investigation into mid staffordshire nhs foundation · pdf file ·...

Inspecting Informing Improving

Investigation into Mid Staffordshire NHSFoundation TrustMarch 2009

Investigation

Summary report

The Healthcare Commission carried out thisinvestigation into apparently high mortalityrates in patients admitted as emergencies toMid Staffordshire NHS Foundation Trust sinceApril 2005, and the care provided to thesepatients. It also considered the trust’sarrangements for monitoring mortality ratesand its systems for ensuring that patientswere cared for safely.

Our particular focus was on emergencyadmissions. We looked at the pathway of carefor patients admitted as emergencies: theaccident and emergency (A&E) department,the emergency assessment unit, and thesurgical and medical elements of emergencyadmissions.

The investigation was carried out betweenMarch 2008 and October 2008. Staff from theHealthcare Commission worked with a team ofexternal expert advisers. The membership islisted in appendix B. We interviewed over 300people, including almost 100 patients admittedas emergencies or their relatives, past andpresent staff at the trust, and staff at otherorganisations. We reviewed the case notes ofmore than 30 patients who were admitted asemergencies and subsequently died. Weexamined over 1,000 documents includingpolicies, reports, audits and records ofmeetings.

Synopsis of events leading to ourdecision to investigateDuring the summer and autumn of 2007, theHealthcare Commission became aware,through its programme of analysis of mortalityin England, of a number of apparently highmortality rates for specific conditions oroperations at the trust.

In our work on mortality, we recognise thatsome ‘alerts’ (that is, indications that patients

may be exposed to greater than expected risk)can be due to errors in the data or toinsufficient adjustment for other factors, so ateam of analysts assesses each case toestablish whether there are sufficientconcerns to follow up with a trust. If we dofollow up an alert, we will initially ask a trustto provide further information. In many cases,this is enough to satisfy us that no furtheraction is needed. We can escalate a case ifconcerns about the safety of patients have notbeen adequately addressed, or we think thesehave not been properly recognised by thetrust.

In this investigation, further analysis showedthat the trust consistently had a high mortalityrate for patients admitted as emergencies,which it could not explain.

The rate had been comparatively high forseveral years, but the trust had notinvestigated this. In April 2007, Dr Foster’sHospital Guide showed that the trust had ahospital standardised mortality ratio (HSMR)of 127 for 2005/06, in other words more deathsthan expected. The trust established a groupto look into mortality, but put much of itseffort into attempting to establish whether thehigh rate was a consequence of poor recordingof clinical information.

The response of the trust to our requests forinformation contained insufficient detail tosupport its claim that the alerts were due toproblems with its recording of data, and notproblems with the quality of care for patients.This response, and the concerns from localpeople about the quality of care, led theCommission to decide that a full investigationwas required.

Our key findings are summarised below andset out in full in the body of the report.

3Investigation into Mid Staffordshire NHS Foundation Trust

Summary

The views of patients and relatives atthe trustWhen we announced the investigation, we hadan unprecedented response. In all, 103patients and relatives contacted us. Of these,99 were critical of, or had had a poorexperience at, the trust. The main areas ofconcern they raised were A&E, the emergencyassessment unit and medical wards 10, 11 and12. Concerns were also expressed about somesurgical wards. A major concern expressed bypatients and relatives related to poorstandards of nursing care.

Although we recognise that this was not astatistically representative sample of patientsand relatives, their concerns reinforced whatwe found through observations, reviews ofcase notes, complaints and interviews –disorganisation, delays in assessment andpain relief, poor recording of important bodilyfunctions, symptoms and requests for helpignored, and poor communication withpatients and families.

In the Healthcare Commission's 2007 survey ofinpatients (the latest national survey available),the trust was in the worst 20% for 39 out of 62questions. This was a poor result. The trustwas in the worst 20% for overall standards ofcare and whether patients felt that they weretreated with respect and dignity in the hospital.

Mortality rates at the trustThrough our programme to analyse mortalityrates in England, we received anunprecedented 11 alerts about high mortalityat the trust, four of these after theinvestigation was launched. Six came from theDr Foster Research Unit at Imperial College,London, as part of its analysis of data, and fivefrom the Commission’s own internalsurveillance of data from all trusts. Details ofthe alerts are set out in appendix E.

The alerts at the trust were wide-ranging andsuggested a general problem with regard tomortality. We considered data across the trust,which showed that mortality was high asregards emergency admissions, but not forelective admissions.

Our analysis focused on patients aged 18 andover who were admitted as emergencies. Theresults were ‘standardised’ (that is, madecomparable with each other by taking accountof various factors) for a number of factors,including age, sex and the type of condition thatthey had when admitted to the hospital. SinceApril 2003, the trust’s standardised mortalityratio (SMR) had been consistently higher thanexpected. If outcomes were the same as wouldbe expected when compared with similartrusts, the SMR would be 100. For the threeyears from 2005/06 to 2007/08, the trust’s SMRfor patients admitted as emergencies aged 18and over varied between 127 and 145.

Looking at the three financial years covered bythe investigation, we conducted a statisticalanalysis of the SMRs to examine to what extentthey could have been due to random variation.We concluded that, for the three years weexamined, there was a less that 5% probabilitythat the high mortality rates at the trust forpatients admitted as emergencies aged 18 orover were due to chance.

Standardised mortality was found to be highacross a range of conditions including thoseinvolving the heart, blood vessels, nervoussystem, lungs, blood and infectious diseases.Our full investigation, including visits to thetrust, examination of documents and wide-ranging interviews, has led us to conclude thatthere were systemic problems across thetrust’s system of emergency care.

The trust’s arrangements for thecollection, reporting and use of clinicalinformationThe trust had a long history of poor informationabout its services. The accuracy of coding ofinformation (that is, the system for cataloguingtypes of surgical and other interventions) hadbeen poor, but had improved since 2007. Thelog of activity in theatres had been badlymaintained and it was not possible to matchinformation between systems, such as thetheatre log and the national Hospital EpisodeStatistics data. Individual patients’ data couldnot be tracked or linked in these differentsystems.

Investigation into Mid Staffordshire NHS Foundation Trust4

Although Dr Foster’s analysis showed that thetrust had the fourth highest hospitalstandardised mortality ratio (HSMR) in Englandfor the three-year period 2003-2006, the trustonly began to monitor clinical outcomes afterthe publication of the high rate by Dr Foster in2007. The trust established a group to considermortality, but considered that poor coding wasthe likely explanation for the high rate.

We found that, when challenged, neither thetrust nor individual consultants could producean accurate record of their clinical activity oroutcomes for patients. This meant that wecould not analyse the volume of surgical workand its outcomes.

Management of patients requiringemergency care

A&E and the emergency assessment unit

The detailed evidence for these findings isoutlined in the section in this report on theA&E department and the emergencyassessment unit (EAU). It came from a widerange of sources including interviews withstaff, relatives and patients, observations,reviews of case notes, complaints, trustdocuments and external reports.

When we visited the A&E department in May2008, the initial evidence raised seriousconcerns. We held an urgent meeting with thechief executive and followed this immediatelywith a formal letter requiring urgent action.

The trust did not have clear protocols andpathways for the management of patientsadmitted as emergencies. The A&Edepartment was understaffed and poorlyequipped. There were too few nurses to carryout an immediate assessment of patients. Thiswas left to the receptionists, who had noclinical training. The patients in the waitingroom could not be seen from the receptionarea. The department lacked essentialequipment, such as sufficient defibrillators forevery resuscitation trolley.

The nurses in A&E had not had enough trainingand development, and leadership had beenweak. Patients often waited for medication, pain

relief and wound dressings. There were delaysin scanning patients out of normal hours. Themost senior surgical doctor in the hospital after9pm was often junior and inexperienced.

There were too few consultants to provide on-call cover all day, every day. There were toofew middle grade doctors. The junior doctorswere not adequately supervised, and wereoften put under pressure to make decisionsquickly in order to avoid breaches of the targetfor all patients to be seen and moved fromA&E in four hours. For the same reason,patients were sometimes rushed from A&E tothe EAU without proper assessment anddiagnosis, or they were moved to the ‘assessand treat’ area, even though staff were notformally allocated to the area and patientswere not properly monitored there.

The EAU was large, with a poor layout, makingit difficult for nurses to see patients. It was busyand frequently chaotic. It was understaffed, andcommunication was often poor between nursesand patients, and nurses and doctors.

During 2007/08, the nurses had little in-service training. Not all the nursing staff hadthe correct skills to observe and care for thevariety of patients admitted as surgical andmedical emergencies. On the bays withcardiac monitors, the nurses had not beentrained to read the monitors. On occasions,the equipment was turned off.

Observations of patients were not carried outas they should have been and poor recordswere kept of patients’ intake and output offluids and food. Patients sometimes receivedincorrect medication or did not get theircorrect medication in a timely manner, if atall. There was poor compliance with generallyaccepted standards of practice in the controlof infection.

Patients admitted as medical emergencies

The detailed evidence for these findings isoutlined in the section on medical admissions.It included interviews with staff, relatives andpatients, observations, complaints, trustdocuments, national surveys and externalreports.


For patients admitted to the medical wards,there was sometimes poor communicationwith, and handover from, the EAU. Care wasreported to be good for patients with heartattacks on the acute coronary unit, althoughthere were problems with the cardiacmonitors. However, because of lack of beds onthe coronary unit, some patients with heartattacks remained in the EAU and were nursedin a non-specialist area.

The reconfiguration of the medical beds onfloor two and associated changes in nursingstaff had led to the creation of clinical areasthat were poorly managed and understaffed.

The care of patients was unacceptable. Forexample, patients and relatives told us thatwhen patients rang the call bell because theywere in pain or needed to go to the toilet, it wasoften not answered, or not answered in time.Families claimed that tablets or nutritionalsupplements were not given on time, if at all,and doses of medication were missed. Somerelatives claimed that patients were left,sometimes for hours, in wet or soiled sheets,putting them at increased risk of infection andpressure sores. Wards, bathrooms andcommodes were not always clean.

Nurses often failed to conduct observationsand identify that the condition of a patient wasdeteriorating, or they did not do anythingabout the results.

There was only one bay, with four beds, forpatients with acute stroke. This wasinsufficient for the number of patients. Therewas no facility on the respiratory ward fornon-invasive ventilation. There had been anumber of problems with arrangements forresuscitation, including some seriousincidents involving the contents ofresuscitation trolleys. The bleep system forthe management of cardiac arrests did notwork effectively on several occasions. Mobilephones had to be used as a contingency.

Patients admitted as surgical emergencies

The detailed evidence for these findings isoutlined in the section on patients admitted in

an emergency with surgical problems ortraumatic injuries. It included interviews withstaff, relatives and patients, observations,reviews of case notes and inquest summaries,trust documents and external reports.

Many doctors and nurses working in surgeryconsidered that staff on the EAU and onmedical wards did not have the right trainingand skills to look after surgical patients.

The general surgeons did not work welltogether and there were few agreed protocolsin surgery. This meant that patients needingemergency operations out of normal hoursmight receive different care and a differentoperation to that received from 9am to 5pm,Monday to Friday.

There were not enough doctors on duty out ofhours, and the most senior surgical doctorafter 9pm at night could be quite inexperienced.

In line with local understanding, theambulance service took most, but not all,patients with severe or multiple trauma toother hospitals with specialised traumaservices. For this reason, there was no traumateam at the trust. However, some staff wereconcerned that nurses on the EAU did nothave the right training to look after thosepatients with traumatic injuries (such asbroken limbs) who were admitted to the trust.In addition, the unit did not have equipment fortraction or specialist hoists. We noted that, attimes, there were too few staff to open asufficient number of critical care beds.

For patients requiring emergency surgery, therewas only one list for theatre at weekends. Therewas no system to assign priority to cases. Oftenemergency caesarean sections or surgicaloperations (such as removing an appendix)would take priority. This meant that patientswith a broken hip might have to wait from Fridayto Monday or Tuesday to have their operation.This inappropriate management meant that, forseveral days, these patients would not beallowed to eat or drink for many hours. Onsome occasions, patients who were designatedas ‘nil by mouth’ were also inadvertently notgiven their essential medication.


From our review of case notes, from inquestsand from findings from the alerts that theHealthcare Commission received on mortality,we noted a number of cases where patientshad developed clots in the deep veins of theirlegs or pelvis and died from these clotsbreaking off and blocking the blood flow totheir lungs. The trust did not have effectivearrangements to prevent this or comply withaccepted national guidance.

The care of post-operative patients was poor,such that signs of deterioration were missedor ignored until a late stage. When things wentwrong, the trust was poor at recognisingerrors, reporting serious incidents andlearning lessons.

Review of case notes The Healthcare Commission reviewed the casenotes of 30 patients who had died. Our casereviews were undertaken on a small scale, butnevertheless threw significant light on thearrangements for clinical quality andgovernance prevailing in the trust. We foundthat, in many of the cases, at least one elementof the clinical management or monitoring oftheir condition was unsatisfactory. Areas ofconcern included infrequent reviews ofpatients by doctors, the lack of systematicmonitoring of whether the patients wererecovering or deteriorating, and the failure torespond adequately to signs of deterioration.There was inadequate monitoring to identifycommon complications of surgery.

What were the reasons for the failingsat the trust? It is the view of the Healthcare Commissionthat there were deficiencies at virtually everystage of the pathway of emergency care. Thiscan be illustrated by following the patient’spathway.

When patients arrived in A&E, they wereusually assessed by reception staff with noclinical training, before waiting in an area outof sight of the staff in reception. There was noregular check by nursing staff of the patients

in the waiting room. Some essentialequipment, such as cardiac monitors, wasmissing or not working. Assessment andtreatment were often delayed.

There were too few doctors and nurses,alongside poor training and supervision, andjunior doctors were put under pressure tomake decisions quickly without advice andsupport from more senior doctors. Doctorswere moved from treating seriously ill patientsto deal with those with more minor ailments,in order to avoid breaching the four-hourwaiting time target. Patients were moved tothe clinical decision unit to ‘stop the clock’ butwere then not properly monitored, since thisarea was not staffed. Patients had to wait formedication, pain relief, wound dressings andantibiotics. There was only a relatively juniordoctor available after 9pm to give advice onsurgical patients. There was no specialisttrauma team. In summary, the care andassessment of patients fell well belowacceptable standards.

Sometimes patients were rushed to theemergency assessment unit (EAU) withoutproper assessment or discussion, and withoutappropriate specialist care. The EAU was alarge ward with a poor layout. It was busy,noisy and sometimes chaotic with too fewnurses. Many of the nurses did not understandthe cardiac monitors and did not always carryout observations adequately to identify whethera patient’s condition was deteriorating. Therewere many instances of patients not receivingthe medication they needed.

There were too few beds for patients who hadhad a stroke, not all patients with heartattacks went to the acute coronary unit, therewas no non-invasive ventilation on therespiratory ward, and critical care beds werenot always available. The medical wards onfloor two were seriously understaffed andthere were grave concerns about thestandards of nursing care.

There were too few theatre sessions atweekends and consequent delay in getting totheatre, especially for trauma patients, andsome patients did not get essential


medication. Post-operative complications werenot always recognised.

Surgical practice was idiosyncratic,relationships were poor and there was littlemultidisciplinary team work. There wereconcerns about the level of cover by medicalstaff at night and at weekends.

Across the trust, there were shortcomings inresuscitation and arrangements to avoidpotentially fatal blood clots were inconsistent.There was a shortage of critical care beds andconcern about access to medical advice fromcritical care specialists.

It is our view that all these factors would havecontributed to a poor outcome for patients.

The trust’s approach to its mortality rate One of the aims of the investigation was toclarify how the trust investigated itsapparently high mortality rates.

The trust assured us that its mortalityoutcomes group undertook reviews of samplesof case notes of patients who had died inhospital during particular periods. This was toascertain whether the deaths were expected(unavoidable) and whether there were anyquestions arising about the quality of careprovided to the patients.

Our scrutiny of their information, however,found that the reviews had not beensufficiently objective or robust. Moreover, thecase notes revealed some sub-standardpractice, which should have been identifiedand learned from.

Arrangements for governance and riskThe chief executive inherited a structure ofgovernance that did not function effectively.Since 2005, there had been considerable changein the structure and responsibilities relating togovernance and the management of risk.

The trust’s system for identifying seriousuntoward incidents was poor, with failures toreport some incidents and opportunities tolearn lessons missed. Other incidents that were

reported by staff consistently highlightedproblems relating to the levels of staff, poorcare for patients, and poor handovers whenpatients were moved from one ward to another.Many of these issues required consideration andresolution at a strategic level, but were rarelyconsidered by the board or by its governanceand risk sub-committees. There was nosystematic mechanism to follow up any actionsrequired or to share lessons.

The medical and surgical divisions failed toresolve problems such as ‘nil by mouth’, cardiacmonitors, the cardiac bleep system, portablesuction, and preventing blood clots andpulmonary embolism. Often these problemswere listed on the corresponding risk register,but little effective action had been taken.

There were many complaints from patients andrelatives about the quality of nursing care.These primarily related to patients not beingfed, call bells not being answered, patients leftin soiled bedding, medication not beingadministered, charts not being completed, poorhygiene and general disregard for privacy anddignity. Worryingly, the trust’s board appeared tobe largely unaware of these. In the reports seenby the board, these complaints were groupedinto, and effectively lost in, categories such as“communication” or “quality of care”.

The trust reported it had made efforts to engageclinical staff, but many senior doctors whom wespoke to considered that the trust was driven byfinancial considerations and did not listen totheir views. They gave credit for the trust havinga clear direction, but said that inflexible ways ofimposing change had left many feelingmarginalised.

Although most non-clinical staff thought thatcare at the trust was good, the majority ofdoctors we interviewed would not have beenhappy for a relative to be treated at the trust.In a 2006 survey, only 27% of staff said theywould be happy to be cared for at the trust,compared with 42% nationally.

The trust generally performed poorly onclinical audit. There was no one taking thelead for clinical audit for a year and the trust-


wide group did not meet at all during thisperiod. When audits were carried out, therewas no robust mechanism to ensure thatchanges were implemented. When re-auditswere required, they were often notundertaken, even if they had beenrecommended by a Royal College. The trustdid not participate in many of the nationalaudits run by the specialist societies.

The trust did not have an open culture whereconcerns were welcomed. Overall, the systemthat was intended to bring clinical risk to theattention of the board did not functioneffectively, and the board appeared to beinsulated from the reality of poor care foremergency patients.

The trust’s board and outcomes forpatientsThe board stated that the care of patients hadalways been a priority. However, noinformation on clinical outcomes went to theboard until the publication by Dr Foster of thehospital standardised mortality ratio (HSMR)in April 2007. Even then, it went only to theprivate part of the meeting.

No annual report on the control of infectionwent to the board until July 2007, and that onlywent to the private part of the meeting.

The routine reports on performance that went tothe board were at so high a level that they didnot identify the failings in care of patients. Theinformation on complaints and incidents wasoften incomplete, or so summarised that it leftnon-executives at a disadvantage in being ableto perform their role to scrutinise and challengeon issues relating to the care of patients.

Informing the public The trust’s board preferred to discuss mattersin private, even those that were notconfidential or commercially sensitive. It didnot discuss the Dr Foster HSMR or the alertsfrom the Healthcare Commission in public.

An outbreak of Clostridium difficile (C. difficile)occurred in the spring of 2006, and rates

continued to be high during that year, but thetrust did not report or acknowledge in publicthat it had an outbreak.

The actions of the trust’s boardThe year 2006/07 was a challenging one forthe NHS, as trusts were required to achievefinancial stability. That year, the trust set itselfa challenging agenda to meet national targetsfor cost improvement, stabilise its finances,and become an NHS foundation trust. Thetrust set a target of saving £10 million,including a planned surplus of £1 million. Thisequated to about 8% of turnover. To achievethis, over 150 posts were lost. Although thestated intention was to minimise the loss ofclinical staff, the number of nurses wassignificantly reduced. This was in a trust thatalready had comparatively low levels of staff(see pages 90-93 for details) and at a timewhen nurses felt they were poorly supportedas a profession.

The combination of the reorganisation of wards,the reduction of beds (more than 100 fewerbeds between 2005 and 2008, 18% of the total)and the loss of staff meant that the care ofpatients was further compromised. Areas withlongstanding problems, such as A&E, were notgiven sufficient attention by managers.

The board claimed that its top priority was thesafety of patients. However, even thoughclinical problems were well known, and thetrust declared a financial surplus in 2006/07, itdid not seek to redress the staffing problem ithad exacerbated by reducing the number ofnurses. The evidence suggests that the toppriority for the trust was the achievement offoundation trust status. The failure of the trustto resolve the problems in A&E and to invest instaff is not consistent with the trust doing itsreasonable best to provide a safe and effectiveservice for patients.

The fact that the organisation concentratedmainly on clinical coding as the explanationfor poor outcomes suggests that there was areluctance to acknowledge, or even consider,that the care of patients was poor.


It was clear from the minutes of the trust’sboard that it became focused on promotingitself as an organisation, with considerableattention given to marketing and publicrelations. It lost sight of its responsibilities todeliver acceptable standards of care to allpatients admitted to its facilities. It failed topay sufficient regard to clinical leadership andto the experience and sensibilities of patientsand their families.

Developments since the investigationwas announcedIt is, of course, impossible to determine whatactions would have been taken by the trust ifthere had not been an investigation. Theagreement at the end of March 2008 to fundthe deficit in the numbers of nurses was takenafter the board knew there was going to be aninvestigation.

Since January 2008, there has been a net gainof 46 qualified nurses and 51 healthcaresupport workers. The trust has increased thenumber of matrons from three to 12. However,in November 2008, the trust’s board noted thatfurther recruitment had been stopped becauseof actual and anticipated financial pressures,although the trust was 40 nurses below thepreviously agreed establishment. The trust,though, has told us that the board has notstopped recruitment and will, as part of the2009/10 business plan, revisit the review of theestablishment and take a view on recruiting tothe outstanding posts.

When we expressed concerns to the trust, itwelcomed them, responded positively andbegan to take action. The trust received formalnotification of our concerns about the A&Edepartment on 23 May 2008. It immediatelyset up a steering group for emergency care.Significant progress has been made, but thereis still a need for further improvement. Twonew consultants have been appointed, but theoriginal consultant went on long-term sickleave. The middle grade rota is now fullystaffed and there is a programme of trainingfor junior and middle grade doctors. Thenumber of nurses increased, but many of the

new staff were inexperienced and there wasstill only one band seven nurse. A new modelof care was introduced in the autumn of 2008.Triage is in place for 12 hours a day.

Ward-based training on the use of modifiedearly warning scores (MEWS) was introducedin the autumn of 2008. A training package wasalso agreed to ensure that staff werecompetent to use cardiac monitors. A four-bedded surgical assessment unit was opened.Two additional beds were opened on thetrauma ward. The trust is reviewing theprovision of emergency theatre lists atweekends. Additional sessions have beenarranged at short notice when necessary.

The mortality group has become the clinicaloutcomes group and is chaired by the chiefexecutive. The trust reports that it is takingaction in order to ensure that changes happenfollowing complaints. Early signs are thatmortality for emergency admissions is lowerthan previously, although the definitive figuresfor 2008 are not available yet.

The trust deserves credit for the improvementin the prevention and control of infection and itwas recently found to comply with the hygienecode.

Overall conclusion about the trustThis was a small trust trying to support arange of specialties. It had become afoundation trust and improved its finances.However, it did not have a grip on operationaland organisational issues, with no effectivesystem for the admission and management ofpatients admitted as emergencies. Nor did ithave a system to monitor outcomes forpatients, so it failed to identify high mortalityrates among patients admitted asemergencies. This was a serious failing.

When the high rate was drawn to the attentionof the trust, it mainly looked to problems withdata as an explanation, rather thanconsidering problems in the care provided.The trust’s board and senior leaders did notdevelop an open, learning culture, informthemselves sufficiently about the quality of



care, or appear willing to challengethemselves in the light of adverse information.

The clinical management of many patientsadmitted as emergencies fell short of anacceptable standard in at least one aspect ofbasic care. Some patients, who might havebeen expected to make a full recovery fromtheir condition at the time of admission, did nothave their condition adequately diagnosed ortreated. As late as September 2008, we foundunacceptable examples of assessment andmanagement of patients. The trust was poor atidentifying and investigating such incidents.

In the trust’s drive to become a foundationtrust, it appears to have lost sight of its realpriorities. The trust was galvanised intoradical action by the imperative to save moneyand did not properly consider the effect ofreductions in staff on the quality of care. Ittook a decision to significantly reduce staffwithout adequately assessing theconsequences. Its strategic focus was onfinancial and business matters at a time whenthe quality of care of its patients admitted asemergencies was well below acceptablestandards.

The trust deserves credit for progress oninfection control and for responding positivelyto the concerns of the Healthcare Commission.

The role of external organisationsAlthough South Staffordshire Primary CareTrust (PCT) commissioned services from thetrust, it was initially distracted by theorganisational change following the mergerthat created the PCT in 2006, and thenfocused on the number of patients treated andthe cost. They had few measures of the qualityof care or outcomes at the trust, and relied inpart on external measures such as theHealthcare Commission’s annual healthcheck. Once the concerns of a campaign groupwere drawn to their attention, the PCT tookaction to address the individual concerns ofpatients and relatives, and to investigate andhelp to improve the quality of care at the trust.

West Midlands Strategic Health Authority(SHA) had also been created in 2006 through amerger and it too suffered from theaccompanying loss of organisational memory.There was nothing to alert the SHA toconcerns about the quality of care until thepublication by the Dr Foster unit of the highhospital standardised mortality ratio in thespring of 2007. The SHA was reassured by thetrust that it was investigating mortalityappropriately.

We thought that information from the coronerwould be useful for the investigation. We weredisappointed that he declined to provide uswith any information about the number ornature of inquests involving the trust.

The national picture and lessons forother organisationsA number of the findings of this investigationin respect of acute hospital care arepotentially relevant to the whole NHS. Theseinclude the need for:

• Trusts to be able to get access to timelyand reliable information on comparativemortality and other outcomes, and fortrusts to conduct objective and robustreviews of mortality rates and individualcases, rather than assuming errors in data.

• Trusts to identify when the quality of careprovided to patients admitted asemergencies falls below acceptablestandards and to ensure that a focus onelective work and targets is not to thedetriment of emergency admissions. Caremust be provided to an acceptable standard24 hours a day, seven days a week.

• Trusts to ensure that a preoccupation withfinances and strategic objectives does notcause insufficient focus on the quality ofpatients’ care.

• Trusts to ensure that systems for governancethat appear to be persuasive on paperactually work in practice, and informationpresented to boards on performance(including complaints and incidents) is not so

summarised that it fails to convey theexperience of patients or enable non-executives to scrutinise and challenge onissues relating to patients’ care.

• Senior clinical staff to be personallyinvolved in the management of vulnerablepatients and in the training of juniormembers of staff, who manage so much ofthe hour-by-hour care of patients.

• Trusts to identify and resolve shortcomingsin the quality of nursing care relating tohygiene, provision of medication, nutritionand hydration, use of equipment, andcompassion, empathy and communication.

• Good handovers when reorganisations andmergers occur in the NHS.

• PCTs to ensure that they have effectivemechanisms to find out about theexperience of patients and the quality ofcare in the services that they commission.

RecommendationsIn this report, we have drawn together thedifferent strands of numerous, wide-rangingand serious findings about the trust which,when brought together, we consider amountto significant failings in the provision ofemergency healthcare and in the leadershipand management of the trust.

We have therefore written to Monitor, theregulator of NHS foundation trusts, inaccordance with the Health and Social Care(Community Health and Standards) Act 2003(s53(6)), to highlight these significant failings.We had previously raised concerns withMonitor about the leadership of the trust, andwe note that both the chairman and chiefexecutive have left the trust in the two weeksleading up to the publication of this report.

Irrespective of the above, we expect the trustto consider all aspects of this report, includingall our findings, which detail serious failings atdifferent levels and across different parts ofthe trust’s services. Here, we highlight whereaction is particularly important.

Action by the board

The trust’s board must ensure that there is asystematic means of monitoring rates ofmortality and other outcomes for patients.This information should inform the board’sdiscussions about the quality of services at thetrust, and also inform action taken to improveoutcomes for patients.

More generally, the trust’s board needs toreflect on its arrangements for overseeing thequality and safety of clinical care within thetrust. In particular, how the trust:

• Develops and promotes an open, learningculture.

• Collects and reports informationaccurately, both internally and externally,and in sufficient detail.

• Identifies and mitigates risks to the safetyof its patients.

• Identifies correctly, and then reports,investigates adequately and learns fromserious incidents and unexpected deaths.

• Learns from, and ensures that necessaryimprovements are made followingincidents, near misses and complaints.

• Engages clinicians and develops effectiveclinical audit.

• Considers and acts on the views andexperiences of patients who use the trust’sservices.

A&E department

Recent improvements to the emergencydepartment – confirmed by a recentunannounced visit we made to the trust – mustbe sustained and extended to ensure that theservice is safe, that it meets the needs ofpatients, and that the department isadequately staffed and equipped at all times.


Staffing and capacity

The trust must continue the work it hasstarted to recruit additional nursing andmedical staff, to ensure that care provided topatients throughout the trust, including atnight and at weekends, is safe and keeps toaccepted standards.

The trust needs to review the training andsupervision of its nursing staff and juniordoctors, to ensure that they are undertakingappropriate roles, are confident and clearabout the expectations placed on them, andare receiving all necessary support.

The trust must ensure adequate availability oftheatre sessions to ensure that it is able tohandle demand in an emergency withoutdelay, and has an effective means ofdetermining which cases requiring emergencysurgery should receive priority.

The trust must ensure that there is adequateaccess for clinical staff to advice and supportfrom medical staff in the critical care(intensive care) service, and ensure this isindependent of the availability of beds in thecritical care unit.

Standards of care

The trust must ensure that its medical andnursing staff deliver basic aspects of care,such as reviewing patients on a regular basis,monitoring their condition, and identifying andmanaging any complications that may arise.The trust must ensure that there is timelyreview of patients by senior doctors.

In the light of specific findings in this report,the trust needs to audit its arrangements forand, where appropriate, equipment used inrelation to: medication (particularly onadmission and for patients who are ‘nil bymouth’); the resuscitation of patients; non-invasive ventilation; cardiac monitoring; andanticoagulation.

National recommendations

Analysis undertaken in this and other trustsshows worrying variations across the NHS in

the quality of coding of clinical outcomes, andvariations in the extent to which statisticalinformation is used to monitor the quality oflocal services and inform decisions at a seniorlevel within NHS trusts.

This is of concern in a modern, information-driven health service where the interpretationand use of data is a fundamental means ofimproving clinical care. We recommend formallythat all NHS trust boards have access tocomparative data on outcomes for patients,including mortality, that is accurate, completeand as up-to-date as possible.

While recognising the challenges in ensuring thatmortality rates are accurate and expressed in away that does not cause unnecessary alarmamong patients, or lead to unhelpfully risk-aversebehaviour among clinicians, we believe thatmortality rates can be published in a meaningfulway to help patients to make informed choicesabout the quality of clinical care.

Boards of NHS trusts need to be focused at alltimes on the safety and quality of the servicesprovided to patients. This includes havinginformation available to boards that properlycaptures the experience of patients, so that non-executives can scrutinise and challenge the carereceived by patients.

The NHS and appropriate professional andeducational bodies need to examine why theexperience of patients on general wards in truststhat we have investigated continues to be of a poorstandard, and take urgent action to improve thequality of nursing care in these areas.

PCTs need to develop more effectivemechanisms to learn about the quality of care,the actual experience of patients and theoutcomes of care in services that theycommission, and give more priority to thisaspect of commissioning.

The NHS needs to ensure effective handoverswhen reorganisations and mergers occur, sothat information on services is transferredeffectively to the new organisation.


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