While I have been quite inert about the ongoings at Mid Staffordshire NHS Trust, I have to say that it didn't surprise me at all. While everyone else has been running around excited, I have known about this Trust for sometime. It was the neighbouring Trust to North Staffordshire NHS Trust afterall. Mid Staffordshire NHS Trust was offered Foundation Status and North Staffordshire NHS Trust was offered University status. They both concealed their high death rates and their substandard services in order to obtain this status.
The Guardian quotes Sir Ian
"Sir Ian Kennedy, the commission's chairman, said: "This is a story of appalling standards of care and chaotic systems for looking after patients. Those are words I have not previously used in any report. There were inadequacies at almost every stage in the care of emergency patients. There is no doubt that patients will have suffered and some of them will have died as a result."
When Sir Ian was told about the issues on Ward 87, he ignored it. Indeed, until very recently, the Health Commission had no system for whistleblowers to report patient neglect.
Dear Dr Pal,
Thank you for your Email which I read yesterday. I was sorry to read ofyour experiences.The Healthcare Commission's complaints remit derives from the NHS (Complaints) Regulations 2004. The regulations are primarily focused on patients, the family and friends and ther public. The issues you raise would appear to be in the context of your employment and so would likely be outwith the complaints remit. At the same time I note that it might be that you are seeking to bring your concerns to the attention wider HealthcareCommission. With this in mind, I have forwarded your Email to the Commission's Serious Service Failures and Investigations branch.
I hope this is helpful.
Howard Davis - Team Leader
Complaints
Healthcare Commission
> Peter House
> 5th Floor, Oxford Street
> Manchester
> M1 5AN
........................................
Thanks Sir Ian. So much for your post Bristol Inquiry systems! And if Sir Ian wants to read Steve Bolsin's report on Ward 87, here it is. The summary of the information is below this post. It should be noted that Sir Ian did nothing to investigate the wider data of the patients on that and other wards at North Staffordshire NHS Trust.
In the year 1999, I warned that the hospitals in the Midlands were ending patients lives needlessly. The Birmingham papers featured the issue. The Department of Health took no action at the time. A letter to Frank Dobson which exists from me to the Department of Health and the General Medical Council was never responded to. When the various issues were reported to the General Medical Council, the Department of Health tells us that the GMC asked whether I should be investigated for unprofessional allegations. During that time period Professor Rod Griffiths was in charge of the area. He did nothing. And that is why you see the status we have now.
Patient deaths were only noticed at Mid Staffordshire NHS Trust because the patients raised the issue. If they had not, the patients would continue to die. The other matter remains that death rate was only recorded when complaints were made. Otherwise, the matter would never have been monitored or noted. The Department of Health has already confirmed that recording death rates is not compulsory. Indeed, Ben Bradshaw tells us that death rate should not be recorded because it is " unreliable". Of course, Ben Bradshaw is full of more hot air than Richard Branson's balloon. Alan Johnson's fake apology today was laughable. Perhaps he should tell us how many patients are dying in the area - actually lets widen it - how many patients are dying in the NHS.
The media have got excited of course. I don't blame them. Shame their stories were consistently neglected for the last 8 years. Perhaps the media could have prevented some deaths. Of course, we can be sure that the death toll is about 4 times that quoted by the Health Commission.
Evidence
The Guardian quotes Sir Ian
"Sir Ian Kennedy, the commission's chairman, said: "This is a story of appalling standards of care and chaotic systems for looking after patients. Those are words I have not previously used in any report. There were inadequacies at almost every stage in the care of emergency patients. There is no doubt that patients will have suffered and some of them will have died as a result."
When Sir Ian was told about the issues on Ward 87, he ignored it. Indeed, until very recently, the Health Commission had no system for whistleblowers to report patient neglect.
Dear Dr Pal,
Thank you for your Email which I read yesterday. I was sorry to read ofyour experiences.The Healthcare Commission's complaints remit derives from the NHS (Complaints) Regulations 2004. The regulations are primarily focused on patients, the family and friends and ther public. The issues you raise would appear to be in the context of your employment and so would likely be outwith the complaints remit. At the same time I note that it might be that you are seeking to bring your concerns to the attention wider HealthcareCommission. With this in mind, I have forwarded your Email to the Commission's Serious Service Failures and Investigations branch.
I hope this is helpful.
Howard Davis - Team Leader
Complaints
Healthcare Commission
> Peter House
> 5th Floor, Oxford Street
> Manchester
> M1 5AN
........................................
Thanks Sir Ian. So much for your post Bristol Inquiry systems! And if Sir Ian wants to read Steve Bolsin's report on Ward 87, here it is. The summary of the information is below this post. It should be noted that Sir Ian did nothing to investigate the wider data of the patients on that and other wards at North Staffordshire NHS Trust.
In the year 1999, I warned that the hospitals in the Midlands were ending patients lives needlessly. The Birmingham papers featured the issue. The Department of Health took no action at the time. A letter to Frank Dobson which exists from me to the Department of Health and the General Medical Council was never responded to. When the various issues were reported to the General Medical Council, the Department of Health tells us that the GMC asked whether I should be investigated for unprofessional allegations. During that time period Professor Rod Griffiths was in charge of the area. He did nothing. And that is why you see the status we have now.
Patient deaths were only noticed at Mid Staffordshire NHS Trust because the patients raised the issue. If they had not, the patients would continue to die. The other matter remains that death rate was only recorded when complaints were made. Otherwise, the matter would never have been monitored or noted. The Department of Health has already confirmed that recording death rates is not compulsory. Indeed, Ben Bradshaw tells us that death rate should not be recorded because it is " unreliable". Of course, Ben Bradshaw is full of more hot air than Richard Branson's balloon. Alan Johnson's fake apology today was laughable. Perhaps he should tell us how many patients are dying in the area - actually lets widen it - how many patients are dying in the NHS.
The media have got excited of course. I don't blame them. Shame their stories were consistently neglected for the last 8 years. Perhaps the media could have prevented some deaths. Of course, we can be sure that the death toll is about 4 times that quoted by the Health Commission.
Medical Division Memorandum
Ward 87
From Ms Teresa Fenech
Directorate Manager for Infectious Diseases City General Hospital Stoke on Trent.
Reference TF/CLS/005
18th May 1999
Point 3
" I informed you that I had undertaken an audit of every single patient on the ward the previous week. I identified a serious lack of baseline and routine observations. In the case of some patients there was also clearly a breach of policy and there was an apparent lack of misunderstanding from the staff of the importance of such issues. I informed you that in my opinion the level of care demonstrated for some patients on the ward at the time of my audit was nothing short of negligent"
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In May 1999, the Medical Division received an Adverse Incident Form from Ward 87 which identified a malfunction of a defibrillator used during resuscitation. A two stage investigation was began.
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A letter from Dr Colin Campbell to Dr John Green, Clinical Director at City General Hospital Stoke on Trent, read as follows: (CAC/ AR/LET 2nd December 1998) Point 2 (first page)
"To summarise other discussions that we have had on the medical PRHOs, I think that the following should be addressed within the directorate as a matter of urgency - (2) They should have proper clinical supervision at all times and help from a more experienced colleague... should always be available (The New Doctor GMC), On discussion with several of them they are still working without immediate supervision for significant periods.”
"To summarise other discussions that we have had on the medical PRHOs, I think that the following should be addressed within the directorate as a matter of urgency - (2) They should have proper clinical supervision at all times and help from a more experienced colleague... should always be available (The New Doctor GMC), On discussion with several of them they are still working without immediate supervision for significant periods.”
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2. A March 2002 report by the Commission of Health Improvement of a Clinical Governance Review at North Staffordshire NHS Trust found serious shortcomings in the supervision of junior doctors,
"CHI was informed that junior doctors working in medicine were often inadequately supervised and often left alone on wards, particularly on the medical assessment unit (MAU). During an evening visit we found only two junior doctors covering MAU, which was full to capacity, with a further junior doctor covering MAU and emergency admissions; one junior doctor covered the medical wards and one covered medical outliers but these patients could be on wards on either site. CHI felt this situation posed a potential clinical risk to patients.”
"CHI was informed that junior doctors working in medicine were often inadequately supervised and often left alone on wards, particularly on the medical assessment unit (MAU). During an evening visit we found only two junior doctors covering MAU, which was full to capacity, with a further junior doctor covering MAU and emergency admissions; one junior doctor covered the medical wards and one covered medical outliers but these patients could be on wards on either site. CHI felt this situation posed a potential clinical risk to patients.”
3. The 2002 report went on to say, in Paragraph 5.78:
"There were a number of concerns raised regarding support and supervision for junior doctors working in medicine. We were told of a number of occasions when it was felt there was a lack of support both during the day and when problems arise whilst oncall. The Trust has acknowledged that medical staffing at all levels is under resourced in medicine".
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