Inquiry into Mid Staffordshire NHS foundation Trust
Mid Staffordshire NHS Foundation Trust provides medical services to a population of around 320,000 people from Stafford, Cannock, Rugeley and rural areas surrounding them. The services are provided through their two hospitals, Stafford Hospital and Cannock Chase Hospital. The two hospitals are well-established .Stafford Hospital was established in 1983 and has nearly 354 inpatient beds in 2008.Cannock hospital was opened in 1991 and has nearly 115 inpatient beds in 2008(Healthcare Commission 2009). Stafford Hospital is an acute hospital providing a wide range of non-specialist medical and surgical services. It has a round the clock accident and emergency department. Cannock hospital has orthopaedic service, elderly care service and rehabilitation (Healthcare Commission 2009).
The Trust was granted Foundation Trust status on 1st February 2008.By this status, it becomes and independent public benefit corporation and is free from Central Government control and outside the performance control by Strategic Health Authorities(SHA).It can manage its own finances, retaining any surpluses and borrowing for any investment(Healthcare Commission 2009).
During periodic inspections by the regulatory authorities, the functioning of the Trust was found to be normal except for shortage of nurses and the lack of facilities for preservation of privacy and dignity of its patients. The trust was rated good as per the existing standards, but was rated ‘weak’ in terms of new national targets (Smith 2009a, 2009b).
Problem in the Foundation Trust
It was found that there was high mortality rate among patients admitted to emergencies at NHS Foundation since April 2005. During the summer of 2007, it was found by the Healthcare Commission through its programme of mortality analysis in England that there is an apparently high mortality rate for specific conditions or operations at the trust. Whenever there are such high rates of mortality, in quite a number of cases they can be due to errors in data or insufficient adjustments in certain factors (Francis 2010a). However a team of analysts assesses each case to decide whether there are any problems to be followed up and set right at the trust. In this process, they request the Trust to provide certain information. Such information usually provides answers to the team of analysts. The analysts’ team then closes the matter. If, however, the team feels that proper care has not been taken for the safety of the patients or the problems have not been properly recognized by the Trust, the team pursues the case further (Healthcare Commission 2009).
In the present case, it is found that the mortality rate in case of emergencies at the Trust was high for several years. The Trust did not seem to have noticed this aberration and investigated into it (Francis 2010a). In April 2007,it was detected by Dr Forster’s Guide that the Trust has a Hospital Standardised Mortality Ratio (HSMR) of 127 for 2005 and 2006 which is high(Healthcare Commission 2009). The Trust constituted a committee to enquire into this, but the committee put much of its effort into establishing that the high rate was a result of poor recording of clinical information but not due to any medical negligence or lack of medical care. There were further inquiries sent to the Trust to elicit some more information as the information already submitted by them was not sufficient to substantiate their contention that the alerts were due to faulty recording of clinical data and not because of any problem with care to the patients. The insufficient response from the Trust and the responses from local people about the quality of care prompted a detailed enquiry (Francis 2010b).
Response to the Investigation and Preliminary Finding
The enquiry committee received a very good response when the investigation was announced. Nearly 103 patients contacted them and almost all of them were totally dissatisfied with the medical service of the Trust. Some of them reported their bad experience at the Trust. The main areas of complaint are A&E, medical wards 10, 11 and 12, emergency Assessment Unit, some surgical wards and nursing care. The enquiry commission could observe through reviews of case notes and interviews with patients that there were problems in areas of timely assessment and pain relief, recording of important physical activities of organisation, the response to patient requests for help and communication with patients and families. The Trust was rated very poorly by the patients whose ranking put the Trust in last 20% of overall Standards of care. The patients also expressed that they were not treated with dignity and respect in the hospital. The analysis of mortality rates in England also singled out the Trust for high mortality rate alerts at 11. The alerts are spread over a wide range which indicated the existence of a general problem regarding mortality in emergency admissions only (Healthcare Commission 2009).
The enquiry committee now began to dig deep into the computation of mortality rate. The focus was centred on patients aged 18 and over who were admitted to emergency. The standardization of results taking into account a number of factors like age, sex and their condition at the time of admission to the hospital was done. The Standardised Mortality Rates (SMRs) were consistently higher for the Trust 2003. For the three years from 2005 to 2008,the SMRs for patients admitted from 2005 to 2008,the SMRs for patients admitted as emergencies aged over 18 years varied from 127 to 145.With the normal rates being 100,these were considered very high(Francis 2010a, Healthcare Commission 2009).
It was found that the mortality rates were not confined to any particular ailment but spread over a variety of conditions relating to heart, nervous system ,lungs, blood vessels and infectious diseases. There were indications of systemic defects in the functioning of the Trust and the situation demanded a detailed enquiry (Donnelly 2009).
Detailed Enquiry and Findings
The first thing that struck the minds of the enquiry committee was the poor information system at the Trust. The accuracy of coding was poor. There is no proper maintenance of log activity in theatres. Because of this, it was not possible to corroborate the information in the theatre logbook to the information available in National Hospital Episode Statistics Data. It was also not possible to track individual patients and link their details to different systems (Francis 2010b, Cook 2009).
The poor information system at the Trust is reflected in their delayed response to the continuously high mortality rate in the year 2003 to 2006 as indicated by Dr Foster’s analysis (Francis 2010b). It was only after publication of the mortality rate report by Dr Foster in 2007, that the Trust swung into action and constituted a committee to look into the mortality. The committee instead of finding out the actual reasons washed off its hands by just saying that poor coding was responsible for high figures of mortality rate. When the committee questioned the Trust and Individual consultants, they were not able to produce accurate record of their clinical activity. There was thus no scope for the committee to go through the volume of surgical work and its results (‘NHS trust pays compensation to victims of ‘appalling’ patient care’ 2010).
Management of Patients in Emergency Care
A number of sources like review of case notes, complaints, Trust documents, external reports, interviews with patients and families and interviews with staff were used to judge the functioning of the A&E Department and the Emergency Assessment Unit (EAU)( Healthcare Commission 2009).
The A&E department was having a dearth of both staff and equipment. The number of nurses was also low which makes immediate assessment of patients difficult. Due to this shortage of nurses, their work is done by receptionists, who had no training in clinical assessment. The nurses also had inadequate training and were under a weak leadership. During 2007-2008, the nurses have no in-service training. The nurses were ill-equipped with the inadequate skills to administer proper care for different patients admitted as medical and surgical emergencies. Some nurses even do not know how to read cardiac monitors provided on the bays and so they were turned off (Francis 2010b).
The infrastructural facilities at A&E department were poor and inadequate. The department did not have sufficient essential equipment like defibrillators for resuscitation trolleys. The patients in the waiting room could not be viewed from the reception area. The EAU had a poor layout, though large and was often busy and chaotic. It was not congenial for proper communication between the nurses and patients(Francis 2010b).
The treatment meted out to patients was defective (Triggle 2010). There were no protocols and pathways for management of emergency cases. Patients had often to wait for medication, wound dressing and pain relief treatment. Scanning of patients took quite a lot of time. The doctor in the surgical ward after 9PM was a junior with no experience instead of a senior surgeon (Healthcare Commission 2009).
The number of consultants to attend on call duty was very less. The number of middle grade doctors was also very low. The junior doctors were not properly supervised. Many times, they were forced to take decisions fast just to meet the targets that all patients in A&E area should be checked in four hours. With such hasty decisions, the patients were rushed from A&E to the EAU without proper diagnosis. Provision of staff at various points was either not there or inadequate (Francis 2010a).
An observation of patients was not carried out according to procedure. No records were kept for intake of food and fluids. The patients were not given proper medication on time. Prescribed procedures for control of infections were not followed (‘Stafford Hospital public inquiry opens’ 2010).
Patients admitted as Medical Emergencies
Like in enquiry in case of surgical emergencies, interviews with staff, patients and relatives; complaints, observations, trust’s documents, external supports and national surveys were used for enquiry in the case of medical emergencies. In general, good care was administered to patients with heart attacks. However there were problems with functioning of cardiac monitors. The number of beds on the coronary unit is insufficient to meet the demand as a result of which patients were treated in the EAU and were administered nursing care in a non-specialist area (Francis 2010a).
Care for patients in medical wards was reported to be unsatisfactory. The interviews with patients and their families reported that whenever the call bell was rung up to call a nurse either when they were in pain or had to go to toilet, the response was either delayed or not there at all. Bathrooms and wards were not regularly cleaned. Patients were left unattended in wet and soiled clothes for long times exposing them to the risk of infection and sores. Medicines were either not given on time or were totally missed. Nursing observation over the patients even when their condition was deteriorating was not there to the required extent. The infrastructural facilities at the cardiac unit were not only deficient but also insufficient. The respiratory ward was not provided with a facility for non-invasive ventilation. Arrangements for resuscitation were highly unsatisfactory with even resuscitation trolleys not functioning properly. The bleep system in cardiac units was functioning only occasionally and its service is substituted by calls over mobile phones (Healthcare Commission 2009).
The conditions in case of medical emergencies were thus far from satisfactory in the Trust (Bramwell 2009).
Functioning of Surgical Emergencies
There is no coordination among general surgeons. This resulted in absence of agreed protocols in surgery. Such a practice is fraught with problem that the patients requiring treatment and operation out of normal hours might receive a treatment that is given to similar patients during regular hours 9am to 5pm Monday to Friday. The number of doctors in surgical wards during off-duty was in adequate. The doctor incharge of surgical ward after 9 pm was inexperienced (Healthcare Commission 2009).
The trust did not have a trauma team and to attend patients coming to the trust with traumatic injuries, an ambulance was provided to take such patients with traumatic injuries to other hospitals with trauma care facilities. However one problem at the Trust was that the nurses at the EAU, because of their inadequate training could not properly diagnose traumatic injury cases and admitted them as medical emergency cases (Healthcare Commission 2009).
For patients needing emergency surgery, there is theatre allocation once at the weekend. There is no provision for taking up emergency cases in between on weekdays. This practice leads to a peculiar situation. Normally priority is accorded for operation to Caesarian cases or surgical operations like one for removing appendix. If in the meanwhile a patient comes with a hip injury to the hospital requiring emergency operation, he will have to wait from Friday to Monday for his turn. In the meanwhile they are not allowed to take food or drink and are sometimes not given any essential medication (Healthcare Commission 2009).
The review of case notes at the Trust revealed another serious occurrence at the Trust. The in quests and alerts received by the Healthcare Commission regarding mortality at the trust indicated that there were a number of cases where the patients developed clots in the veins in their legs or pelvis. Such clots used to burst and block blood flow to their lungs resulting in death. The Trust did not have effective mechanism to prevent such type of occurrences. The post operative care of operated patients was also poor as a result of which the symptoms of deteriorating condition of the patient were missed. When such things happened, the trust did not have the inclination to learn any lesson from such happenings (Francis 2010a).
The Administration at the Trust
Having thoroughly gone through the medical and surgical processes at the hospital and spotted the serious lacunae, the enquiry committee now focussed its attention on the administrative aspects at the Trust to find out as to how the administration must be functioning to allow functioning of the Trust to deteriorate to this extent (Francis 2010b).
The first point and one of the main aims of the enquiry was the attitude and response of the Trust to high mortality rate in emergencies. In their response to the committee’s enquiry, the Trust assured them that its Mortality Outcomes group reviewed certain samples of case notes of deceased patients to verify whether they were unavoidable deaths or due to inadequate care afforded to the patients. The committee examined the information given and found that both reviews and case notes were both substandard (Francis 2010a).
It was found by the committee that the governance of the trust was weak. The Chief Executive took over an ineffective governance. The Trust’s mechanism for identifying problematic areas was poor .There were many occasions when staff highlighted shortage of staff, inadequate care for patients and poor system of movement of patients from one ward to another. But the Trust Management did not pay attention to solve those issues and allowed them to persist and deteriorate further to bring the quality of patient care further down (Donnelly 2009).
Problems like ‘nil by mouth’, bleep system malfunctioning at cardiac unit, occurrence of clots and bursting of veins were all listed in corresponding risk registers. But the medical and cardiac were insensitive to these observations (Donnelly 2009).
There were many complaints from patients and their relatives about quality of nursing care. All the earlier discussed issued problems like patients not being given food, calls not being responded to, medicines not being administered to or belatedly administered to, poor hygiene and disregard for privacy and dignity of patients. But it seemed that the board was not aware of these problems, the culprit being the practice of these items being grouped under innocuous category ‘quality of care ‘ or ‘communication’. There was an impression among the senior staff that even though the Trust has direction, it did not have sufficient financial resources to make necessary changes for betterment of the situation (Healthcare Commission 2009).
The attitude of the Trust towards Clinical Audit was indifferent. Very frequently the changes suggested by Audit teams were not implemented. When reaudits were suggested, they were not arranged for. The Trust never participated in any of the specialist audits conducted by specialist societies. The communication system which intended to bring ground level realities to the attention of the Board did not function effectively and the Board seemed to be totally oblivious of the undesirable happenings in treatment of patients (Francis 2010b).
The reporting system at the Trust hospital was defective. Till the information was published by Dr Foster’s publication, the hospital standardised mortality rate at high levels did not attract the attention of the Board. Various reports that were sent to the Board were so prepared that they never reported the discrepancies. It was found by the committee that the governance of the Trust was weak. The Chief Executive took over ineffective governance. The Trust’s mechanism for identifying problematic areas was poor. There were many occasions when staff tried to bring the deficiencies to the notice of the Board, but the efforts failed (Francis 2010b).
The Enquiry committee has also got some surprising findings. It found that the NHS trust, in an effort to achieve financial stability in 2006-07 reduced the number of impatient beds and cut down the strength of nursing staff and was forced to compromise with quality of nursing care at the hospital. The Committee was of the opinion that the Trust Board was more interested in safe guarding its foundation status rather than caring for medical care for the patients. It commented that the Trust was more interested in Public Relations and marketing relegating Medicare to the background. The Committee was caustic in its comment that the board failed to provide necessary Clinical Leadership (Healthcare Commission 2009).
View from Managerial Concept
The happenings at the NHS Foundation Trust and the revelations during the enquiry brought out certain deficiencies when viewed from Managerial aspects as detailed below.
1. Deficiencies in Induction of New Staff
It was commented by the enquiry committee at some places that the nurses did not know their work properly (Francis 2010b). An example was the inability of the nurses to read readings in monitors attached to trolleys. Such things can happen only if there was no proper induction for the new staff in the organisation.
2. Lack of motivation and dedication
In such a sensitive organisation like a community hospital, motivation and dedication to duty are very important since deficient service there may even result in loss of life. Among the mortalities in emergencies in case of which the Trust did not make proper studies, nobody knows how many deaths would have been avoided (Francis 2010a).
3. Absence of Teamwork
There is absolutely no coordination between various departments nor there was any team spirit. Team Spirit and coordination between wards in a hospital is like a proper supply chain to business. This is evident from the findings of the committee that the doctors and nurses in surgical wards do not have good opinion of working skills of nurses working in Strategic Health Authority (SHA) (Healthcare Commission 2009). Nothing was done to rectify such lacunae and the patients suffered.
4. Failure of Communication channels
There is utter failure of communication mechanisms in any direction in the Trust. There was no communication from the lower staff to the Board. There was no communication from the Board to either the middle level authorities or lower level functionaries. There was no proper communication between nurses and patients. The communication channel of the patients to ventilate their grievances and complaints to the Board was non-functional since the Board never paid heed to such complaints. When ordinary Business organisations were very particular about open communication in their organisations, the scant regard paid to such communication in a public utility hospital is likely to drive that organisation to disaster and that is exactly what happened in case of NHS Trust (Healthcare Commission 2009).
Lack of Leadership
There was a total failure of leadership in NHS Trust (Cook 2009). The leadership seems to have failed on all fronts. There was no inspiration, no direction, no rectification, no reward or no punishment from the higher authorities to the lower workers or functionaries. The junior doctors and nurses were working on their own and the result was chaos and disorder. It is surprising that till the enquiry the Board is not aware of deficiencies in the functioning of Hospital even though they were in the knowledge of all other stake holders.
The enquiry committee submitted its findings in detail to the Trust Board. The response of the Board was said to be positive. The nursing strength was immediately increased. The number of consultants was also increased. Efforts were said to have been made to rectify the deficiencies in other fields.
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