Neglected: lessons of fatal error in NHS care

Public inquiry chairman says Mid-Staffordshire did nothing – even after a mistake killed a patient

In his final summing up to the public inquiry into the Mid-Staffordshire Foundation Trust, the biggest scandal in NHS history whose report is due to be published next week, the chairman, Robert Francis, quoted the case of a diabetic patient who died because nurses forgot to give her insulin.

A police investigation was launched into the act of gross negligence in 2007 but no prosecution was ever brought. A manslaughter investigation by the Health and Safety Executive is pending and two nurses involved in her care are awaiting disciplinary hearings before the Nursing and Midwifery Council.

Ron Street, 79, the “close friend, soulmate and carer” of Gillian Astbury, who was 66 when she died, spoke for the families of hundreds of other patients today when he said he wanted people held accountable for her death.

Up to 1,200 “excess deaths” occurred at the trust from 2005-8 as a result of horrific standards of care which left de-hydrated patients drinking from flower vases and others screaming in pain. In a letter to the inquiry,  Mr Street wrote: “I am not here for myself. I am here for Gillian and the rest of the dead. When they took Gill away from me they took away my contentment. I don’t want anyone else to suffer that. Bereavement comes to us all but it is how it comes to you that is important.”

Mr Francis, QC, told a seminar on organisational culture at the inquiry, that despite its gravity, the gross error that led to  Ms Astbury’s death had failed to trigger remedial action.

“A report on the incident by the in-house solicitor said there had been several systemic failures and it was clear similar issues in other cases were occurring regularly. That never registered with the trust board or with the strategic health authority. One then asks this: what about accountability?” he said.

Mr Street has waited six years for the report, the most extensive inquiry ever held into the NHS and one of the most eagerly awaited which is examining how regulators allowed the scandal to happen. That it will make uncomfortable reading for all involved, from the most junior healthcare assistants to senior ministers and officials in the Department of Health, is a given.

Ms Astbury was admitted to Stafford Hospital with a fractured hip following a fall at home on  1 April 2007. After repeated instances in which Mr Street had found her lying in soiled bed linen, with meals left out of reach and bloody tissues discarded on the bedside table, she died  10 days later in a hypoglycemic coma after she  had been transferred to a new nursing team who had not read her notes and learnt she needed regular injections of insulin for her diabetes.

Mr Street, a former care-home manager, said : “All I was interested in was looking after Gill. Had it not been for Stafford Hospital I would have made that my life task.”

Nursing in the NHS had gone from “Nightingale to nightmare”, he said, and “rampant complacency” among the regulators had resulted in trusts neglecting their duty to patients while focusing on hitting targets.

“There is a culture problem. It is about people’s attitudes. There is a lack of responsibility and a lack of compassion.

“I am not a vindictive person but I would like the people at Stafford held to account. I don’t necessarily want them clapped behind bars but I do want a message sent out across the NHS that you cannot do this with impunity,” he said.

To take the sting out of the report, Jeremy Hunt, the Health Secretary, has spent months preparing the ground for its publication, with a series of speeches blaming staff in failing trusts for causing a “crisis in standards of care” and allowing the “normalisation of cruelty”  to develop.

He has announced changes to the regulatory framework, a new focus on compassion, better training for staff, and the recruitment of patients to monitor standards of care by use of a “friends and family” test.

Experts have warned the scandal was a failure of professionalism rather than a failure of regulation and that its remedy lies with a new focus on professional responsibilities, a duty of candour and a culture of openness.

But Mr Francis told the organisational seminar that the word “culture” had been used 836 times during the hearings.

“It seems to me it is used as an explanation of what went wrong when no one can think of anything else. I have not counted the number of times the words “patient” or “family” turned up in evidence but they have been used surprisingly little given what brought these events about.”

Referring to suggestions of a “Kiss up, Kick down” attitude among staff in the NHS, with reports of bullying, target-driven priorities and low morale, he asked: “Is there a top-down managerial culture of fear?”

He quoted Professor Ian Kennedy, former chair of the Healthcare Commission which first revealed the scandal, who said politicians were most interested in “how any story about Mid-Staffs would be received” rather than “embracing changes that needed to be made”.

The board of the trust had felt unable to discipline the chief executive, Martin Yeates.

However,  he had subsequently suffered a “disastrous decline” in his health. “That is a form of accountability though a rather sad one,” Mr Francis said.

Mr Yeates never gave evidence to the Francis inquiry, claiming he was too ill to do so. He has subsequently taken up a post as chief executive of a charity working in the field of drug addiction.

Caring in the NHS the ‘callous’ face

Dec 2012

Alexandra Hospital, Worcestershire, where an 84-year-old man died of starvation and 34 others won compensation for neglect. Patients were left thirsty with drinks out of reach and lying in their own excrement. A woman aged 86, a former nurse, was left unwashed for 11 weeks, an investigation by the Care Quality Commission found.

July 2012

Inquest found Kane Gorney, 22, a cancer patient at St George’s hospital Tooting, south London, was so desperate for a drink after losing a third of his bodily fluid that he dialled 999 for help from his hospital bed, after staff failed to listen or check his medical records. He died in 2009.

June 2012

Ronald Bowman, a 74-year-old with dementia who got out of a locked ward at Pontypool Hospital, Wales, three times before drowning in a river. Nurses were supposed to check on him every 15 minutes while he was in hospital recovering from an illness but failed to do so. Police found his shoes by the bank of the Cwmbran River and three weeks later his body was discovered four miles downstream.

Sept 2011

James Paget Hospital, Gorleston, Norfolk, was threatened with prosecution over lack of nutrition and hydration of elderly patients, following an inspection by the Care Quality Commission, the NHS watchdog. Inspectors found food was not suitable for patients and they were not supported to eat and drink, despite an earlier warning.

Sept 2011

East Surrey hospital, where secret filming for the Dispatches programme on Channel 4 exposed the bullying of an 80-year-old man, Ken Rasheed with Parkinsons disease. Nursing staff seemed unaware he was close to death and were filmed telling him off for not swallowing his pills even though he could only do so with yoghurt, not water. One nurse said: “This is a busy ward – other people need care as well. He died on the ward in 2010 after contracting septicaemia and E coli.

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