How do we know we can trust the latest polls? | Brief letters

Drs Mellon and Prosser explain (Letters, 6 May) why the opinion polls were wrong at the last general election – a failure to obtain representative samples. Specifically, pollsters did not contact enough people from hard-to-reach groups that do not vote in elections. What I want to know is, has this mistake been eliminated in the current polls, which are being respectfully reported, on voting intentions? Are the pollsters now doing the job properly? Can we trust these polls?
Oliver Williams
London

•I agree with Chris Birch (Letters, 9 May). Subtitles flash on and off, cover translations, appear at different places on the screen and sometimes continue over the following programme. Theresa May gabbles, Jeremy Corbyn has a beard, both impossible for lip-readers. It’s no wonder we retire to bed, exhausted.
Jean Jackson
Seer Green, Buckinghamshire

• I don’t find it at all strange that a teenager would have Margaret Thatcher’s picture on his bedroom wall (G2, 9 May). Our son had her picture on his dartboard.
Barbara Freeman
Leicester

• Richard Carden (Letters, 8 May) perhaps misses the point when he attributes English councils’ democratic deficit to first past the post. Since 2001, every council without an elected mayor has by law had a quasi-mayor (the leader) making almost all the decisions. In effect that’s one-person rule (give or take a small sofa cabinet chosen by the leader) irrespective of the council’s political balance.
Nick Beale
Exeter

• The correspondence regarding grandparents (Letters, passim) reminds me of a very old joke: My grandparents were called Pearl and Dean but we knew them as Grandma and Grandpapapapapapapapapapapa.
Steve Vanstone
Wolverhampton

• A friend of mine used to refer to his daughters’ long-term unmarried partners as his “sons-in-love” (Letters, passim).
Dr Brigid Purcell
Norwich

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How do we know we can trust the latest polls? | Brief letters

The surgeon who cruelly betrayed his patients’ trust | Barbara Ellen

Breast surgeon Ian Paterson has been convicted of 17 counts of “wounding with intent” and three counts of “unlawful wounding” and is now bailed, awaiting sentencing.

Many women have come forward to claim compensation, which sounds richly deserved. For years, Paterson performed hundreds of unnecessary or inadequate surgeries, for mainly female patients at the Heart of England NHS Foundation in Birmingham and private clinics run by Spire Healthcare.

As the case unfolded, there was a recurring theme of Paterson’s charming bedside manner, but also of his arrogance-cum-“God complex”, which was allowed to go unchecked, despite many concerns and complaints. Sometimes, Paterson would perform unnecessary disfiguring operations. At other times, his signature “cleavage-sparing mastectomy” procedure left patients in greater danger of developing secondary cancers.

Reading this, one feels sickened for the patients. There’s a nightmarish feel, almost reminiscent of the 1988 David Cronenberg film Dead Ringers, in which an insane surgeon performed gruesome gynaecological operations. Paterson’s patients were at their most vulnerable and in such a specifically female way. For women, breasts are not just another body part but can be bound up in maternal and sexual identity. Paterson’s patients trusted him, not only with their bodies and lives, but also with their identity and he violated them in the cruellest possible way.

Paterson has also undermined general trust in surgeons, not least with this recurring theme of arrogance and “God complex”. These are all too familiar complaints when it comes to surgeons. However, is it always a case of the surgeon being arrogant or could it sometimes be about the solid confidence that you need to do the job? My partner is a surgeon and, from what I’ve gleaned from him and other surgeons, a high level of confidence, in their decisions, in their ability, is crucial. They’re cutting people’s bodies open; they need to be in charge, to make the tough calls. The last thing anyone wants is an unconfident, self-doubting surgeon.

This doesn’t mean that surgeons think they know it all. Far from it. Good surgeons not only welcome second opinions, they continue to train, learn new techniques, question and push themselves, like the driven type-A personalities so many of them seem to be. It sounds as though Paterson had stopped all that, if he ever started, instead letting himself slide into a state of self–serving toxicity and, from the sounds of it, lucrative complacency.

In someone like Paterson, the “God complex” would emanate not from innate belief, but the self-conviction that, ultimately, their wrongful behaviour is justified. Certain details spring out: the endless operating, the fact that Paterson kept himself apart from colleagues. Not only is performing unnecessary operations simply not done, able surgeons are much more likely to confer over diagnoses, to want to share knowledge and expertise. When someone shies away from doing this, it suggests not so much arrogance as a fear of exposure or a mask for incompetence.

None of this excuses how Paterson was allowed to continue mutilating patients or placing them in danger, unhindered, for so long. The culture of secrecy and protection around high-ranking medical professionals must be stamped out. Moreover, I’m sure that some surgeons are just arrogant sods who bully patients. No one is defending that, however good they may be at their jobs.

However, this case shouldn’t lead to people automatically distrusting or fearing confident surgeons. While Paterson’s actions are the stuff of nightmares, they also feed straight into a paranoid, 1950s-style narrative of haughty surgeons badgering patients into doing as they’re told. In truth, whatever Paterson was (incompetent? greedy? psychotic?), his crimes clearly demonstrate that he wasn’t on the normal surgeon spectrum, not even at the arrogant end. What Paterson did was criminal and pathological.

The surgeon who cruelly betrayed his patients’ trust | Barbara Ellen

Jeremy Hunt orders investigation into baby deaths at NHS trust

The health secretary has ordered an investigation into the deaths of a number of babies at an NHS trust in the Midlands, after seven of them were judged to have been avoidable.

Jeremy Hunt made the move after bereaved families and the local coroner criticised the quality and safety of maternity care at the Shrewsbury and Telford Hospital NHS trust. He has asked NHS England and NHS Improvement to look into an undisclosed number of deaths at the trust in recent years, amid concern that some were not properly investigated at the time.

The BBC said it had obtained details of at least nine suspicious deaths that occurred at the trust between September 2014 and May 2016, seven of which were later deemed to have been avoidable if the newborns had received better care.

Five of the deaths involved apparent failures by staff to correctly monitor a baby’s heartbeat.

Dr Edwin Borman, the trust’s medical director, said the rate of baby deaths at the trust – which handles 4,700 deliveries a year – was no worse than anywhere else in the NHS.

However, he told BBC News: “In the case of foetal heart monitoring, we have identified a number of cases where learning has not been fully implemented. We’ve put systems in place to make improvements.”

John Ellery, the coroner in the June 2016 inquest into the death of Kye Hall at Telford’s Princess Royal hospital, said errors by staff had contributed to the baby boy’s death.

“His death was caused or contributed to by failings at the Princess Royal hospital, Telford, namely a failure to reclassify Kye’s mother as a high-risk case on two occasions and a failure to auscultate [listen to] his foetal heart rate at two critical times prior to delivery,” the coroner said.

Kye was born on 15 August 2015, but he died four days later as a result of hypoxic ischaemic brain injury and birth asphyxia, or serious oxygen deprivation.

The trust accepted during the inquest that some recordings of Kye’s heart rate when he was still in the womb were not taken or written down, and that his mother, Kate Anson, could have been referred to the consultant-led maternity unit when her blood pressure dropped.

Last week, an inquest into the death of a one-day-old girl, from a group B streptococcus infection while in the trust’s care, found she could have lived had she received better medical attention. The trust accepted that Pippa Griffiths would probably have survived if staff had spotted the infection earlier.

Pippa was born at home on 26 April 2016. When her mother, Kayleigh, rang the maternity unit at 6.30pm to voice concern about Pippa’s feeding, staff reassured her. She said she called again at 2.55am the next day to report brown mucus, although midwife Claire Roberts said she did not remember the baby’s mother saying that.

Sarah Jamieson, the trust’s head of midwifery, said afterwards: “We are truly sorry that we were unable to provide the appropriate care that would have prevented Pippa’s death.”

Maternity services at the trust were strongly criticised last year in an inquiry, commissioned by NHS England, into the death of a baby girl, Kate Stanton-Davies, in 2009.

Her mother, Rhiannon, said: “Look at the failings, learn from them, move on. To not do that, they haven’t just killed my daughter, but they have disregarded the value of her life, her memory.”

The inquiry found a “lack of a safety culture” in the maternity unit at the time. It also found staff had not been held accountable for their failings related to Kate’s death, and that lessons needed to improve patient safety had not been learned.

The nine suspicious deaths include those of twins Ella and Lola Greene, who were stillborn in 2014 after staff failed to correctly read and interpret their heart rates. The trust also accepted other inquest findings that poor foetal heart monitoring was a factor in the deaths of Graham Scott Holmes-Smith in 2015 and Ivy Morris in May 2016.

Other deaths under examination include that of Oliver Smale in 2015. The coroner said his death could have been prevented if he had been born earlier by caesarean section.

The Department of Health said: “Earlier this year, the health secretary asked NHS regulators to undertake an investigation at Shrewsbury and Telford NHS trust in light of disclosures that in a number of tragic cases standards of care fell far below those that parents would expect.”

Jeremy Hunt orders investigation into baby deaths at NHS trust

NHS trust triples injury payout to £9.3m under controversial new rules

The first case settled under controversial new compensation rules for serious injuries has seen an NHS trust forced to nearly triple its payout to a 10-year-old girl left with cerebral palsy from £3.8m to £9.3m.

The case, involving East Lancashire Hospitals NHS trust, will send fresh shockwaves through the NHS and insurance companies, which have been braced for big increases in claims since the new “Ogden” formula was announced last month.

Despite intensive lobbying, the new rules came into force this week, and immediately resulted in a dramatic escalation in one payout. As recently as January, it was agreed that the 10-year-old would receive a lump sum capitalised at £3.77m, but this will now be increased to £9.29m.

Her solicitor, Leonie Millard of Forbes Solicitors in Accrington, said: “The benefit for the claimant from the new -0.75% discount rate, is immense. It vastly improves the long-term future financial ability to meet her needs for the rest of her life, which is expected to be long. Her parents are comforted to know that there is funding to ensure that her needs are properly met when they are no longer around.”

Until now the Ogden formula for paying out compensation assumed that the claimant could earn 2.5% interest a year on a lump-sum payment. But under the new rules, the rate is assumed to be -0.75%.

In documents published after the budget, it emerged the government’s finances will take a near-£6bn hit as a result of the increased bill faced by the NHS and other parts of the public sector as a result of the changes made to the way compensation awards will now be calculated.

The Office for Budget Responsibility said the government would be setting aside an extra £1.2bn a year to meet the expected costs to the public sector – and it would push up car insurance premiums by about 10%.

The Association of British Insurers said it was “crazy” that up to 36m insurance policies could be affected in what it alleged would be “over-compensating” a few thousand claimants a year.

It is estimated that the cost of the average car insurance policy could increase by £60 a year, but for younger and older drivers, the increase will be higher. Comparison site comparethemarket.com said the average price for drivers aged 17 to 20 will rise by £115 to £1,650. The total increase in premiums paid by all motorists is expected to reach £2bn.

Direct Line, one of Britain’s biggest insurers, has already blamed a £217m slump in profits on the new Ogden rate, as it pencilled in bills for some individual cases doubling from £10m to £20m.

The lord chancellor, Liz Truss, has said there will be consultation on the new rules, but the insurance industry says it has yet to be told the shape of any reforms that might be forthcoming.

The ABI said: “The first wave of impacts on insurance costs are already being felt. A number of insurers have already publicly confirmed that premiums are going up as a result of the decision in February to cut the discount rate.”

Huw Evans, director general of the ABI, said: “The massive rise in insurers’ claims costs, which makes premium rises for millions of customers inevitable, results from a wholly avoidable decision by the lord chancellor. It was based on pressure from claimant lawyers, poor legal advice and an outdated formula that does not reflect the choices available today for a prudent claimant. With the public purse hit by £6bn, the government consultation cannot come soon enough.”

But Michael Redfern, the QC who was counsel for the 10-year-old girl, known only as “LMS”, said: “The large increase in lump-sum awards is offset by lack of return on lump-sum low-risk investment and the ability to keep pace with inflation.

“We welcome the new discount rate, the first change in 17 years, which addresses the actual lack of meaningful return on safe lump-sum investment opportunities. The only person to benefit from the new discount rate is the claimant. It has no impact on legal costs.”

NHS trust triples injury payout to £9.3m under controversial new rules

Talk about death, be kind and trust your instincts: tips for new nurses

Don’t be afraid to question senior doctors

Never be scared to question a doctor, however senior they may be. We are our patients’ advocates and can protect them from potential mistakes. A good doctor will respect you for this. If you feel something isn’t right but are not confident enough to challenge a situation yourself, go to someone you know, trust and respect – watch how they deal with it and learn.
Emma McLellan, staff nurse in the ICU, Manchester

Learn to trust your gut instinct

I believe good nurses are really tuned into their gut instinct and new nurses should learn to trust it. A nurse’s gut instinct is their deeply grounded knowledge base developed in practice, their critical awareness and what they have learned from previous situations plus an overall sense of knowing the patient well. You’ll just know something doesn’t add up, or you may convinced there’s something more going on, so make sure you go that extra mile to cover all bases. Maybe, for example, all of a patient’s baseline observations are normal, but you just sense that there is still that underlying thing you can’t put your finger on – monitor them really closely because you’ll often be right.
Zoë Hartwright, community mental health nurse, Shropshire

Death is a part of nursing – talk about it with patients

Death is a regular part of nursing. Patients need someone to talk frankly about death. We plan births for nine months, but talking about death always seems awkward and hard. One of the best things you can do for a patient who is nearing the end of their life is to give them opportunities to talk about their death and how they would like it to be. Being able to give advice and support to help them get their affairs in order can relieve a lot of their pain and worry. It is possible to have a good death but the conversations have to be had.

When death is unexpected this is very hard to deal with. I worked in an accident and emergency department for 10 years and learned that life and death is unpredictable. I have seen many patients and nurses struggle with the last words that they said to that person, so I try to adopt the approach of being kind. Really think about what you say during emergency situations – it is likely that patient can hear you right to the end – even if the rest of their body is not responding. Use their name, talk calmly to them, explain everything you do as you are doing it. Speak to them as if they are awake.
Christine Bushnell, advanced nurse practitioner, nurse partner in a GP surgery and trainer, Harrow

Don’t treat patients you don’t like differently

It’s OK not to like some patients. That’s bound to happen, and some patients really won’t be very likeable. Just be aware of yourself; notice that you don’t like the patient and make sure you’re not treating them any differently. Maybe confide in a trustworthy colleague and ask them to let you know if you are behaving differently towards that patient. And draw on other people, often you find that another colleague works well with a patient you just can’t seem to get along with; make the most of that by getting them to tell you the good qualities of the patient, or even letting them take the lead.
Elizabeth Cook, clinical charge nurse, south London

Be kind to patients’ relatives

It’s very hard not to take it personally when relatives are difficult with you. As a nurse in paediatrics, I found it tough at first as a newly qualified nurse without any children of my own. Now that I am older and I have my own children, it is different. When dealing with emotional or difficult relatives, try to put yourself in their position and understand that they do not have anything against you – they are just desperately worried about their child, for example, and you may be the nearest person to them and so they might take it out on you. It is important to listen without judging and, if treated with hostility, try to respond with kindness. Speak to your manager if certain behaviour from a family member is bothering you, but ultimately try to be understanding.

Don’t say, “I know how you feel” when you have never been in that situation. Instead you can say something like: “I can’t begin to imagine how worried you must be, but we are doing everything we can, if you have any questions please ask and if I can’t answer them I will find someone who can, etc”.
Sally al-Habshi, paediatric emergency nurse, Leicester

Be nice to healthcare assistants

Always be nice to healthcare assistants, they’re amazing. Make lists of jobs you need to do – a good list helps everything. And always remember that when you’re having a bad day, your shift will come to an end and you can go home and eat pizza.
Laura Thompson, ward manager, London

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Talk about death, be kind and trust your instincts: tips for new nurses

NHS mental health trust to be prosecuted amid claims it failed to offer safe care

A mental health trust is to be the first NHS provider to be prosecuted under legislation brought in after the Mid Staffs scandal.

Southern Health NHS foundation trust is being taken to court after a patient sustained serious injuries during a fall from a low roof at Melbury Lodge, Royal Hampshire county hospital, Winchester, in December 2015.

It is accused of failing to provide safe care and treatment resulting in avoidable harm to a patient and other patients being exposed to a significant risk of avoidable harm, the Care Quality Commission (CQC) said on Monday.

Legislation allowing the CQC to prosecute for such alleged offences was introduced in 2014 as a response to events at Mid Staffs, which was was criticised by a public inquiry for the “routine” neglect of patients between 2005 and 2009.

Southern Health provides services to 45,000 people across Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire.

Melbury Lodge includes a specialist mother and baby unit for women suffering with mental illness, as well as a ward for older people with mental health problems.

In its most recent report, in September last year, the CQC noted that anti-climb guttering had been installed to prevent patients getting on to the roof and that the fence had been fixed to reduce potential footholds after concerns were previously raised about its accessibility.

Basingstoke magistrates court will hear the case relating to Melbury Lodge this year.

Julie Dawes, interim chief executive of Southern Health said: “I express again our apologies to the patient involved, and the patient’s family. The safety of people using our services is of central importance to us and we are doing everything we can to improve the safety and quality of our services at present.

“Since the incident the trust has made significant improvements to Melbury Lodge, investing over £1m. This includes climb-proof guttering to prevent a similar incident taking place, as well as comprehensive refurbishment of the interior to make the ward safer and more therapeutic for patients.”

NHS mental health trust to be prosecuted amid claims it failed to offer safe care

NHS trust may use Uber taxis to transfer non-emergency patients

Uber taxis could soon be used to transfer non-emergency patients with illnesses ranging from cancer to dementia back and forth from NHS hospitals in a deal that could play a part in “cracking down” on bedblocking, according to the social care company behind it.

The agreement with Barts health NHS trust in London will allow patients to use Uber for journeys including hospital appointments, the care service startup Cera said.

The firm will use UberAssist disabled access cars and the UberWav service for wheelchair users. Carers will also be able to use the system alongside traditional forms of transport to determine the most efficient method for moving people, Cera said.

Patients will be looked after by Ceracarers under the London scheme, which uses a smartphone app to coordinate care, book drivers, and keep relatives informed.

Dr Ben Maruthappu, a former doctor and Cera’s co-founder, said the move would “radically integrate care and transport through technology”, adding: “Older people and those with disabilities will now have access to the highest-quality drivers, while carers will be able to efficiently travel to ensure they can provide services in the right place at the right time.”

“These partnerships tackle major challenges in the NHS, cracking down on bed-blocking and delayed discharges, while providing high-quality and efficient care.”

As well as the five London hospitals that make up the trust, clinical commissioning groups in Harrow, Brent and Hillingdon in north London will also use the service.

The Unison general secretary, Dave Prentis, said: “Social care and the NHS are in such a state of crisis that any initiative to ease the pressure will be welcomed by patients and staff.

“But the funding chasm between what is needed and the pitiful amount councils currently have to commission care is too deep. Nothing short of an emergency injection of cash in the budget, followed by the sustained and realistic funding of health and care will be enough.

“The government must also ensure that all companies that win care contracts don’t exploit staff and pay at the very least the minimum wage.

“Sadly there are still many out there breaking the law and getting away with it.”

David Mowat, minister for community and social care, said: “This is an interesting and innovative proposal which will help raise awareness of the challenges faced by the vulnerable elderly, and those with specific conditions that are becoming increasingly common in our society.”

NHS trust may use Uber taxis to transfer non-emergency patients

Nuffield Trust health policy summit 2017 – watch it live

The Nuffield Trust’s annual health policy summit takes place on 2 and 3 March.

Speakers include Simon Stevens, chief executive of NHS England; Dr Sarah Wollaston, chair of the health select committee; and Clare Marx, president of the Royal College of Surgeons.

Follow the summit live on the network here, or on Twitter via the hashtag #ntsummit

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Nuffield Trust health policy summit 2017 – watch it live

Worcestershire hospitals trust ordered to urgently improve patient safety

The NHS watchdog has ordered a troubled hospital trust to urgently overhaul patient safety or face sanctions weeks after two patients died after enduring long waits on trolleys in a corridor.

The Care Quality Commission has given Worcestershire Acute Hospitals Trust six weeks to make significant improvements at the three hospitals it runs in Worcester, Redditch and Kidderminster.

The regulator has served the trust with a section 29A notice, which sets out changes it must make by 10 March or risk penalties such as a special administrator being brought in to start running it.

Caragh Merrick, the trust’s chair, admitted to staff in an email after the CQC’s move that the trust had “lost sight of the basics [of caring for patients]. As staff we must all be held accountable for our actions,” she added.

Previous lapses means that from now action to improve patient safety will be taken from “the ward to the board” in an attempt to “guarantee consistent high professional standards”, said Merrick.

The trust was in the headlines recently when two patients died, reportedly on 1 and 3 January, in the A&E unit at the Worcestershire Royal hospital in Worcester when it was struggling to cope with the sheer number of patients needing care.

In one of the cases, a female patient on an emergency trolley in a corridor within A&E suffered an aneurysm and died later in a resuscitation bay. The second patient died after suffering a cardiac arrest on another A&E trolley within the department after waiting 35 hours for a ward bed elsewhere in the hospital.

The trust was put into special measures in December 2015 after CQC inspectors raised concerns about safety in its A&E, children’s care, and maternity and gynaecology services.

It was embroiled in another controversy last year when CQC staff found that 10,000 patients’ x-rays had not been assessed, which prompted concern that serious illnesses had been missed.

Worcestershire Royal hospital recently became so busy that it had to divert A&E patients to its sister Alexandra hospital in Redditch during the NHS “winter crisis”.

The trust is due to end 2016-17 with a deficit of £37.5m, down significantly on its £59m overspend in 2015-16.

A major consultation to shake up healthcare at the trust’s hospitals is under way.

Worcestershire’s three NHS clinical commissioning groups (CCGs) launched the consultation in January which, if the option proposed was picked, would move many planned operations to the Alexandra, but concentrate most emergency care at the main Worcester hospital.

More day-case and short-stay surgery would go to the county’s smaller Kidderminster hospital.

Worcestershire hospitals trust ordered to urgently improve patient safety

London NHS hospital trust hit by cyber-attack

The largest NHS trust in England has been hit by a cyber-attack that could affect thousands of files across at least four London hospitals.

Barts health trust, which runs five hospitals in east London – the Royal London, St Bartholomew’s, Whipps Cross, Mile End and Newham – has sent a message to staff urging them not to open email attachments from unknown senders.

It was reported that the trust had been targeted with ransomware, which is normally delivered via emails that trick the recipient into opening attachments and releasing malware on to their system, in a technique known as phishing.

The trust has not confirmed those reports or said how much of its system has been affected by the attack or whether patient data has been compromised.

A spokeswoman said: “We are urgently investigating this matter and have taken a number of drives offline as a precautionary measure.

“We have tried and tested contingency plans in place and are making every effort to ensure that patient care will not be affected.”

According to the Health Service Journal, the trust’s filing system between departments has been turned off while the investigation takes place.

Staff at the Royal Free London foundation trust were also warned to beware of attacks on Friday, the Guardian has learned.

“We have been informed of a major cyber-attack on NHS organisations. Please exercise extreme caution when opening any email attachments from unknown source or that don’t seem relevant to you. We will be carrying out security scans on all computers within the trust so please leave them switched on until further notice,” wrote the trust’s IT director, Tosh Mondal.

A spokesman said the email was in reaction to the Barts attack and that the Royal Free London, as well as Barnet and Chase Farm hospitals, had not been affected.

In October the Northern Lincolnshire and Goole foundation trust was hit by an attack in which malware was used to encrypt files and demand a ransom in order to restore access. The trust did not pay the ransom but was forced to cancel patient appointments as its systems were shut down to remove the virus.

John Bambenek, a threat intelligence manager at the firm Fidelis Cybersecurity, said: “The trouble is that local authorities and governments aren’t very prepared and they have extremely valuable information that simply can’t be lost, so they’re a tempting target for cybercriminals.

“Cyber defence is essential, but it’s no longer enough; organisations of all sizes need to invest in detecting threats as well. Only then will cyber criminals be caught early enough to expel them from the network before serious damage is done.”

London NHS hospital trust hit by cyber-attack

Guardian Public Service Awards 2016 health and wellbeing winner: Deventio Housing Trust

“Quite often people are in hospital and they’ve got nothing: no food, no clothes, no toiletries,” says Kate Gillespie, Derventio Housing Trust’s strategic lead for its Healthy Futures initiative. “We get all that sorted out, so people at least have a bit of dignity when they are discharged.”

That’s just the start of the scheme’s work with homeless people due to leave hospital. Many have multiple, complex needs, such as mental health problems and addictions, and are trapped in a vicious cycle of ongoing health issues and repeat admissions.

Over a 12-week period, staff work intensively to find housing for patients, settle them into their new homes and help them live independently – while making better use of primary care, rather than relying disproportionately on acute services.

“Sometimes it’s because they don’t manage their health, so they actually get ill enough to need to go in [to hospital] all of those times,” Gillespie says. “We’ve also got people who are going in because it’s their social contact. They’re so isolated that the only kind of love and nurture they get is a trip to A&E, where they get a sandwich and a cup of tea and a ‘there, there’ from the nurses. When someone has nothing else they’re going to keep coming back for it.

“It’s like they’ve got a dependency on acute care. We transfer that dependency to us, and then take the time to wean them off it. If we get someone who’s in A&E three times a week, the next step down from that is a walk-in centre. Then their GP, then the pharmacy.”

Healthy Futures, which also offers brief interventions to help with the timely discharge of inpatients with less complex housing and support needs, has worked with more than 330 patients since it began in October 2013. Some 170 patients have received ongoing community-based support.

In the six months before becoming Healthy Futures clients, those patients had been admitted to acute beds on 487 occasions, had gone to A&E 616 times, and had called 999 and been taken there by an ambulance 364 times.

The project has led to an 88% fall in avoidable admissions of clients, a 90% drop in clients’ visits to A&E, and 84% fewer 999 ambulance transfers. Hospital stays have also been cut by an average of 16 days. Two thirds of patients felt their physical health had improved, and the same proportion reported better mental health.

Healthy Futures’ achievements come despite working in a climate of cuts to adult social care, at a time when finding housing is harder than ever. Key to getting funding has been its use of robust data proving its impact and efficiency. Patients give consent for their health records to be accessed, so their use of acute care before working with the project can be tracked – and commissioners can clearly see the positive effect.

Great staff are also vital, Gillespie says. “They’re just amazingly capable and patient and resourceful. I’m immensely proud of them.”

Guardian Public Service Awards 2016 health and wellbeing winner: Deventio Housing Trust

"Poor decisions and lack of compassion" reported at NHS trust

A secret medical review showed mothers and babies died at an NHS trust in the Manchester area where clinical errors, bad staff attitudes and chronic shortages were commonplace.

The review, carried out by new maternity director Deborah Carter at Pennine Acute Hospital NHS trust which operates North Manchester General and the Royal Oldham hospitals, outlines a string of avoidable deaths and long-term injuries caused by failures over many years.

The report details how a premature baby was left to die alone in a sluice room rather than its mother’s arms, another woman who died of a catastrophic haemorrhage after her symptoms were put down to mental illness and a baby who died because staff failed to identify its mother’s rare blood type.

Long-term failures led to “high levels of harm for babies in particular” and repeated warnings over years had not led to improvements.

The internal review only came to light following a freedom of information request by the Manchester Evening News. The paper said the trust tried to suppress the report and even claimed it did not exist.

On Wednesday night the trust said more staff had been taken on and progress was being made to improve care.

The report identifies “clear evidence of poor decision-making which has resulted in significant harm to women” and “real issues” on maternity wards resulting in “high levels of harm for babies in particular, which has significant life-long impact”.

Staff shortages are linked to a series of deaths, including one baby who died because antenatal staff had failed to spot its mother’s blood type. But bad attitudes and a lack of compassion among staff were also cited.

In one case a mother died from a “catastrophic haemorrhage” after staff ignored the symptoms of hypoxia, a condition caused by lack of oxygen, while medics believed the woman had mental health issues.

Another incident involved the birth of a 22-week-old baby. The report states: “When the baby was born alive and went on to live for almost another two hours, the staff members involved in the care did not find a quiet place to sit with her to nurse her as she died, but instead placed her in a moses basket and left her in the sluice room to die alone.”

The report cites “worrying repetitive themes” across the department, including failures to monitor basic vital signs, poor documentation, lab results left unchecked, critical information left off patient records, a “rigid mindset” among staff who tended to view patients’ conditions as “uncomplicated”, repeated breaches of safety procedures and little performance monitoring of the high numbers of agency staff on the trust’s books.

The trust received more legal claims and paid out more in damages than any other between 2010 and 2015, nearly half the claims relating to mothers and babies – payouts that totalled more than £25m.

Prof Matthew Makin, medical director at Pennine, said: “The priority is for all of the trust’s services to meet the high standards that patients expect and deserve. We are steadily making the necessary improvements so that patients can receive reliable, high quality care across all of our services.

“In addition to the appointment of a new head of midwifery, 31 new midwives started … across our two maternity units at north Manchester and Oldham last month.

“In addition to 58 new midwives joining us since April, the new management team is being supported by Central Manchester NHS foundation trust, who are providing supplementary clinical leadership support in order to stabilise and strengthen services on the north Manchester site.

“We have fully reviewed our risk and governance arrangements including learning from incidents and complaints, and are making progress in improving the way we listen and involve our staff to address the longstanding problems and challenges facing our teams.”

"Poor decisions and lack of compassion" reported at NHS trust

NHS teaching trust to go into special measures after inadequate rating

A large NHS teaching trust is to be placed in special measures after inspectors rated it inadequate.

St George’s University Hospitals NHS foundation trust in Tooting, south-west London, will enter special measures after the Care Quality Commission (CQC) said it was inadequate for safety and on the issue of being well-led.

The trust was also told it requires improvement for being effective and responsive, although it was rated good for caring. Eighteen NHS trusts in England are in special measures.

An inspection at St George’s in June and July revealed that several of the buildings, including operating theatres, were so poorly maintained they were not fit for purpose. Other problems included staff not following infection control policies and about half of staff working with children had not completed the required safeguarding training.

Two years ago, the trust was ranked as good.

Prof Sir Mike Richards, the chief inspector of hospitals, said: “I am disappointed that we have found a marked deterioration in the safety and quality of some of the trust’s services since we inspected two years ago, as well as in its overall governance and leadership.

“Our inspectors found that several of the trust buildings – including operating theatres – were in a state of disrepair, which meant they were not fit for purpose. There were poor fire detection systems and a heightened risk of water contamination, which meant that people were put at risk.

“We also observed that not all staff followed infection control procedures, even when challenged by colleagues.

“Worryingly, we found that areas in which children and young people with mental health conditions were cared for had not been checked for ligature points, and that half of the medical staff working with children and young people had not completed level three safeguarding training, which is a requirement for all staff working with children.

“We took urgent action requiring the trust to address the most immediate of our concerns, and the trust has now introduced a range of supportive measures as a means of stabilising the organisation.”

The trust, which operates hospitals at the St George’s and Queen Mary’s sites, serves about 1.3 million people.

The interim hospital trust chairman, Sir David Henshaw, said progress had been made but added: “There will be no quick fix to the problems we face. Many of these challenges are due to very poor board and senior management decisions in the past and a failure to tackle the big challenges head-on.

“We owe it to our staff and patients to make St George’s better again. The CQC’s report is a key part of this improvement journey.”

The other 17 trusts in special measures for quality of services are Barking, Havering and Redbridge NHS trust; Barts; Brighton and Sussex; Cambridge University; Colchester University; East Kent; East Sussex; London Ambulance; Medway; North Cumbria; Princess Alexandra hospital; Sherwood Forest; South East Coast Ambulance; Walsall; West Herts; Worcestershire Acute and Wye Valley NHS trust.

Eight more trusts are in financial special measures owing to large deficits and poor management.

NHS teaching trust to go into special measures after inadequate rating

NHS trust criticised for underestimating risk posed by patients who killed people

An inquiry has criticised an NHS mental health trust for underestimating the risk of violence posed by patients who went on to carry out killings, two of which could have been prevented. Sussex Partnership NHS foundation trust has been criticised for not taking more seriously the families of disturbed patients who pleaded for help because they feared that their relative would commit violence.

The review of 10 homicides that occurred between 2010 and 2015 included the death of 79-year-old Donald Lock on the A24 near Worthing in Sussex in July 2015 after his car collided with that of Matthew Daley, who stabbed him 39 times.

An independent review of the trust’s handling of patients involved in the cases has found that it did not always learn from mistakes and on occasion “severely underestimated” the risk presented by certain patients. It was criticised for misjudging the risk posed in seven of the 10 killings.

In several cases, the process was said to be “inadequate and the risk posed by the service user went unrecognised or was severely underestimated”. Some diagnoses were acknowledged as flawed, yet were not changed even when patients carried out a fresh offence. “Sometimes service users made threats to kill others, but no further action – for example informing the police or warning the person threatened – was taken,” the report said.

The experts concluded that two of the 10 killlings could have been avoided, though they did not say which. The two did not include Lock’s death, for which 36-year-old Daley – who had a history of psychiatric problems including psychosis and who claimed diminished responsibility at his trial – was convicted of manslaughter.

The trust has already admitted that it “got things wrong” in Daley’s case and should have carried out a formal assessment of his mental state. Lock’s family say that he would “still be here today” if trust staff had done their job properly. Daley’s trial heard that his father warned doctors that unless his son received proper care for his condition, he would “hurt someone or worse”.

Colm Donaghy, the trust’s chief executive, apologised for incidents “which had devastating consequences for those affected. I realise this [review] may bring back painful memories for them. I also understand that some, if not all, will feel angry about our services. On behalf of the trust, I want to extend my sincere apology and condolences”.

A major NHS report earlier this month found that the number of killings by patients being treated for mental health problems is falling, probably as a result of improved NHS care. Patients with schizophrenia, psychosis or other disorders committed a total of 870 homicides across the UK between 2004 and 2014, which was just over one in ten (11%) of all killings in that time. Such homicides resulted in 67 deaths in 2014.

Sophie Corlett, director of external relations at the mental health charity Mind, said the NHS needed to do more to help those who feared that an unwell relative might harm themselves or others. “It’s vital that people are taken seriously when they say they are approaching crisis and ask for support. We still hear of too many cases where people have been turned away despite asking for help,” she said.

“If people don’t get support when they’re at their most unwell and vulnerable, there can be tragic consequences for people themselves, and sometimes – mercifully rarely – for others too. The lesson of this report is that these consequences can and should have been avoided.”

The trust jointly commissioned the review with NHS England to help it improve its handling of patients judged a risk to themselves or others.

NHS trust criticised for underestimating risk posed by patients who killed people

Southern Health trust interim chair resigns

The interim chair of troubled Southern Health NHS foundation trust has become the latest senior figure to quit the organisation.

The trust has been widely criticised for failing to investigate more than 1,000 unexpected deaths of patients with mental health problems or learning disabilities.

Tim Smart was appointed to the post in May, shortly after the resignation of Mike Petter, who stood down just before the publication of a critical report by the Care Quality Commission (CQC), which said the trust was still not doing enough to protect people in its care.

But Smart faced criticism after the chief executive, Katrina Percy, who had been under sustained pressure to stand down, did so last month, only for the trust to reveal that she would continue to be employed in a new role as strategic adviser, with the same pay and benefits.

On Monday, a trust spokesman said: “Tim Smart has taken the decision to resign from his position as interim chair, with immediate effect, for personal reasons. Since his appointment in May this year, Tim has made a considerable contribution to the trust, driving through changes necessary to improve our services. We would like to thank him for his time and dedication.

“We are working with NHS Improvement to appoint a new interim chair as soon as possible. In the meantime, Malcolm Berryman, as deputy chair, will ensure that the duties of the trust board are carried out.”

The trust’s leadership was censured in an independent report commissioned by NHS England after 18-year-old Connor Sparrowhawk, who had learning disabilities, drowned in a bath after an epileptic seizure at Slade House in Oxfordshire in July 2013.

In December, the report, carried out by the audit firm Mazars, concluded that failures by the trust’s board and senior executives meant there was no effective management of deaths or investigations and a lack of “effective focus or leadership from the board”.

The CQC, which subsequently carried out a snap inspection, identified similar failings, noting that the leadership did not proactively address risks “before concerns are raised by external bodies”.

Percy had been urged to quit, including by Sparrowhawk’s mother, Dr Sara Ryan. There was also pressure from the Liberal Democrats’ health spokesman, Norman Lamb, and the former shadow mental health minister Luciana Berger, before Percy finally stood down.

On her resignation, Smart praised Percy as having “shown great resilience, devoting herself to the patients and staff of Southern Health”. He also said she had left the trust well-positioned. But the trust’s appointment of Percy to a new role prompted more criticism, with Ryan describing it as “totally sickening”.

Earlier this month, Smart compounded the anger when he disclosed that Percy’s new role had been created for her. Her salary is quoted in the trust’s annual report as between £180,000 and £190,000.

In June, the trust accepted responsibility for Sparrowhawk’s death and agreed to pay his family £80,000 in compensation. Last October an inquest jury concluded that neglect contributed to the death of the teenager, who was known affectionately as Laughing Boy or LB.

Southern Health trust interim chair resigns

Mental health trust apologises after woman has to sleep in police car

A mental health trust has apologised after a patient had to sleep in the back of a police car in a hospital car park because there was no bed available for her.

Katie Simpkins, 23, from Corsham in Wiltshire, was detained under the Mental Health Act for her own safety but there was no hospital bed available in the whole of the county.

Officers allowed Simpkins to sleep under a blanket in the back of their patrol car and watched over her until a bed became available.

She and her husband, Tristan Simpkins, 25, released a photograph of her in the back of the police car to try to raise awareness of the lack of beds available in such situations.

Avon and Wiltshire Mental Health Partnership NHS Trust confirmed there were only two beds available for people detained under section 136 of the Mental Health Act, which gives police the power to take a person from a public space to a place of safety.

A trust spokesperson said: “We work closely with the police to ensure they know the availability of places of safety. In this instance we were unable to provide a bed straight away and there clearly could have been better communication. We apologise and will be mindful of this in the future.

“Once the matter came to our attention, we made contact with Mr Simpkins to give him and his wife our full support.”

Police had detained Katie Simpkins under section 136 early last Saturday.

Her husband said police rang round but could not find a place for her in a mental health unit. They took her into the custody suite at Melksham police station until later on Saturday afternoon, when officers were told a bed was available at Green Lane hospital in Devizes. However, when they got there at 5pm they were were told it was not ready.

Tristan Simpkins said: “The hospital suggested she go back to custody and they would call when it was ready, but the police officer said: ‘Custody is not the right place for her.’ He didn’t want to risk her missing the bed so he said they’d wait, and he’d wait with us.

“Katie had her medication, became drowsy and he let her sleep in the back of the police car with her blanket. When I saw her lying in the back of the police car I felt frustrated – but I’ve become used to it. I feel hopeless.”

He praised the way the police had tried to help. “It wasn’t their fault they couldn’t get a bed but these officers were all really lovely with her,” he said. She was finally admitted at 9pm.

Sgt Mike Hughes, who oversees mental health issues for Wiltshire police, said: “When a person is in crisis and has been detained under the Mental Health Act we always endeavour to avoid detaining them in custody, which is only ever used as a last resort. However, sometimes no health-based place of safety is available and our main priority has to be keeping the person safe from harm.”

He added: “There is always room for improvement, and we continue to work closely with our partner agencies to make sure all the people we have contact with receive the best possible support and care.”

Mental health trust apologises after woman has to sleep in police car

Hospitals trust put in special measures after botched operations

A number of occasions where surgeons operated on the wrong part of a patientwere among incidents flagged up by a damning watchdog report which recommended that a hospital trust should be put in special measures.

The four cases involving the surgeons in 2015 were among seven “never events” – serious incidents that are wholly preventable – according to a report by the Care Quality Commission (CQC) into Brighton and Sussex University hospitals NHS trust.

The report also highlighted problems with a culture of bullying and discrimination.

Other issues included patients being kept in surgical recovery rooms – usually just a temporary stop before being returned to a ward or intensive care unit – for up to three days. These areas were also used for emergency medical patients because of an overcrowded A&E and “to help meet the emergency department’s targets”.

The CQC inspectors said there had not been enough staff to ensure patients were receiving safe care and that the culture at Royal Sussex County hospital was one where poor performance in some areas was tolerated.

As well as the safety issues, the report highlighted a culture of bullying at the organisation, where people from black and minority ethnic backgrounds reported that “discrimination was rife”.

The CQC document highlights a 2015 NHS Workforce Race Equality Standard report which concluded: “Following job application, the relative likelihood of white staff being appointed was 1.26 times greater than for BME staff.” It added: “BME staff felt very undervalued and bullied.”

Some lesbian, gay, bisexual and transgender staff also told inspectors they did not feel they were treated equally and felt discriminated against.

Prof Edward Baker, the deputy chief inspector of hospitals for the CQC, said: “It is clear that the problems we have found on this inspection go right through Brighton and Sussex University hospitals NHS trust.

“It is a matter of some concern that we found there was a distinct disconnect between the trust board and staff working in clinical areas, with very little insight by the board into the main safety and risk issues, and seemingly little appetite to resolve them.

“For some time the trust has been failing to meet national standards on waiting and treatment times, there were high numbers of cancelled appointments and operations, and delays in providing diagnostic results. We found that the executive team had failed on multiple occasions to provide resources or support to clinical staff in critical care and there was no acknowledgement that they understood the problems staff identified.

Dr Gillian Fairfield, the trust’s interim chief executive, apologised for the failures identified by the CQC, which she described as “completely unacceptable”.

“The NHS as a whole is seeing growing demand for services and, like many other trusts across the country, this has caused us significant challenges which has affected the standard of the care we are providing our patients. These challenges have been made worse by the fact that our older buildings are not fit for purpose.

“It would be wrong for us to use these pressures and challenges as excuses, however, and we know we should and need to be doing better for our patients and staff.”

Hospitals trust put in special measures after botched operations

Voters don"t trust politicians to program for ageing population, survey shows

The ageing population is cited by the Abbott government as the driver of many policy changes, such as well being cuts and tax reform.

But focus groups carried out across the nation by the Ipsos Thoughts and Mood survey have a clear message for legislators. Voters understand that demographic adjust calls for policy alter, but politicians must proceed with severe caution.

The survey “Our Ageing Population” identified Australians are quite concerned about the problem and deeply concerned that governments haven’t got policy right.

“They are concerned about the broad-reaching implications for the nation’s housing, employment and healthcare sectors … Perceptions that the federal government is not introducing policies which will deal with these perceived problems only serves to heighten nervousness about Australia’s potential in the face of this critical demographic shift,” the survey concludes.

Most not too long ago treasurer Joe Hockey raised the likelihood of humans living to 150 as he foreshadowed a “deep conversation with the Australian people” about ageing following the government releases the newest intergenerational report. And the ageing population is also cited as a reason the government wants to lower spending on healthcare.

“The idea that health has to be cut to support the ageing population frightens folks since they feel the method is under immense strain previously and they can not see how much more can be taken away, and in regional Australia they feel specially under-serviced,” explained Dorothy Dudley, director of the Thoughts and Mood report.

And whilst some respondents have been prepared to accept the Abbott government’s $ 7 Medicare copayment (the policy that was on the table at the time of the surveys) they have been suspicious that it would lead to even greater payments and a “US-style system” where healthcare grew to become unaffordable.

The report includes quotes from emphasis group participants on the subject.

• “I do not personally have a dilemma with the $ seven co-payment, I’m pleased for my taxes to go towards healthcare even if I’m not sick, it’s undoubtedly far better than a whole lot of other things.”
  
  


• “We have 1 of the ideal techniques in the planet. If there’s no income, then put up the levy for the vast majority but do not slug pensioners with a co-payment. It is not just the pay a visit to to the medical professional. It’s pathology, then their medication. It truly adds up. The vast bulk of people really do not abuse it, but individuals get sick all the time. If you discourage individuals from going to the physician they’ll get chronically sick and it will cost a lot more.

• “They won’t just end at $ 7 it’ll just hold going up, it will get to become like the US where you could be bleeding out of your head and they refuse to see you. But that’s the place we’re headed. We’re not caring as much.”

Respondents were equally anxious about the strategy to increase the pension eligibility age to 70 – a policy that applies to these born after 1965 – and normally concerned at the prospect that the pension would grow to be much less generous but that they would be unable to continue to perform.

“The Coalition government’s strategies to boost the age pension eligibility age to 70 by 2035 created significantly discussion,” the report stated. “The fact that the age pension is so strongly linked with the idea of retirement was evidenced by several participants complicated the ‘pension eligibility age’ with a ‘retirement age’, despite the fact that an official retirement age does not exist in Australia.”

It recorded comments from respondents like this:

• “We’re up in arms about the retirement age.”


• “The objective posts are continually moving.”


• “Raising the retirement age is just weird. It would suck if you got to a point the place you cannot keep going and it’s like ‘you have to work yet another five years’.”

• “The retirement age thing, that have to rely on your occupation.”


• “Tony [Abbott] wants to come out right here [to regional NSW] and see what it feels like to pick a tonne of apples each and every day. What your joints truly feel like at the finish of the day. See if thinks he could do it till he’s 70.”


• “The 70 age limit is problematic. Not everyone can do that, not if they have a genuinely bodily work. It’s got to be versatile. If you’re a tiler or a bricklayer, your physique can’t just preserve undertaking that. You are fortunate if you final to 65.”

The government has ruled out sudden changes to superannuation this term, but will include superannuation tax breaks in its “root and branch” review of the taxation method,

But according to the report there is “also a deal of anxiety about gaining accessibility to superannuation with a perception that the superannuation goalposts had been continually changing”.

It discovered that “across the board, fingers were pointing at the government who several participants felt had not actually completely addressed the difficulties they foresaw”.

• “Government wants to be innovative, not so tunnel-visioned. They’ve got to feel. What if that was my mum, my dad? What would they need?”

• “What measures are our leaders putting in right now to assist us to make confident it doesn’t come about? I’m not feeling really comfy with anything actually, are you?”

• “There utilized to be a distinction between Labor and Liberal and now they’re the identical. I’m also cynical about every thing in our society. It is all driven by the bottom line. Acts of goodwill, not for cash, are quite rare.”

Voters don"t trust politicians to program for ageing population, survey shows

We asthmatics know our issue ideal. So trust us with Ventolin, GPs and chemists | Giles Fraser

‘Generally speaking, people with asthma know how properly their lungs are functioning. We don’t go to the physician for exciting.’ Photograph: Corbis

I have had asthma considering that I was a kid. People long sleepless nights, as well frightened to lie down, breathing as if via cotton wool. In fact, it is the breathing out that is frequently more challenging it’s like pushing against some hidden force that will not allow you expel the air from your lungs. And the wonder of Ventolin is that, most of the time, it can open up your lungs in a few moments.

Oh how I need to have that magical blue puffer. I can’t leave the residence with out it. And when I run out or get rid of it (and, being disorganised, this occurs quite a great deal), I panic. Beg, borrow or steal: I require a single with me at all instances.

But it really is quicker and less complicated to get recreational pharmaceuticals in my element of south London. It normally requires over a week to get a doctor’s appointment and often 3 days to procedure a repeat prescription. You can go into a pharmacy and inquire for an emergency supply but there is absolutely no consistency in whether a pharmacist will permit you to have one. Some do so straight away, other folks give you the third degree and hold you waiting for an hour or so, some just refuse. I now have a pretty comprehensive mental directory of the useful pharmacists and the unhelpful pharmacists in central London. In a quantity of European countries you can buy them in excess of the counter. I generally stock up if I go to France.

Five and a half million men and women in this country have asthma and 1,242 people died of asthma attacks in 2012. Worryingly, a report just published on asthma deaths in the United kingdom concludes that there is a large degree of complacency between health care pros about its treatment.

This corresponds to my very own long, albeit personal, encounter of dealing with medical professionals treating my asthma. The issue is that GPs often will not pay attention effectively to the insight that asthmatics have into their own situation. It is profoundly irritating to sooner or later get an appointment when a single is gasping for air only to be provided a fundamental and patronising tutorial in how to use Ventolin. Normally speaking, folks with asthma know how properly their lungs are functioning. I can normally guess with surprising accuracy what my expiration charge (peak movement reading) is at any provided second. We don’t go to the doctor for fun. They want to pay attention to their sufferers much more.

Yes, we asthmatics can be our very own worst enemies. Numerous of us will not use our preventative inhalers as considerably as we ought. And some of us are foolish adequate to smoke also. But none of this will take away from how hard it frequently is to get the medicines we require.

Personally, I believe Ventolin ought to be offered in excess of the counter in this nation. It is not as if there are people queuing up to use Ventolin at raves. Nor have I ever heard of anybody who has harmed themselves by taking too considerably of their puffer – yes, if you overdose you can get a bit shakey. But you can overdose on water.

Is not it time we started out trusting asthmatics a bit much more in the treatment method of their very own condition?

We asthmatics know our issue ideal. So trust us with Ventolin, GPs and chemists | Giles Fraser

Mid Staffordshire NHS trust fined for "avoidable and tragic death"

Gillian Astbury died at Stafford hospital in 2007. Photograph: Rui Vieira/PA

The Mid Staffordshire NHS basis trust has been fined £200,000 and ordered to spend far more than £27,000 in expenses over what the judge described as “the wholly avoidable and tragic death of a vulnerable patient”.

The Overall health and Safety Executive brought an unprecedented criminal case against the believe in above the death of Gillian Astbury, 66, who died in 2007 due to the fact nurses at Stafford hospital failed to give her the program insulin she needed to remain alive.

The Francis inquiry into bad requirements of care at Mid Staffs looked in detail at the Astbury situation and criticised the HSE for an apparent inability to determine whether it should prosecute, despite the inquest jury’s findings that there had been a gross failure to give care. The HSE announced last August that it would bring the situation. In court, the trust pleaded guilty to an offence under the Wellness and Safety at Perform Act.

The court heard that health-related personnel did not comply with – and often did not even search at – Astbury’s healthcare notes, which plainly stated that she essential insulin, normal blood exams and a specific diet regime. Problems had been made as her ward underwent as a lot of as eight shift adjustments and 11 medicines rounds per day. The technique for handovers, when nurses arriving for the next shift ought to be informed of the demands of the individuals, was “inconsistent and at times non-existent”, the believe in admitted.

“Mid Staffordshire NHS basis trust failed to apply a correct handover technique, or to oversee the correct completion of nursing records and the monitoring of care ideas,” stated Peter Galsworthy, HSE head of operations in the West Midlands. “In performing so, they put Gillian Astbury at risk. The trust’s programs have been just not robust adequate to make sure that staff regularly followed concepts of very good communication and record retaining. Gillian’s death was completely preventable. She just essential to be provided insulin.

“Gillian Astbury and her loved ones were failed by Mid Staffordshire NHS foundation believe in. Each hospital patient has the right to expect much more. Significant security management flaws had been recognized by our investigation. We expect lessons to be learned across the NHS to avert this taking place once again.”

Astbury, who had been admitted to the hospital in 2007 due to the fact of fractures to her arm and pelvis, lapsed into a coma right after nurses failed to give her the insulin injections she needed to stay alive. Two nurses had failed to notice her high blood sugar levels – each have been disciplined and 1 was struck off by the Nursing and Midwifery Council final year.

“It was a wholly avoidable and tragic death of a vulnerable patient admitted to hospital for care but who died simply because of a lack of it,” said the judge, Mr Justice Haddon-Cave.

“A important fine is referred to as for to reflect the gravity of the offence, the loss of a lifestyle and in purchase to send out a robust message to all organisations, public or private, accountable for the care and welfare of members of the public.”

Mid Staffordshire NHS trust fined for "avoidable and tragic death"