Yes, They Really Should Have, Shouldn't They?

"I can't believe they did what they did. Someone should have checked everything they needed was there before they got my mum into theatre.

"I just hope we don't experience anything like it again."

So much for the NHS being the wonder of the world...

Adam Brooks, clinical director for specialist support, which covers operating theatres at NUH, said: "We're sorry that Mrs Taylor's operation was delayed on 1 December.

"The specialist equipment (metal plates and screws) needed for her surgery had not returned from being sterilised – which is vital for the safety of such a procedure. We apologised to Mrs Taylor at the time and were able to reschedule her operation for the following week.

"All of our theatres equipment at NUH goes through a thorough checking process to ensure everything is of the highest quality and within sterilisation dates."

Look, Adam, no-one's suggesting that it doesn't, or that it should be any different. What they do expect is that your surgical staff should ensure they have everything they need to hand before they start searching for a place to stick the epidural.

It's only common sense, after all. Haven't your staff ever put together anything bought from MFI or IKEA?

Oh, Well, So Long As The Paperwork's In Place....

A father has hit out after a York Hospital doctor failed to consult next of kin before filling in a “do not attempt resuscitation” form for his son.

Gosh, and they said this’d never happen!

… kidney patient Andrew Watson’s condition deteriorated one night while his parents, Peter and Sheila, were asleep at their home in Wigginton.

Peter Watson only found out the following afternoon about the decision not to attempt cardiopulmonary resuscitation if his son went into cardio respiratory arrest.

Whoops! However, the hospital has an excuse ready.

Not a good one, admittedly:

However, hospital bosses said a DNACPR form was not a consent form, but was intended as a record that a discussion about the decision had taken place.

*BZZZZZT!*

Still wrong. Because no discussion had…

Mr Watson said he disputed some of the findings of an investigation into the incident.

He said: “I do not intend to let this lie, as I do not want any patient, partner or next of kin to be put through the same distress that we had to suffer, and I don’t believe the trust will do anything constructive if left to manage it themselves.”

Does anyone? Anyone at all? Bueller?

Sarah Lovell, directorate manager for acute and general medicine, who investigated the matter, said in a report that Andrew had not been well enough for the decision to have been discussed with him and the doctor concerned had intended to discuss it with his next of kin.

Well, that road to hell is just paved with intentions, eh, Sarah?

She acknowledged staff could have made more pro-active attempts to arrange for a discussion much earlier in the day.

And could have, say, not simply filled the form in regardless….

Accountability? What Accountability..?

A GP who sent a four-year-old girl home with a fatal pneumonia infection can continue practicing medicine after a hearing found he had “learned his lesson”.

Oh, really?

Dr Shoab Ibrahim failed to listen to the concerns of the girl’s parents and did not carry out “simple but important” tests that would have shown she was seriously ill.

Yes, clearly a very easy mistake to make for someone whose job consists mostly of listening to patients and then ordering tests….

/facepalm

Ibrahim, who practices at the Robert Frew Medical Centre, in Silva Island Way, Wickford, was told by the General Medical Council he was guilty of misconduct in his treatment of the girl, but that his failings were “highly unlikely to be repeated”.

Panel chairman Sheleen McCormack told him: “You have shown insight into your misconduct and you have remedied the deficiencies in this case.

“The panel does not consider your fitness to practice is impaired.”

That doesn’t seem to jibe with this part of the summing up, though:

Ms McCormack said the girl’s parents had been “clear, consistent and reliable” in their evidence, whereas the doctor was “inconsistent in several material respects”.

That sounds very, very close to ‘We caught you out in a lie several times’. Doesn’t it?

Ibrahim, who qualified in Pakistan in 1988, can now continue practicing without restrictions as a result of the decision.

Great. Glad he isn’t my GP.

They Shoot Horses, Don't They?

The family of an elderly patient who died from dehydration said they were forced to give him water through a damp flannel - after hospital staff refused to put him on a drip.

One nurse allegedly told the man's daughter: 'You can take a horse to water but you can't make it drink' just days before he died.

If you treated a horse the way you treated that man, the RSPCA would want a word...

Another blundering doctor even said Kenneth was ready to be discharged only hours before he passed away - and told coroners his family were happy with his treatment.

Can you be done for perjury in a coroner's court?

Bosses at Royal Derby Hospital, where Kenneth had undergone a routine hip operation, have admitted a string of failures at an inquest into his death.


The hearing even discussed whether Mahya Mirfattiahi should face a police investigation for initially telling a coroner's officer the family were happy with his treatment.

No surprises what conclusion they eventually came to...

But Coroner for Derby and South Derbyshire, Robert Hunter eventually decided not to refer the doctor's actions to police.

Shocker, eh?

Dr Hunter was due to record a verdict last night - telling the family it could be one of accidental death, with a rider of neglect.

And it came to pass that this was, indeed, the verdict.

Brigid Stacey, director of nursing and midwifery, told his inquest: 'I offer sincere condolences to the family of Mr Walters and formally apologise for the insufficiencies.'

That's nice, dear. Who's losing their job, then?

Oh, no-one? How surprising...

The Strange Case Of Abiola Abara

Abiola Apara, 58, was sacked after a string of concerns were raised over her management of the hospital’s Lionel Cosins elderly people’s ward.

But it took a while:

Apara was initially suspended following complaints from staff and patients in spring 2007. Then, in September 2007, the entire ward was re-staffed. The hospital has refused to release details of its probe or comment on any irregular activities, but a source confirmed the investigation into Apara had looked into her recruitment of nurses.

And what was wrong with her recruitment of nurses?

The concerns came to light after Eileen Curry made an official complaint about conditions on the ward. Mrs Curry, 66, of Weathersfield Way, Wickford, complained following the death of her mother Catherine Talbot, 89. She was admitted to the hospital in April 2007 with shingles, and died the following month from blood poisoning caused by an infection she received in hospital. Mrs Talbot also caught superbug Clostridium Difficile while in the hospital. Mrs Curry told the Echo: “I was shocked when the hospital explained to me why conditions on the ward were so bad, partly because of the manager’s involvement in recruitment. “My mother was partially-sighted and deaf. She would have struggled to hear anyway, but the strong accents made it even harder for her to know what was happening. Many of the nurses failed to have any empathy with the patients, and were also rough with my mother. “It is nearly four years since my mother died, and the tribunal is only just happening.”

Ah. There’s a lot of clues here, isn't there?

Alan Whittle, hospital chief executive, wrote to Mrs Curry about her original complaint and stressed staff should look after patients regardless of any cultural differences.

Hmmm, that sounds awfully familiar….

Spending Other People’s Money On Other People….

The Fryatt Hospital and Mayflower Medical Centre in Harwich, Essex, opened in December 2005, having been built using a scheme similar to the private finance initiative (PFI).

Yay!

Oh:

But since its opening, the hospital has been dogged by problems.

There was a three-year delay in getting GPs to move into the centre, half the floor had to be replaced, people were unhappy with the fact that its minor injuries unit was not open at night, and its x-ray department was cut to three days a week.

However, most complaints centred on the fact that its operating theatre was not being used. It was intended for minor procedures including foot operations.

Now North East Essex Primary Care Trust, which runs the hospital, has admitted it never will be.

Don’t panic, though! No-one’s been sacked or demoted for this. You see, it’s all the fault of…unforeseen changes.

Well, the lack of use of the theatre part, anyway. The report doesn’t say what amazing, innovative excuse the Trust came up with for all the other complaints…

Matt Bushell, acting chief executive, said changes in patient safety regulations regarding anaesthetics since its opening meant the operating theatre was now no longer "viable".

It’s impossible to renovate it, then?

A spokesman for the trust added that it had been "the victim of unfortunate timing" regarding changes in legislation.

Or the victim of utterly incompetent management…

Mr Bushell stressed that the theatre only took up about five per cent of the space of the hospital, which offered more than 60 health services.

John Brown from Harwich Town Council described the new hospital as a "white elephant" and said: "It has been a waste of money."

"For the millions it cost to build the new hospital they should have spent a fraction of that renovating the old hospital," he said.

Quite…

"Ah, my children of the NHS. What beautiful music they make..."

A pensioner died after his chest was bled 'empty' when he was wrongly connected to a blood pumping machine and a hospital worker left the room.

NHS staff failed to use enough clamps to disconnect 76-year-old Dr John Baines from the device after a gruelling six-hour bypass operation, on January 29.

This meant his blood was pumped into the machine, which was filling in for his heart and lungs during the surgery, but not pumped back into his body.

Someone will swing for this, surely?

Deputy Assistant Coroner Mairin Casey ruled that no one member of staff was to blame and his death was caused by a 'series of collective errors'.

Wha..?

In a bypass operation, the pumps are operated by specially trained health professionals known as 'perfusionists', who work with the surgical team in connecting and disconnecting the machine to the patient.

However, the perfusionist who had been involved in the discussions about the complex operation was replaced before it began by two others, who oversaw the machine during the surgery.

One of them, Andrew Sutcliffe, said they clamped the line from the patient's neck and assumed two other clamps required had been attached by other members of the team.

He said: 'I think the issue is that we had clamped the common line. But clamps hadn't been applied where we would have expected them to.'

And you didn't think to check? Somehow, 'professional' isn't the word I'd have used...

Miss Casey recorded a narrative verdict and said the mistake was the result of collective rather than individual error.

She said: 'I'm confident that from the earliest point the human error was acknowledged to the family and to all who needed to subsequently investigate this matter.

'I'm also satisfied that there's no culpability in respect of an individual in this case.'

Nice! In effect, so many of you screwed up it'd be 'unfair' to hold any one of you responsible, so you get off with a massive fine (paid for by us taxpayers, of course) and a 'lessons have been learned' statement.

"I think we've relied on an assumption that doctors, when they come out of medical schools, are competent to prescribe."

A seven-month-old baby boy died after doctors gave him 12 times the correct amount of anti-epileptic drugs he should have received in 24 hours, an inquest heard.

A mistake? A single doctor's error compounded by tiredness and overwork?

Well, not really:

Medical staff involved in his care, including a consultant paediatrician, a specialist registrar and a senior house officer, were suspended from prescribing medicine and could still face disciplinary action.

'Could'? In any other profession, that would be a 'will'...

After Lucas's death, the senior registrar was forced to take two prescribing tests but failed both.

If that's the senior registrar, can you imagine what the juniors are like?

Head Injury? Well, Maybe...But You've Had A Few Sherbets, Haven't You?

Following on from Dick Puddlecote's post yesterday, it seems alcohol + illness makes it hard to diagnose - particularly for those medics who have already made up their minds:

Confused and in distress, this man seems to be in need of medical attention.

But when this picture was taken, Arnold Siddall had just been dumped outside a hospital A&E department because staff thought he was drunk.

In fact he had suffered a fractured skull, but no one at the hospital read a form written by a paramedic which said the 47-year-old had hit his head on a pavement.

So he was turfed out, and eventually arrested. Whereupon, on suffering a fit, he was brought back to hospital. Too late.

Now a coroner has ruled that Mr Siddall could have survived had he been treated at once, rather than a full 14 hours after his fall.

His family released the poignant image of his final hours yesterday as they demanded assurances that no patient could ever be betrayed by the NHS in the same way.

Good luck with that!

The trust has paid his family a five-figure out-of-court settlement negotiated through solicitors Pannone and has apologised for Mr Siddall's treatment.

Anyone want to bet this won't happen again?

Toddler sucks on used needle at 'health' centre

Here we have another example of the age old problem of a lethargic attitude in the public sector.

A toddler's parents must wait 12 months to discover whether he has been infected by a discarded needle he put into his mouth at a health centre.

Harvey Mills, aged 21 months, took the hypodermic needle from a bin in an open cupboard at Cannon Street Health Centre, Hathershaw, Oldham.

Harvey's mother Shareen Mills, 28, was holding his four-month-old brother for an injection when she looked up and saw Harvey with the needle in his mouth, standing next to an overflowing sharps bin.

Health officials have apologised and have started an investigation

I should bloody think so too.

[Gail Richards, chief executive of NHS Oldham, said:] "We have also issued immediate instructions to all NHS staff emphasising the importance of ensuring sharps bins are kept secure and used appropriately at all times."

Why should this need to be emphasised at all? Isn't it simple common sense? A jeweller wouldn't leave a display cabinet unlocked and unguarded while he/she pierced another customer's ears, yet we regularly hear of NHS workers going about their duties in an incredibly cavalier manner?

At least the jeweller would just lose some stock, which isn't ideal, but is easily rectifiable. There is more than just a financial penalty for cock-ups in the NHS though. In this case, it's possible that a child's entire future could be blighted due to one startling lack of diligence.

Source: BBC Manchester

Quangoes of the week

From AOLNews:

Public Health Minister Dawn Primarolo will announce the new Alcohol Improvement Programme at the National Alcohol Conference in Nottingham. It is hoped the £6 million* measures will help reduce alcohol-related harm.

They include establishing regional alcohol managers, pulling together local information, and increasing access to specialist treatments. Twenty of the most deprived primary care trusts (PCTs) in the country will share £3 million of the funding...

Another £2.7 million will be spent on regional alcohol managers and £450,000 will go to the National Support Team.

An extra £1 million will fund a new Alcohol Learning Centre.

Via The Fat Bigot, who sumarises thusly: "Perhaps £1million out of the 6 will actually go directly into something that might improve patient care, the rest will be spent generating and circulating paper. What better example do we need of the futility and wastefulness of government-led, top-down management of a service?"

* Maybe they'll fund this from the 10p tax on plastic bags that they are thinking of introducing in Wales? See previous post.

Big Government f***s up, yet again (2)

The new contracts for NHS dentists which our very own government introduced* turn out to be a fraudsters' charter.

* Or indeed imposed, depending on your point of view. I know of nothing that suggests NHS dentists were actually lobbying for such changes, above and beyond the usual "Can we have some more money, please?"

Waste in the private sector

When you point out how wasteful and inefficient the State sector is, the traditional Leftie retort is "Ah yes, but there is waste and inefficiency in the private sector as well".

To which the counter-retort is "Ah yes, but the consumer doesn't pay for the waste; the consumer only pays what the goods and services are worth. Plus 17.5% VAT where appropriate. For example, 'Waterworld' may have been the most expensive film to make of all time, but the film was not that brilliant that cinemas could charge people double the normal price to see it."

In case that doesn't shut them up, or they ask "Who does pay, then?" or in the unlikely event that they say "Then the poor long-suffering shareholder must bear the cost", then is useful to look at a real life example; the Blu-Ray vs HD DVD 'war'.

Sony and Hitachi spent oodles of money in developing rival formats. If you were a shareholder in Hitachi, then you have paid an element of R&D and lost your money, and if you were a Sony shareholder, the gamble has paid off nicely*. But most sensible shareholders in Japanese electronic giants would own shares in both companies, so the only question is, do the gains (future income from licensing the Blu-Ray patents) exceed the cost of developing both formats? Almost certainly yes. So the shareholders haven't really lost out either.

So yes, superficially there is 'waste' in the private sector, but it doesn't really matter.

In any event, it pales into insignificance when you read about the NHS hospital wards crawling with vermin.

* When you think of the rival formats that Sony has developed and miserably failed to market, for example MiniDisc and ATRAC (instead of MP3) and so on, they had to get lucky sooner or later.

"Health inequality gap widening"

Nulab are so obsessed with the fact that better-off people's life expectancy is improving faster than that of people in 'deprived areas', that they forgot to give themselves a pat on the back for improving life expectancy by an average of 2 years over the last decade (at enormous cost to the taxpayer, of course).

Oh ... which is a piss-poor result really, seeing as life expectancy increased by an average of 2.7 years every decade over the course of the twentieth century.