission, ombudsman and others are highlighting major inconsistencies and shortcomings in the handling of complaints and those problems cannot be allowed to continue. So we urgently need to learn from what is working and fix what doesn’t, to ensure patients have complete confidence in the National Health Service.”

Anna Bradley, the chair of Healthwatch England, a patient group, said: “Hundreds of thousands of incidents of poor care go unreported every year across the NHS precisely because people fear they either won’t be taken seriously or that nothing will change as a result.”
 
Peter Walsh, the chief executive of the patient safety charity Action Against Medical Accidents, said the new independent patient safety investigation service, set up by Jeremy Hunt to promote airline-level safety in the NHS, should improve investigations.
“The ombudsman’s findings are doubly worrying, as they were only reviewing cases where there had already been a complaint under the NHS complaints procedure. If this is how the NHS investigates when there is a formal complaint, one has to wonder how it investigates when it is left entirely to its own devices,” said Walsh.
“Unfortunately, in our experience it is not uncommon for NHS bodies to carry out investigations without even informing the patient or family affected by an incident.”

Neil Harris
(a don't stop till you drop production)

Home: helpmesortoutthenhs.blogspot.com
Contact me: neilwithpromisestokeep@gmail.com

Thursday 10 December 2015

A failure to investigate deaths at the Southern health NHS Foundation Trust.

Yesterday I posted a story about a disabled man who was given a 'Do Not Rescusitate' notice by Doctors because he was..... disabled.

This is a 'Guardian' article about the scandal at "The Southern Healthcare Trust", where deaths of vulnerable people in the Trusts care have not been properly investigated;

The Guardian 9/12/15.

An NHS hospital trust failed to properly investigate the deaths of more than 1,000 patients with learning disabilities or mental health problems over four years, an independent inquiry has found.

A leaked copy of the inquiry’s report severely criticises a “failure of leadership” at Southern health NHS foundation trust and accuses senior managers of not looking into and learning from deaths.

NHS England commissioned Mazars, an audit firm, to examine the 10,306 patient deaths which occurred at the trust between April 2011 and March 2010.

While most of those deaths were expected, 1,454 were unexpected.

The Mazars report, obtained by the BBC, concludes that failures by the trust’s board and senior executives meant that no “effective” management of deaths or investigations took place and there was a lack of “effective focus or leadership from the board”, the BBC said.

The Mazars inquiry team found that when trust board members did ask questions, executives reassured them that investigations were thorough. However, the report concluded: “This is contrary to our findings.”

It also found that the culture of the NHS trust, which is led by chief executive Katrina Percy, “results in lost learning, a lack of transparency when care problems occur, as well as assurance to families that a death was not avoidable and has been properly investigated”.

Of the 1,454 unexpected deaths, the trust regarded 272 as critical incidents but classed only 195 of them – or one in seven – as a serious incident that needed to be investigated.
But while it looked into 30% of the deaths among adults with mental health problems, it did so with only 1% of those with learning disabilities and 0.3% of over-65s with mental health problems.
 
Patients with a learning disability died at an average age of 56, which is seven years earlier than the usual life expectancy.

“These are shocking revelations that if proven, reveal deep failures at Southern health NHS foundation trust,” said Luciana Berger, Labour’s shadow minister for mental health.
“For there to have been so many unexpected deaths in one trust is of deep concern itself, but for so many of those deaths not to have been investigated is extremely alarming. It raises serious questions about the leadership and culture of care at the trust.”

NHS England ordered the inquiry after Connor Sparrowhawk an 18-year-old with learning disabilities, drowned in a bath at the trust’s Slade House unit after suffering an epileptic seizure. Coroners had also criticised the trust at inquests for producing reports into deaths that were inadequate or very late, but that had failed to prompt the improvements that were needed and staff often made little effort to engage with the relatives of those who had died, the Mazars report found.
Sara Ryan, Sparrowhawk’s mother, told the BBC: “There is no reason why in 2015 a report like this should come out. It’s a total scandal. It just sickens me.”

The trust provides community services, mental health, learning disability and social care services to about 45,000 people in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire.

The Mazars report said that the trust was unable to show that it had a good system in place for learning from deaths and did not use effectively the extensive data it collected on deaths.

It also found that the trust looked into too few deaths involving either those with a learning disability or older people with mental health problems and failed to involve relatives in almost two out of three of the investigations it did undertake.
Southern accepted that its response to patient deaths was not good enough but denied that its death rate was higher than would be expected.

“We fully accept that our reporting processes following a patient death have not always been good enough. We have taken considerable measures to strengthen our investigation and learning from deaths including increased monitoring and scrutiny,” it said in a statement.

“We would stress the draft report contains no evidence of more deaths than expected in the last four years of people with mental health needs or learning disabilities for the size and age of the population we serve.”

The trust has “serious concerns” about the way Mazars had
interpreted the evidence. It added that while it had “had one or more contacts” with the patients in the previous 12 months, “in almost all cases referred to in the report, the trust was not the main provider of care”.

Jan Tregelles, the chief executive of the charity Mencap, said: “Twelve hundred people with a learning disability are dying avoidably in the NHS every year. This is a national scandal.”

All such deaths need to be properly analysed so that other avoidable deaths can be prevented, she added.

Neil Harris
(a don't stop till you drop production)

Home: helpmesortoutstpeters.blogspot.com
Contact me: neilwithpromisestokeep@gmail.com

Wednesday 9 December 2015

D.N.R. orders yet again.


This is a continuing problem in The NHS; the use of "Do Not resuscitate" orders on peoples files when this has not been discussed with either patients or their families/carers.

This is just the worst situation....a doctor making a judgement based on a persons disability.

It could be you!

Kent hospital apologises for putting do not resuscitate order on Downs Syndrome man before he died

December 8, 2015 | by SWNS Reporter               
 
A man with Down’s Syndrome was given a ‘do not resuscitate’ order by hospital staff, who listed his learning difficulties among the reasons for doing so.
Andrew Waters (SWNS Group)
 
East Kent Hospitals NHS Trust have admitted breaching the human rights of Andrew Waters, 53, by placing the ‘DNR‘ notice on him.

Mr Waters’ family were not consulted or informed and only found out after he was discharged from hospital and they found the crumpled note in his bag.

The order was placed on him when he stayed at the Queen Elizabeth, the Queen Mother Hospital in Margate, Kent, in 2011 because of problems related to his dementia.
Hospital staff decided he should not be resuscitated if he developed heart or breathing problems.
Mr Waters died in May but the order did not have a bearing.

His brother, Michael Waters, said: “For someone to make that decision, without consulting a family members or any one of his carers, was just totally unacceptable.
“No-one has the right to make such a decision in such a disgraceful way, to put those reasons down.
“We were there at hospital and involved in his care at every point.
“The form was a folded up piece of paper found in his bag after discharge, by his carers.
“There was nothing wrong with Andrew’s health at the time which would have an effect on his resuscitation.”

A statement from the Trusts apologised unreservedly for the distress caused to Mr Waters’ family.
It read: “The trust accepts that it breached its duty owed to the patient.“Actions have been taken to ensure this does not happen again and the trust has now reached a resolution with the family.”
Michael Waters welcomed the apology and the trust’s admission that they breached Andrew’s human rights.
Michael said: “It’s taken a long time for the hospital to admit this, which we’ve found hard.
“All we ever wanted from this case was a simple apology.
“People with Down’s Syndrome deserve the right to live like you and me.”


Rosie Neale, 55, who runs a support group called Little Buddies for families and carers of Down’s Syndrome sufferers in Kent yesterday condemned the DNR decision.
She said: “It is just dreadful. I just think it is wrong. They have got a right to live like everybody else.”
Rosie, whose 12 year-old daughter Emily suffers from Down’s Syndrome, added: “I have been quite lucky with my daughter.
“She has not been ill very much. But my experience of being told that my daughter had Down’s Syndrome was not very good. It was just come in, have a look at what’s wrong.”

The lawyer who brought the case says trust breaks down between doctors and families if the reasons behind resuscitation orders are not communicated effectively.
Leigh Day solicitor Merry Varney, also fought the case of Janet Tracey, which established last year that doctors had a legal duty to consult and inform patients about DNR orders.
She said: “Sometimes they can be really aimed at trying to give a patient a dignified death.
“This is not about giving up on someone or writing them off.
“But that’s generally what I hear people say they feel, if they find out about these after the decision has been made.
“I still receive around three calls a fortnight from families or patients who are concerned about what a DNR means and whether it means not to treat more generally.
“Unfortunately, the portrayal of cardio-pulmonary resuscitation in TV dramas sometimes suggests it’s a quick fix and works for everyone.
“That’s simply not the case – and there’s a real onus on healthcare professionals to communicate that.”

Yesterday that two orders not resuscitate were placed on Andrew Water’s medical records without the knowledge of his family.
The Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders were placed on his medical records giving his disability, Down’s Syndrome, as one of the reasons.

Mr Waters, who died from an unrelated cause in May, took legal action against the Queen Elizabeth the Queen Mother Hospital through a litigation friend, his brother Michael.

In August 2011 Mr Waters, who suffered from dementia, was admitted to the hospital where it was decided he required a feeding tube.
Without consultation with his family or with carers from his residential home, a DNACPR order was placed on his file.
Despite holding a ‘best interests meeting’ to discuss Mr Waters’ feeding tube, resuscitation was not discussed and his family were not informed of the order, even on his discharge.
In September 2011 he was again admitted to Queen Elizabeth the Queen Mother Hospital in Margate, Kent.
Throughout his time at the hospital his family visited virtually every day, yet on admission a DNACPR order was again imposed without any discussion or consultation.
The rationale for the DNACPR order was stated to be:”Downs Syndrome, unable to swallow (PEG fed), bed bound, learning difficulties.”
It inaccurately recorded the family as “unavailable” and was marked as indefinite in duration.
Following his final discharge back to the residential home where he lived, staff at the home found the DNACPR in Andrew’s possession.
The manager of his residential care home contacted Andrew’s Community Learning Disabilities Nurse who telephoned the hospital and challenged the doctor about the order.
She then informed Andrew’s family as she felt they needed to know, not least as Andrew had by that time been admitted back into hospital.

His family were shocked to learn about the imposition of the DNACPR, not only in light of the comments on the form itself but also the fact a decision to withhold potentially life sustaining treatment had been made with no consultation with the family, let alone their agreement.
Initially, apologies were offered from the Trust but without any actual acknowledgment of any wrongdoing.

Andrew’s brother, Michael Waters : “I still feel very angry about this, especially the fact that my brother’s Down’s Syndrome was put as the reason for the DNACPR.
“As a family we are also upset that the doctor concerned has still not offered any personal apology despite this admission from the Trust.”

Jan Tregelles, CEO of Mencap, said: “Many families who have lost their loved ones to poor care within the NHS have told us about the inappropriate use of Do Not Attempt Resuscitate (DNAR).
“There have been circumstances where DNAR notices have been applied without the knowledge or agreement of families.
“DNAR orders have also been applied hastily, in inappropriate situations, solely on the basis of a person’s learning disability.
“This is unacceptable and highlights the failures of care that are a daily reality for many people with a learning disability trying to get access to good quality healthcare.
“1,200 people with a learning disability are dying avoidably in the NHS every year.
“The Government must take action to ensure that people with a learning disability get the right healthcare within the NHS and put an end to this scandal of avoidable deaths.”

Merry Varney from the Human Rights team at Leigh Day said:
“The acknowledgment that it was unlawful and in violation of human rights to impose a DNACPR order on Andrew without first discussing it with his relatives is welcomed.
The decision to impose a DNACPR order is a critical and sensitive one, and it is important that family and carers of patients who lack the mental capacity to make their own wishes known, are involved in the decision making process.
“The Trust had initially argued that there was no unlawfulness as the DNACPR was not acted upon and because “there is no indication that [Andrew] was even aware that the decision had been made or understood its significance.”
“Although it is disappointing not to have reached this agreement whilst Andrew was alive, the family welcome the Trust’s acceptance that their actions amounted to a violation of the human rights of a vulnerable adult and hope that no other family will have to endure the nasty surprise of discovering a DNACPRR decision has made unilaterally.”
Down’s Syndrome sufferer Jack Adcock, six, died after a hospital doctor at Leicester Royal Infirmary called off life-saving treatment after mistakenly thinking he was under a Do Not Resuscitate order.

Neil Harris
(a don't stop till you drop production)

Home: helpmesortoutthenhs.blogspot.com
Contact me: neilwithpromisestokeep@gmail.com