Monday, 23 April 2012

NHS Failing to learn from mistakes (Guardian)

Firstly we hope you like our new layout. We thought it was time for a bit of a 'Spring clean' in here, dust away the cobwebs and put a fresh face on it. I love it!

The content remains the same though, so be prepared for more posts from Robin and I on all things health.

This week I am drawn to an article in the Guardian newspaper with the headline;
'NHS failing to learn from mistakes, says ombudsman Dame Julie Mellor'.

When I first saw the headline I thought 'well that's not going to be of any interest to our readers because I'm sure Dame Mellor is
the parliamentary and health service ombudsman for England'. Indeed she is, however, the story she is referring to is from Aberystwyth - must be bad if England are getting involved eh!

The Ombudsman for Wales, Peter Tyndall, was asked to look into a case involving an 81 year old male patient with diabetes who died whilst in hospital.

Upon review of the case it seems there were a number of holes in the charts for the patient, including blood sugar monitoring, which begs the question as to whether the monitoring was even carried out in the first instance. Worrying.

I want to quote a couple of paragraphs because I think they are important points:

Tyndall's report said Joseph had a hypoglycaemic attack, caused by low blood sugar levels, to which the hospital's failings contributed. The attack had an "unspecified causal effect" on his subsequent cardiac arrest and deterioration, that left him needing 24-hour nursing care. He died, aged 81, in April 2009, days after being discharged to a nursing home.

Joseph's (the patient) daughter, Rowena Jones, a nurse at another hospital governed by the Hywel Dda health board, said: "I've worked in the NHS all my life. I love the NHS but I'm not prepared to defend poor record-keeping, poor nursing, poor management and lying."

This patient died in 2009, which means that, in order to get to the point of having a verdict from an Ombudsman, this family have had to wait 3 years. That's a very long time, in my opinion, to realise something so straight forward and fundamental led to the death of an elderly man, reliant on the care of others.

It seems that the Ombudsman thought it was an unacceptable period of time to wait also as he fined the Health Board £1700 for the time taken to pursue their complaint.

A few weeks back I wrote a complaint to Cardiff and Vale Health Board relating to a hospital stay I had, whereby the staff had failed (among other things) to write in my notes from 8.30am to 4.30pm, despite monitoring my BP and urine ketone levels. I was told by some anonymous reader that my complaint was trivial, however, I think this post highlights the importance of regular record keeping.

I suppose, to finalise this, I should put in the quote from the Health Board, all things being fair:

"The health board takes seriously any allegation of breaches of professional standards and will always investigate these as it did with the previous case. All nursing staff have been reminded of the professional standards expected of them by the health board and their professional body, the Nursing and Midwifery Council."

And look - another HB blaming their staff!

Lynnette Spragg

1 comment:

  1. I should like to notify previous readers of the blog, 'Two Flew Over..' set up in May 2011 that I , Gillian Brightmore, am no longer associated with, or have anything to do with ,the blog ,'Birds of a Feather...'

    As Timothy A.Pychyl points out in, 'Psychology Today' the old adage does still apply that, "birds of a feather flock together" and that the use of language is a, "good indicator of personality." Furthermore that a , "personality can be judged from linguistic expression." Need I say more.