Fatal flaws

The tragic death of 10-year-old Robert Powell could have been prevented. Nick Davies unravels a shocking story of medical negligence, cynicism and bureaucratic failure

Fifteen years ago, Will Powell saw his 10-year-old son die. Within days, he began to suspect that doctors who had looked after the boy had been negligent. He filed a complaint. Within months, he began to suspect that somebody was tampering with his son’s medical records. He filed more complaints, and spent 15 years fighting for the truth. Now, finally, he has it – and he was right.

Read more: http://www.theguardian.com/society/2006/jan/04/health.healthandwellbeing

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The Care Quality Commission inspects hospital, several areas require improvement.

The Care Quality Commission inspected Kettering Hospital and found several areas requiring improvement. http://www.northantstelegraph.co.uk/news/top-stories/kettering-hospital-pledges-to-improve-standards-1-5420712 Published on 27th August 2013

Areas highlighted in the report include:

1. Risk assessments were not always completed and care was not planned or delivered for some people in such a way as to meet their individual needs or ensure their welfare and safety.

My response: Q: Why not? Lack of skill or time to complete them? Shouldn’t this be done on admission and reviewed appropriately?

2. Staff knowledge of reducing the risk of pressure ulcers for bed-ridden patients was “varied”

My response: Q: Why? Lack of training? Lack of time to attend training? Pressure sores can be a killer!

3.No effective screening of some areas where children were being treated.

My response: Q: Why not? Lack of time or knowledge?

4. Marked reduction in the availability of medical staff in the A&E department at the weekends

My response: Q: Why? Shortage of medical staff? Have they got a Bank of medical staff to call on?

5. A reluctance by staff to investigate whether children were being abused at home was also highlighted in the report.

My response: Q: Why? Lack of skill and/or confidence to do this? Fear of getting it wrong?

Why couldn’t professional staff who have a duty of care carry out what they are paid to do?’ [A duty of care is the legal obligation to safeguard others from harm while they are in the hospitals care.]

I come across a lot of these reports which highlight poor practices and weak areas. So many that I ask myself these questions over and over again: Why?

As you will have read I have included my own [quick] views. I could spend a lot of time writing more but I believe that those at the hospital are the ones who know the reasons why. Staff go into this profession because they generally care. I wonder how they are feeling when they cannot do their jobs properly due to-lack of time, training, support etc.

I would like to say that there are a tremendous amount of brilliant staff working in the Health and Social Care Sectors who do a fantastic job. Unfortunately there are some, for various reasons, who do not or who are unable to do a fantastic job.

You may be a relative or a friend of the vulnerable person receiving care or in need of care. If you are concerned about them, or their care or treatment, please speak up. Even if everything turns out to be fine, at least you will have raised the issue and made it known that someone is watching out for that person. You may without knowing it have stopped something bad happening. Be observant and learn to recognise the warning signs of neglect and abuse and the risk factors (see www.spcconsultancy.com/abuse.html).

If you have any concerns about care in a care or nursing home, care received at home or in hospital you can do the following:

Contact any of these and discuss your concerns-

Hospital:

-Speak to the ward sister or senior nurse

-You can also talk to the Patient Advice and Liaison Service (PALS) – every hospital has a PALS office that you can walk into and share concerns

-Ask for a meeting with the manager of the care/nursing home, or the manager of the care agency or the person in charge of the ward

-Ask what they will put in place so it doesn’t happen again

-Ask the individual who has been affected what s/he wants to happen. (it may be best to ask them away from the manager/staff so they can give an objective view and not feel that they have to say what they feel the manager/staff would want them to say.)

-Ask for a copy of the complaints procedure or you may be able to access it from the internet.

You can also leave your hospital experience on this website:

http://www.nhs.uk/servicedirectories/Pages/HospitalCommentInput.aspx?searchtype=hospitalcommentsearch

Care or nursing home, care received at home

-Ask for a meeting with the manager of the care/nursing home, or the manager of the care agency

-Ask what they will put in place so it doesn’t happen again

-Ask the individual who has been affected what s/he wants to happen. (it may be best to ask them away from the manager/staff so they can give an objective view and not feel that they have to say what they feel the manager/staff would want them to say.)

-Ask for a copy of the complaints procedure or you may be able to access it from the internet.

You can also leave your experience of care by going on this website and clicking ‘care’ on the right hand side:

http://www.nhs.uk/servicedirectories/Pages/HospitalCommentInput.aspx?searchtype=hospitalcommentsearch

For concerns on care homes/care agencies and hospitals you can also contact these:

The Care Quality Commission. Tel: 03000 616161http://www.cqc.org.uk/contact-us

Your local Age UK shop/office         http://www.ageuk.org.uk/

Your local Healthwatch office          http://www.healthwatch.co.uk/

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Rating your hospital stay/experience [Friends and Family Test].

This Friends and Family Test asks if you would recommend the hospital ward or accident & emergency unit to a friend or family member. It is hoped that everyone who uses the service will respond to this questionnaire and it seems logical to use technology to record the patient’s experience.

The disadvantage of this is that if you do not have access to a computer, or the internet, or know how to use it then this could prove difficult. Libraries have computers and staff who will help you use them. I did see on TV last week a volunteer going round to people in the hospital beds, with an IPad, asking them the questions. I think this was done for the cameras as you should be asked at the end of your stay or 48 hours afterwards, not during your stay. Although that would be a good idea; if you were not happy with the care you could let people know.

The questions are fixed. The advantage of this is that everyone is asked the same questions. The disadvantage is that the questions may not be suitable for all patients.

A few weeks ago I was in the reception of an NHS hospital waiting for a meeting to discuss some consultancy work. I arrived early and enjoyed the peace and quiet of sitting and observing the comings and goings.

The area was very clean, open, and spacious and had hand gel machines strategically placed on its walls. It was encouraging to see just how many people used it, either on their way in or out of the hospital, and without any prompting to do so.

There was a mixture of race and culture staff at reception and all were very polite and respectful to all who appeared at their counter. An elderly gentleman was directed towards the row of seats where I was sat. He was hunched over, had a shuffling gait and one of his feet dragged along the floor. I periodically looked his way, ready to ask if he needed any help, but didn’t want to ask in advance…

He sat down to my right. I looked his way and smiled; he didn’t give me eye contact. I debated whether to start up a conversation and whilst deciding whether to or not a porter came over to him, wheelchair facing the elderly gentlemen. The elderly gentleman was looking at the floor and after a very short while noticed the footrests of a wheelchair. He slowly looked up, up at the porter.

The porter did not speak, just stood there. I was thinking, ‘Respect. Give the gentleman some respect and say his name. Talk to him.’ But he didn’t. I looked at him and still no communication, either verbal or in body language was coming from the porter to the gentleman or myself.

The elderly gentleman struggled to get up off his seat and I helped him up. I looked to the porter expecting him to help or at least to raise the footrests of the wheelchair so the gentleman could walk into the space so he could turn around and sit down without catching himself on them. The porter didn’t move. I raised one footrest and assumed that the porter would raise the other one. He didn’t. Instead he was physically trying to guide the man into the space so he could be seated, but couldn’t as the other footrest was digging into his leg. I moved the footrest and the elderly gentleman quietly thanked me. I looked up at the porters face, still expressionless. I took a note of his name and wrote it on my notepad, along with date, time and name of hospital.  I called into the Patient Advice and Liaison Services (PALS) office, which was on the ground floor, and reported it.

I hope the rest of the gentlemen’s hospital experience was good.

The questions of the survey are listed below. If you were this gentleman how would you rate it?

Recommend to friends and family?

How likely are you to recommend this hospital to friends and family if they needed similar care or treatment?

1

2

3

4

5

Don’t know

Your ratings (optional)

Cleanliness How satisfied are you with the cleanliness of the area you were treated in?

1

2

3

4

5

Staff co-operation How satisfied are you that the hospital staff worked well together?

1

2

3

4

5

Dignity and respect How satisfied are you that you were treated with dignity and respect by the staff?

1

2

3

4

5

Involvement in decisions How satisfied are you that you were involved in decisions about your care?

1

2

3

4

5

Same-sex accommodation How satisfied are you that the hospital provides same-sex accommodation?

1

2

3

4

5

Your review (optional)

I would hope something like this … Porter was disrespectful and did not acknowledge me etc etc but the staff on the ward were very good, they treated me with dignity and respect etc etc.

Note to readers:

For the majority of time staff do a great job but sometimes, through various reasons they don’t always get it right. The Porter did not get it right but lets hope the rest of the staff did. One person getting it wrong does not mean all the staff will do the same. Lets tell them when they do things well [and when they don’t].

Click here to see the survey on-line

http://www.nhs.uk/NHSEngland/AboutNHSservices/Pages/nhs-friends-and-family-test.aspx

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