In court with the Mid Staffordshire NHS Trust.

The Mid Staffordshire Hospital scandal continues; The health and safety executive are now prosecuting the Health Authority for some of the most blatantly negligent of the 600 odd deaths caused by poor staff and management at this nightmare group of hospitals.

Except it is being wound up and effectively a 'legal body' is being taken to court when it should have been the management and those directly responsible.

This would be just a farce except one of the deaths occurred last year - long after the scandal was exposed, the official report was published and  a 'new' trust created to take over.

You can read about Mid Staffs and The Francis Report on the archive pages of this Blog.

This is from The Daily Telegraph;

Sponsored

 

Mid Staffordshire NHS Foundation Trust charged over four deaths

The trust at the centre of the worst ever NHS scandal is facing criminal charges over the deaths of four patients

 

     

By Laura Donnelly, Health Editor

15 Oct 2015

The trust which ran Stafford Hospital is to face criminal charges related to the deaths of four patients - one as recent as last year.
 

The Health and Safety Executive (HSE) has brought charges against Mid Staffordshire NHS Foundation Trust over the deaths of four elderly patients between 2005 and May 2014.

Mid Staffordshire NHS Foundation Trust was at the centre of one of the biggest scandals to hit the health service over the deaths of hundreds of patients, amid appalling failings in care.

The HSE said the charges related to the deaths of Patrick Daly, aged 89, who died in May 2014, Edith Bourne, aged 83, who died in July 2013, Ivy Bunn, aged 90, who died in November 2008, and Lillian Tucker, aged 77 who died in October 2005.

Mrs Tucker died after a junior doctor gave her a penicillin-based drug despite being told she was allergic to the antibiotic, an inquest heard. She had suffered fall, which led to a small fracture while on a family holiday in the area.

His son later said he "would not touch the hospital with a barge pole" after detailing the family's repeated warnings about his mother's allergy.

The HSE said it had charged Mid Staffordshire NHS Foundation Trust following a "thorough and comprehensive investigation into the circumstances of four deaths of patients under its care".

The trust is due to appear before Stafford Magistrates on November 4. A new trust began to run the hospital last November.

Last week police and health officials said they are investigating claims of an NHS “cover-up” over the death of a three-year old boy, Jonnie Meek, at Stafford Hospital, last year.
 
The parents of Jonnie Meek, who died at Stafford hospital, say failings were covered up .

This probe will check claims that statements from health workers who witnessed his death were falsified.
It is very rare for the HSE to act in cases involving clinical failings, and the body has previously been criticised for its reluctance to prosecute.
 
The Mid Staffs inquiry accused the body of “looking for reasons for not taking action rather than starting from a consideration of what is in the public interest. “
 
“The more serious and widespread a failure is, the less likely it is that the HSE will decide to intervene, even where it is apparent that no other regulator is likely to do so,” Robert Francis, the chairman of the inquiry said.

Last year the same trust was fined £200,000 over the death of Gillian Astbury, 66, who died in 2007 because nurses at Stafford hospital failed to give her the routine insulin she required to stay alive.
Wayne Owen, HSE principal inspector in the West Midlands, said: "We have concluded our investigation into the death of four patients at Stafford Hospital and have decided there is sufficient evidence and it is in the public interest to bring criminal proceedings in this case."

The trust remains in place as a legal entity but no longer provides patient services.
University Hospitals of North Midlands NHS Trust took over the running of Stafford Hospital and Royal Stoke University Hospital.

The Mid Staffs special administrator Tim Rideout said the remaining "shell organisation" would oversee any "potential criminal liabilities".
He added: "I am committed to bringing matters to a conclusion as efficiently and effectively as possible in the best interests of the families concerned.

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

Home: helpmesortoutthenhs.blogspot.com

Contact me: neilwithpromisestokeep@gmail.com

 

First response to the health Minister's response.

The Government’s responses to the Francis report are now out; I’ve only scanned the headlines so far because it’s a mass of documents and a lot of data to download. I’ll do a proper analysis in a couple of days.

So far pressure is being put on the Royal College of Nursing to split its union function away from its regulatory one – which I have called for a long time. No mention of doing the same for the BMA – it’s just as important that Doctors are both regulated and represented properly and one organisation can’t both punish and protect at the same time.

Every patient will have a named nurse – which sounds fine as it makes one person responsible. However there are three shifts a day, sickness and holidays as well as courses to attend etc. it means if the named nurse isn’t there nothing will happen. Better to have a named Doctor to supervise overall treatment and be responsible but of course that is never going to happen.

The problem is that patients often rarely see a nurse – most work is done by unqualified care assistants. There should be a regulatory body for them with the ability to ‘strike off’ a care assistant. That’s not happening.

The new criminal offence I dealt with a few days ago if you scroll back – a pointless gimmick.

The ‘duty of candour’, will require that patients or families are told when there has been a medical error – at the moment they get hushed up. It’s alright as far as it goes but doesn’t go far enough.

It may be that I just reviewed the report without meaning to, hopefully there is some more in it besides.

I think my fear is that the Health Secretary, who still practises on a part time basis, is still too concerned about the sensitivities of the health professionals.

Neil Harris

(a don’t stop till you drop production)

NHS nursing shortages.

On Tuesday 12 November 2013, The Royal College of Nursing issued a valuable report on nursing vacancies. Using Freedom of Information legislation the union found that average vacancy rates at hospitals are around six per cent.

Extrapolating the figures from the 61 NHS trusts that replied, the College said this would amount to nearly 20,000 full-time equivalent nursing, midwifery or health visitor vacancies over the whole country.

Dr Peter Carter, chief executive and general secretary of the RCN, said: “Understaffing remains a real issue across the NHS, and we know that many trusts are down to the bone in terms of the number of frontline nursing staff they have due to cutting posts to save money.

“Unsafe staffing levels have been implicated in a number of high-profile investigations into patient safety. We call on employers in the NHS to put an end to boom-and-bust workforce planning and develop clear standards to ensure safe staffing levels are met, supported by robust inspection based on reliable data.”

 

All the reports into NHS scandals – The Francis Enquiry, the investigation onto the 14 failing trusts, have all highlighted that inadequate staffing levels result in poor care and worse outcomes. They also stress out staff.

The Francis report argued for minimum levels of staffing – something the government has refused to consider.

As the waiting times in Accident and Emergency grow, the reason is not a ‘shortage of beds’ as is often said – this is not true. There are plenty of empty beds and empty wards. Every so often they shut a hospital because there are so many closed wards. The shortage of beds is because there is a shortage of nurses – staff who leave aren’t replaced.

Worse than that, the RCN pointed out that “the Department of Health stopped collecting vacancy data in 2011, when vacancy rates for nurses stood at 2.5 per cent”.

Neil Harris

(a don’t stop till you drop production)

My review of The Berwick Review, Part 2.

 

I slogged my way through the main body of the report. It’s probably the shortest of the recent studies, with the fewest boring footnotes, addendums and figures. It’s also perhaps the least helpful. There’s not much data there and as you should know from me by now, original data is like finding a vein of ore in rock.

It seems to be a selection of powerpoint presentations and flipchart images. I can see these being ‘cascaded down’ throughout the NHS in the months to come.

That’s the correct managementspeak, I think.

I can also see tired and depressed people just turning off as one page merges into another.

Here are the good intentions, nothing anyone could disagree with here;

“Place the quality of patient care, especially patient safety, above all other aims.

Engage, empower, and hear patients and carers at all times.

Foster whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work.

Embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.”

Here a fine sentiment, again no problem with that;

“At its core, the NHS remains a world-leading example of commitment to health and health care as a human right – the endeavour of a whole society to ensure that all people in their time of need are supported, cared for, and healed. It is a fine institution. But the events at Mid Staffordshire have triggered a need to re-examine what the NHS does and determine how it can improve further. The only conceivably worthy honour due to those harmed is to make changes that will save other people and other places from similar harm.”

 

Here are the problems;

“The following are some of the problems we have identified:

●Patient safety problems exist throughout the NHS as with every other health care system in the world.

●NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.

●Incorrect priorities do damage: other goals are important, but the central focus must always be on patients.

●In some instances, including Mid Staffordshire, clear warning signals abounded and were not heeded, especially the voices of patients and carers.

●When responsibility is diffused, it is not clearly owned: with too many in charge, no-one is.

●Improvement requires a system of support: the NHS needs a considered, resourced and driven agenda of capability-building in order to deliver continuous improvement.

●Fear is toxic to both safety and improvement.”

 

Here the solutions;

 

“To address these issues the system must:

●Recognise with clarity and courage the need for wide systemic change.

●Abandon blame as a tool and trust the goodwill and good intentions of the staff.

●Reassert the primacy of working with patients and carers to achieve health care goals.

●Use quantitative targets with caution. Such goals do have an important role en route to progress, but should never displace the primary goal of better care.

Executive Summary

 

●Recognise that transparency is essential and expect and insist on it.

●Ensure that responsibility for functions related to safety and improvement are vested clearly and simply.

●Give the people of the NHS career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning.

●Make sure pride and joy in work, not fear, infuse the NHS.The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.

And here the recommendations;

We have made specific recommendations around this point, including the need for improve training and education, and for NHS England to support a network of safety improvement collaboratives to identify and spread safety improvement approaches across the NHS.”

Our ten recommendations are as follows:

1. The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.

2. All leaders concerned with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support.

3. Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.

4. Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported.

5. Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives.

6. The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS.

7. Transparency should be complete, timely and unequivocal. All data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.

8. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.

9. Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.

10. We support responsive regulation of organisations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to wilful or reckless neglect or mistreatment.”

My conclusions tomorrow.

Neil Harris

(a don’t stop till you drop production)

Home: helpmesortoutthenhs.blogspot.com

With the toe of my size 11, 12 hole, Doc Marten boot.

The Nursing and Midwifery Council (NMC) has met and struck off two Accident and Emergency nurses from Stafford Hospital, part of Mid-Staffs NHS Trust, where so many died, needlessly.

There have been far too few examples of disciplinary action taken and all of them far too late. In the case of Tracy White, she is not only still employed by the hospital – she’s now a manager!

Despite White being struck off as a nurse, Maggie Oldham the current Chief Executive said of her; “She has been employed as a clinical site manager. We will now take time to give careful consideration to the NMC panel’s decision”.

I’d give her some careful consideration – with the toe of my size 11, 12 hole Doc Marten boot.

It’s her co-defendant I really want to Blog about, Sharon Turner;

She was foul-mouthed and abusive about patients, falsified A and E waiting times to make it appear as though A and E had dealt with patients within the 4 hours target, bullied other nurses into falsifying records and was racially abusive towards junior doctors. Here are a few choice quotes;

“I don’t give a flying F@#k about patients, they can wait”

“I’ll make your life hell and get rid of you in 6 months” (to a fellow nurse)

“I’ll drive you to drink and you’ll be out of here” (to another nurse)

“He should have taken a few more pills and done the job properly” (about a nurse who took an overdose)

“she’s a dirty little monkey” (referring to an elderly patient and refusing to assist a nurse change her)

I could go on. The point is that this nasty, viscious, cruel, lazy, racist bully was as much a menace to her co-workers as she was to the patients who were unlucky enough to receive her ‘care’.

Oh and by the way, Sharon Turner, you are very welcome to take my comments up with me, any time you wish.

One bully is a problem, when it’s tolerated and spreads it becomes the culture at work.

The bully picks on the weak – that’s usually the patients but it’s also workmates who are unprotected.

So Turner picked on junior doctors because they have little respect from their fellow doctors.

In particular, she picked on racial minorities because their colleagues were less likely to protect them.

It was tolerated by her fellow nurses (all guilty of not taking action) because of the bullying attitude that senior medical staff and management have towards nurses and care assistants in general.

Can you tell how angry I am?

Neil Harris

(a don’t stop till you drop production)

Home: helpmesortoutthenhs.blogspot.com