Help me sort out the NHS!: Never Events

Showing posts with label Never Events. Show all posts

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

Saturday, 7 September 2013

Another Bart's Health NHS Trust scandal.

If you’ve been following this Blog, you will remember that back in May I highlighted my concerns about Bart’s Health NHS Trust. A mega merger trust which uses the historic name of St. Bartholomew’s Hospital, much loved and respected since medieval times but now reduced and diminished and merged into a group of hospitals.

Between them all they are far and away the leading lights in my ‘Bottom 21’ of hospitals with the worst record for ‘never events’; the things that should never happen because simple things like ‘tick lists’ would prevent them; like cutting of the wrong limb, operating on the wrong person or leaving instruments inside people.

Here’s another one hitting the headlines for all the wrong reasons.

By the way, how do you have a course in ‘care and compassion’ – can you teach that? I think if you don’t have it or you lost it, you shouldn’t be looking after people. Sorry.

The London Standard

Sophie Goodchild

06 September 2013

A London hospital was warned today that it must improve care, after maternity staff were reported to have used “disrespectful” language about women they were looking after.

The Royal London in Whitechapel was criticised by NHS watchdog the Care Quality Commission after a visit by its inspectors. They also found that elderly patients did not always receive appropriate care and treatment.

Their report highlights how staff shortages at the hospital — part of Barts Health NHS trust—have left doctors and nurses struggling to maintain basic care standards. This comes weeks after a damning CQC report into care at Whipps Cross University Hospital, which is also part of Barts Health.

The trust is one of half a dozen considered high-risk by Sir Mike Richards, the CQC’s chief inspector of hospitals. It is already being forced to axe services and suspend expansion plans while it tackles a £50 million financial crisis.

Inspectors who visited the Royal London on June 4 and 5 said they overhead maternity staff making comments about patients such as: “I hope bed six isn’t still here,” and: “Bed nine was terrible last night.” There was a lack of experienced staff to meet the needs of mothers and babies, with some women never seeing the same midwife twice.

Midwives told inspectors they felt senior managers were not listening to their concerns, especially in relation to staff shortages. One employee told inspectors: “I don’t have confidence in managers to treat staff properly.”

Staff on the post-natal ward complained “the management are never present” and do not “treat us well”.

Care plans for patients with pressure sores were not always fit for purpose.

Queues for staff rooms in the ante-natal clinic meant private conversations could be overheard.

The CQC found the Royal London was failing five national standards: on care and welfare of people who use services; co-operating with other providers; staffing; supporting workers; and respecting and involving people who use services.

Today the CQC warned that some “pretty basic” care requirements were not being fulfilled as they should. Barts — Britain’s biggest health trust — said it was “extremely sorry” for failings identified at the Royal London.

The trust said it had put measures in place since the inspection, including a training programme in care and compassion for all 500 staff involved in caring for the elderly. Maternity staff had also been reminded of “the very high standards of care we expect”.

Last month, after an inspection in May and June, Whipps Cross in Leytonstone was criticised for its “dirty and unsafe” maternity ward and treating women among “overfilled bins and stained floors”, with women having to wait up to four hours to be seen. Barts Health said it had “taken immediate action to rectify the failures”.

Of course the management reaction will be to shut hospitals and sell off the land.

The government reaction will be to privatise it all.

Our reaction?

Rally round the hospitals, save the sites and the departments, fight to break up the trust and win back local control.

Neil Harris

(a don’t stop till you drop production)
Home: helpmesortoutthenhs.blogspot.com

Tuesday, 3 September 2013

More privatisation news.

This article is from today’s ‘Independent’, it exposes government scheming to privatise the George Elliot Hospital – one of our problem trusts. I checked out its record of ‘never happen events’ which, at four is not so good but not so bad either:

George Eliot Hospital NHS Trust 4

Wrong implant/prosthesis 2

Wrong site surgery 1

Retained foreign object post-operation 1

There are other causes of concern – my remedy would be a management shakeout and reorganisation but what does the health secretary propose? To sell it off or give it away.

One of the front runners is SERCO, a private contractor which has been exposed fiddling the figures in Cornwall where it runs a 24 hour emergency doctor service. It got caught again when it lied about tagging bills and again making up invoices for delivering prisoners to court;

“The NHS has been “put up for sale” by the Coalition government, Labour have claimed, as it emerged that the Department of Health has approved the possible sell-off a district general hospital.

Board papers published by the NHS Development Authority (NDTA) show that the George Eliot Hospital in Warwickshire could be acquired by another NHS trust or “a franchise that may be a non-NHS organisation”.

If the hospital were acquired by a private company it would become the second in two years, after the Hinchingbrooke Health Care Trust was taken over by Circle Health in February last year.

The Health Service Journal reported that the Department of Health had been willing to see the trust begin a process that could lead to franchising, but was awaiting approval from the Treasury, which has now been granted. Andy Burnham, Labour's shadow health secretary said that the decision represented “privatisation driven from the top”.

“Everywhere you look, chunks of the NHS are being broken up and handed to the private sector. With this announcement, it is now proceeding at a pace and scale never seen before,” he said.

“Ministers have spent all year running down the NHS and their real intent is becoming increasing clear - preparing the ground for more privatisation.

”Far from doctors deciding, this is privatisation driven from the top down. David Cameron needs to be reminded he's never been given the permission of the British public to put the NHS up for sale.“

The NDTA report, authored by the organisation's director of delivery and development, Dale Bywater, said it would be ”prudent“ for services to commence with a new ”strategic partner“ at the George Eliot on 1 April 2015.

Hinchingbrooke Hospital in Huntingdon, Cambridgeshire, last year became the first in the history of the NHS to be run by a private company. The Circle Partnership pledged to turn around the failing 223-bed trust, which was £40m in debt. The trust received high scores in recent patient feedback tests.

The George Eliot Hospital NHS Trust provides hospital and community services for around 300,000 patients. The trust has been seeking a partner ”via a competitive procurement process“ for several months.

According to the HSJ, several organisations have indicated an interest in running the George Eliot, including Circle Health, Serco and Care UK as well as other local NHS trusts.

Mr Burnham has also written to the health secretary Jeremy Hunt, after it was reported that a multi-million pound contract to treat NHS patients with brain tumours was awarded to healthcare giant Hospital Corporation of America International (HCA), which has donated money to the Conservative party. Mr Burnham has asked to know what contact ministers had with HCA, which has donated at least £17,000 to the Conservative party since they came to power.”

Neil Harris

(a don’t stop till you drop production)

Home: helpmesortoutthenhs.blogspot.com

Friday, 26 July 2013

The Keogh Review review, part 3.

The Good,the Bad and the Ugly

These are my conclusions about the report.

The Ugly

The 14 Trusts were failing 10 years ago, failing now and likely to be failing in 10 years time unless real changes are made.

A number of the trusts, despite prior warning of inspection, were still unsafe or not properly staffed when Keogh came calling.

If management couldn’t get its act together to sort everything out before an inspection, when would it? Unless the management changes it is going to happen again, as soon as the Keogh spotlight has moved on.

The report doesn’t identify management or managing clinicians as a problem and it should have spelt that out. The problems start at the top even if they don’t finish there.

The managers get the big rewards, they should pay the price when things go wrong.

The Bad

Because it was so quick, the report does little except highlight areas of concern and raise good intentions for the future. These include;

The need to listen to patients.

Staff morale – every study indicates that low morale or alienation leads to increased mortality rates for patients.

Inadequate staffing levels – a danger for staff.

Too much reliance on agency staff or a high staff turnover to fill the gaps and ignoring the problems that forced staff to leave in the first place. Long service is a sign that people are happy. Happy people make happy patients.

Not enough consideration given to junior doctors and nurses – to tap their enthusiasm and idealism.

In short – too many question marks and too few answers.

The Good

As reports go, it was quick and decisive and Keogh identified the safety problems, taking action quickly.

As he says, after taking emergency action it’s time to debate what was going wrong and then check up on how the Trusts have acted following the review.

Plainly, managers need to be losing their jobs if it doesn’t improve – however much you argue about numbers, people have been dying. From the tone of the report, it is implied that there will be follow up action.

He wants Junior Doctors and Nurses to be involved far more than they currently are. The implication is that they are likely to be more up to date, more modern in their outlook, more committed and more concerned than their older, worn down colleagues.

He wants hospitals to listen to patients.

It gives every indication that Keogh wants to change things for the better. Let’s keep an eye out on what happens next.

My say;

For what it’s worth, my view is that there was too much time spent on whether the mortality figures are helpful or not – it’s a red herring. Mortality figures have proved to be a very useful indicator of problems, up till now. Unfortunately managers have realised that and have been massaging the figures, ‘gaming’ the codes. You can go on expensive courses to learn how to do it.

However, there are many other indicators and they are all of value.

Here’s three lists that the report took account of:

In-patient, Cancer survey, PEAT – privacy and dignity, Complaints about clinical aspects, Ombudsmans Rating, PEAT Environment, PEAT Food, Friends and Family test, Patient voice comments.

Then they looked at;

Harm incidents, ‘never events’, patient safety incidents, medical error, MRSA/ C-Diff infection rates, litigation, coroners concerns.

Then they looked at indicators of staff dissatisfaction and alienation;

Ratio of Nurses to beds, periods of working, vacancies unfilled, sickness rates, staff leaving rates.

As I found when I was analysing the never events, when you look at any one indicator it doesn’t obviously have much relation to any other indicator.

As I also found when I was comparing never events with mortality rates, a trust can succeed on some indicators, but failing on others can still be an indication that the trust is failing.

We need to be looking at the widest possible range of indicators, for patient outcomes, for staff alienation, for clinical excellence and pro-actively look for areas of concern.

The more indicators the better, the less likely they can be fixed. Broadly, if hospitals are failing on several indicators, its time to take a close look at everything else.

And that, I think, is what Keogh’s report is saying.

But;

My big problem is that nowhere is there any mention of democracy – of democratic control. Once upon a time, we paid the taxes, the government ran the NHS and was responsible for any failures. When things went wrong a minister had to resign. Now, Foundation Trusts are independent, the government is off the hook and we have no control. Neither do the local authorities, whose elected representatives used to have some influence. It seems that all we have left is to stand protesting at the hospital gates. Or Blogging!

You don’t have to be very political – ‘No taxation without representation’, cuts across left and right. At the very least, we need to take back control and ownership of our NHS, because we could have done a better job.

Then;

There is no mention of democracy in the workplace.

No mention of the Trades Unions and professional bodies representing staff – they should have a role.

There’s no breakdown of the workforce and the role that inequality, prejudice and bullying plays in creating alienation.

As I keep saying;

1) The majority of NHS staff are working class.

2) The majority of NHS staff are women.

3) The majority of NHS staff are from ethnic minorities.

But this report does not discuss equal opportunities and fairness at work or the climate of fear and division that there is, right now.

Then;

There are managers, often with little or no experience of running hospitals - ordering clinicians about. Once upon a time, Doctors ran hospitals, helped by administrators, who ‘administered’. I know which I’d prefer.

It’s not just Doctors – there are nurses, care assistants and all kinds of specialists. A hospital is a whole collection of competing specialisms and interests fighting for scarce resources.

And that’s not even taking account of healthcare outside of hospital, fighting over the same money.

What Keogh has done is lay down a marker – a brand new start. He’s opened a debate and we need to dictate the form that debate takes. Because if we do nothing the agenda will be set by NHS bureaucrats, hospital managers, a biased press, Big Pharma, private finance initiative rip-off merchants, and private healthcare.

Then we really will be left standing at the gates.

Neil Harris

(a don’t stop till you drop production)

Home: helpmesortoutthenhs.blogspot.com

Thursday, 25 July 2013

The Keogh Review review, part 2.

At the conclusion of Sir Bruce Keogh’s letter to the health minister are these paragraphs;

“Finally, not one of these trusts has been given a clean bill of health by my review teams. These reviews have been highly rigorous and uncovered previously undisclosed problems in care. The rapid responsive review reports and the risk summit summaries make uncomfortable reading.

However, this is not a time for hasty reactions and recriminations. Any immediate safety issues we uncovered have been dealt with. It is a time for considered debate, a concerted improvement effort and a focus on clear accountability. So, I expect the carefully considered and agreed action plans to be enacted with serious consequences for failure to do so.”

I’ll be taking him up on that and here are a few issues for debate;

It’s clear that there were arguments raging amongst the people involved in the review, as these passages on mortality rates show:

“It is important to understand that mortality in all NHS hospitals has been falling over the last decade: overall mortality has fallen by about 30% and the improvement is even greater when the increasing complexity of patients being treated is taken into account. Interestingly, the rate of improvement in the 14 hospitals under review has been similar to other NHS hospitals.”

Which shows that the 14 had had some improvements, but they had started 10 years ago lagging behind and after the decade ended, they were still lagging behind.

The usual excuses didn’t explain what was going wrong, though;

“Factors that might have been expected – and are frequently claimed - to impact on high mortality, such as access to funding and the poor health of the local population, were not found to be statistically-correlated with the results of these trusts. The average for the 14 trusts is broadly the same as the England average in terms of funding and the socio-economic make-up of the populations they serve.”

This following passage says it all really – some of the failing hospitals were more concerned about explaining away the bad figures rather than improving patient outcomes. That makes it a management failure although nowhere in the report is there any mention of managers or boards.

“Clinical coding accuracy, and depth of coding, can in some cases impact on mortality indicator values for hospitals. Coding patients to make them appear sicker or identifying a higher amount of co-morbidities can improve mortality ratios. No statistical measure is ever perfect, but some organisations were not engaging in the message the data was giving as they felt it was wrong. Investigation into the signals that the data gives needs to be both about how data quality can be improved by clinician engagement and also clinical care and service delivery investigation to identify if improvements can be made. We found some trusts focusing too much time on the former and not the latter.”

This passage in the covering letter is an attack on government leaking a few days before publication – that 13000 had died needlessly in these trusts (a Lynton Crosby briefing, allegedly), which echoed leaks earlier in the year that 30,000 had died in the NHS as a whole, due to neglect. As I said back then, this was a political attack on the public ownership basis of the NHS and on its staff, who deserve better;

“the complexity of using and interpreting aggregate measures of mortality, including HSMR and SHMI. The fact that the use of these two different measures of mortality to determine which trusts to review generated two completely different lists of outlier trusts illustrates this point. However tempting it may be, it is clinically meaningless and academically reckless to use such statistical measures to quantify actual numbers of avoidable deaths. Robert Francis himself said, ‘it is in my view misleading and a potential misuse of the figures to extrapolate from them a conclusion that any particular number, or range of numbers of deaths were caused or contributed to by inadequate care’”

This next passage confirms what I have been arguing about for so long – that the Accident and Emergency is the heart of any hospital. Shut it down and you start the process of closing the hospital. If it isn’t working right, the problem is going to spread further:

“Over 90% of deaths in hospital happen when patients are admitted in an emergency, rather than for a planned procedure. It is not altogether surprising, therefore, that all of the 14 trusts we reviewed had higher than expected mortality in non-elective (urgent and emergency) care and only one (Tameside General Hospital) had high mortality for elective (planned) care. The performance of majority of the trusts was much worse than expected for their emergency patients, with admissions at the weekend and at night particularly problematic. General medicine, critical care and geriatric medicine were treatment areas with higher than expected mortality rates.”

Here he is saying that you have to look at the whole system and especially at staffing and staff morale;

“Understanding the causes of high mortality is not usually about finding a rogue surgeon or problems in a single surgical speciality. It is more likely to be found in the combination of problems that to a differing extent are experienced by all hospitals in the NHS: busy A&E departments and wards, the treatment of the elderly in and out of hospital, and the need to recruit and retain excellent staff. Such issues are complex and require a ‘whole system’ approach to deal with them. This is why it has been so important that this review has involved all the key players.”

My conclusions tomorrow.

Neil Harris

(a don’t stop till you drop production)

helpmesortoutthenhs.blogspot.com

Wednesday, 24 July 2013

The Keogh Review review part 1.

You will all have been surprised that I waited so long before I Blogged about Sir Bruce Keogh’s (The NHS Medical Director) review of the 14 failing hospital trusts – it’s not like me. That’s because this needed some thought.

The Keogh Review, came about because of the public anger at the unneccesary deaths (600 to 1200) which occurred at Mid Staffordshire NHS Foundation Trust and in particular at the failure of the management, doctors and nurses to provide basic, compassionate care to the elderly, terminally ill and sick patients who were unlucky enough to be treated at this group of hospitals. I commented widely on the Francis report into this scandal in my other (rather silly) Blog at the time of publication:

helpmesortoutstpeters.blogspot.com

The exposure of Mid-Staffs came about through the Dr Foster Unit based at Imperial College, London and headed by Professor Brian Jarman, who had been analysing mortality rates. The unit collated and published mortality figures for all hospitals so that they could be compared with what was expected. If the rate was too high, it was a cause for concern. It’s still controversial – you can ‘fix’ the figures by changing the way deaths are coded. I wrote a lot about that too. Some hospitals feel they are unfairly hit for serving high risk communities or undertaking more complex operations or treating high risk individuals. There’s a lot to argue about.

All the same, the result was the identification of 14 Trusts that gave cause for concern – too many deaths over a long period.

As a result, Keogh, his team and Pricewaterhouse went in, consulted and then analysed whether there was a problem and, if so, how to deal with it. The press seem to have looked only at his covering letter to the Health Minister, which is by way of a summary. We need to look a bit further.

My first point is that it’s a remarkably quick report – far too quick to be final but that’s really commendable. The patients in those areas have waited too long, things needed to change and quickly. I think that’s starting to happen.

Secondly, the most remarkable thing is how useless the management of the 14 Trusts are. They knew that they were going to be investigated, it wasn’t a secret. Not least, Keogh had a travelling consultation process which went to each trust area to talk to patients. That means they had plenty of notice of an inspection.

So, take a look at this damning passage;

“3.2 Where we took immediate action to protect patients

The most important part of my remit was to take action to protect patients from harm where we found instances of poor care or risky environments or practices. We employed the ‘precautionary principle’ in undertaking this review. Where we found areas of concern, we acted immediately (we didn’t wait for a disaster so that we could be absolutely certain).

Actions taken included: immediate closure of operating theatres; rapid improvements to out of hours stroke services; instigating changes to staffing levels and deployment; and dealing with backlogs of complaints from patients.”

1) The review had to shut operating theatres?

The only reason to do that would be that they were unhygienic or there was equipment unsuitable for use.

Was no one checking? Managers, Surgeons, Nurses?

2) Out of hours stroke services.

This simply means that those hospitals were not treating strokes out of hours because they didn’t have specialist staff available. If your stroke was at the weekend you waited in a bed till Monday.

Nowadays everybody knows that if you don’t treat strokes quickly, outcomes are worse, people are more disabled than they need to be and are more at risk of dying. Minutes count. Sometimes just taking Aspirin in time makes a difference.

3) Changes to staffing levels and deployment – not enough nurses and doctors.

All of this would have been obvious to the lowliest member of staff and to most members of the public – yet it took this review to sort it out.

I was very critical back at Easter about the way Leeds General Hospital’s Children’s Heart Unit was closed down. It happened the day after the campaign to save it had won a High Court Judgement declaring that the decision making process which led to proposals to shut it down had been flawed. At the time I felt this was badly handled by Keogh – I thought it was highly ‘political’.

I now realise that he was in the midst of this whole process of 14 hospital inspections and in some cases this was leading to emergency actions. I can imagine that he was appalled by what was being discovered and trying to do something quickly to sort it out. It’s in that context that interested and biased parties were lobbying him about Leeds.

I still don’t think it was handled well but I now understand the pressures that he was under at the time. His ‘mistake’ was one which was on the right side, compared with those made in the past which avoided the problems. He’s trying to make a new start.

It also isn’t right to look at this report without taking in the other changes that have been happening recently: last week, England’s new Chief Inspector of Hospitals, Professor Sir Mike Richards ordered investigations into Barts Health Trust as well as Barking, Havering and Redbridge; Croydon; and South London Healthcare, based on their appalling record in ‘never events’, the errors that should never happen.

There is a clear change in direction at the Care Quality Commission: how it does its job of inspecting trusts and care homes, although changing that will take time. In particular, inspections need to be carried out by people with some qualification and experience to do so.

I get the feeling that the clinicians have finally got the message that something very wrong was going on and that they had better do something to change it. I hope so, anyway.

Am I getting soft in my old age? Well, I am being won over, the question is whether I’ve just been schmoozed by this report or whether it’s for real. I’m going to be a bit more critical in the second part of this review.

Neil Harris

(a don’t stop till you drop production)

helpmesortoutthenhs.blogspot.com

Thursday, 18 July 2013

Exclusive - you read it here first!

VHOLD THE

FRONT PAGE !

There’s no messing about on this site – back in May I applauded the BBC in researching and publishing the list of ‘Never Events’, that’s where hospitals mess up in ways which the NHS has indicated should never happen – they are unnecessary and preventable. I put the figures into an easy to read form and republished them. I also highlighted the ‘bottom 21’ as a real cause for concern and I picked out Barts as a trust that should be investigated. Here’s what I wrote back then;

“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.

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.”

That was two months ago. This is from today’s report from the ‘London Standard’;

“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 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.

The investigation — one of four announced into London trusts — is a setback to Barts’s hopes of becoming a self-governing foundation trust by 2016. Fifteen months ago Barts took control of Newham and Whipps Cross hospital trusts to become the biggest NHS trust in Britain, and the busiest A&E service in London with more than 6,000 attendances a week. Sir Mike said: “There is too much variation in the quality of care patients receive — poor hospitals will need to up their game and learn from the best. I will not tolerate poor or mediocre care.” Barts is preparing to axe up to 1,000 vacant posts and move overlapping services to single sites in a bid to save cash.

It has been hamstrung by private finance initiative costs of about £115 million a year for the new Royal London site; a fall in patient numbers; and an £8.5 million redundancy and redeployment bill for 112 staff axed following last year’s merger. It has also had fines for leaving orthopaedic patients to wait more than a year for treatment.

The other London trusts being investigated are Barking, Havering and Redbridge; Croydon; and South London Healthcare.”

Remember, you read it here first.

Neil Harris

(a don’t stop till you drop production)

Home: helpmesortoutthehs.blogspot.com

Wednesday, 18 March 2015

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.

Saturday, 7 September 2013

Tuesday, 3 September 2013

Friday, 26 July 2013

Thursday, 25 July 2013

Wednesday, 24 July 2013

Thursday, 18 July 2013