I wrote the below to all Councillors in four boroughs plugging the photo shoot above. By the way everyone is welcome not just Councillors!
Dear Barking & Dagenham, Havering, Redbridge & Waltham Forest Councillors
Dear Barking & Dagenham, Havering, Redbridge & Waltham Forest Councillors
A recent meeting of the Save King George Hospital campaign group decided to call a photo shoot outside King George Hospital this Wednesday 1st November at midday.
BHRUT, the management board of King George and Queens Hospitals meets at King George Hospital on the 1st November commencing at 9am with a scheduled finish time of 11am.
Cllr Athwal, the Leader of Redbridge Council announced on 14th October that he, along with the Leaders of Barking & Dagenham, Havering and Waltham Forest Councils would be writing to Mr Hunt, the Secretary of State for Health, seeking that the planned closure of King George A&E in 2019 be reviewed due to the expanding North East London population.
There are signs that both King George and Queens Hospitals are already buckling under the pressure of not being able to cope with rising patient demand. Local Clinical Groups have been critical of care standards at our hospitals regarding excess death, incorrect cancer diagnosis and never events. An extract from the board papers is at the end of this email, along with some of the press about it (1)
The number of swabs left in patients is especially concerning. The Telegraph claim that for the year end April 22 swabs were left in patients in the whole of England for year ending April 2017 (2). Local CCGs give the impression 3 swabs were left in patients at King George and Queens over an unspecified period which appear far higher than the national average (1)
These lapses in safety are important because the Department of Health has given an assurance that King George A&E would not be shut until Queens was found to be of a high standard (3)
The board will be asked to support the call for the King George A&E closure plan to be reviewed. It would be exceptional for the board to do this, but NHS Chief Executives elsewhere have spoken out lately (4) The photo shoot will hopefully have Councillors from all four boroughs present. I will do a facebook live broadcast in the hope of local media using the broadcast. The BHRUT Trust Secretary has been copied in for any comments the board may wish to make.
It would be much appreciated if you could circulate this email to your contacts.
1 – Extract from Redbridge Clinical Commissioning Group September Board Papers below
Section 2: Operational Quality Improvements and Challenges Provider quality performance improvements and challenges addressed through the CQRM
6.1 BHRUT Mortality Outlier Status. 6.1.1 Since the previous governing body report the quality team supported by CSU contracting colleagues have made it a priority to progress commissioner actions to ensure an improvement in the Trusts mortality rates. We have also sought and been provided with full assurance from the Trust that they will meet all the new reporting requirements stipulated in the National Guidance on Learning from Deaths. The contractual action that the CCG has taken is detailed in the integrated performance report and confirms the contract performance notice remains in place. 146 6.1.2 The CCG continues to be significantly concerned around the Trust’s Mortality Reduction Improvement Plan which was discussed in detail at the Quality & Safety Committee (QSC) in September; that although an improvement plan has been put in place, we are yet to see a reduction in their Summary Hospital-level Mortality Indicator (SHMI) rates. The Trust’s plan included a new mortality improvement programme, new delivery trajectory, mortality reduction programme risk log and their mortality reduction programme governance structure. This provides assurance to the QSC that as the responsible commissioner, we are taking this extremely seriously and it has been escalated to our regulators, NHSE and NSHI. It was noted at the Committee that the [second] mortality reduction programme is a vast improvement in comparison to the previous one, but that the Trust had not provided any explanation for the increase in their SHMI and their Hospital Standardised Mortality Ratio (HMSR) from March 2016. Concerns were raised that almost every action in the improvement plan had the same owner and confirmation was provided to the QSC that has been communicated to the Trust. 6.1.3 The Trust report that early indications from their internally available raw data show that BHRUT’s HSMR level is coming down; however this is not reflected in the nationally available data which has a 6 month reporting lag. It was agreed that a gateway process to review the plan every 2 months will be put in place. Fluctuations in the reported SHMI reflect actions taken 6 months ago, so it was agreed that we should not expect to see an improvement from BHRUT mortality reduction actions until the spring of 2018. 6.1.4 The Committee was in agreement that they were not assured by the documents provided by the Trust. Next steps to be agreed prior to the next Q&SC meeting in October. 6.1.5 The Trust have provided assurance that they have a clinically lead improvement plan in that place that will ensure patients presenting to the emergency departments with pneumonia receive the required care. This plan was developed following the external review of people who died with a diagnosis of pneumonia. The review report has now been shared with commissioners following a formal request.
6.2 BHRUT – Never Events 6.2.1 As previously advised, BHRUT has declared three Never Events related to retained objects during surgery. Following the second Never Event, the Trust commissioned a perioperative review by the Association of Peri-Operative Practice (AfPP). The review was undertaken from 3 to 5 May 2017, and a report summarising the findings and recommendations has been provided to the leadership team of the anaesthetics directorate. This has informed an action plan to ensure a review of processes, quality standards, training and education to ensure the delivery of safe perioperative care. 6.2.2 The serious incident reports have been submitted to the CCG for review; the first was reviewed at the August Serious Incident Panel and the second and third to the September panel. The first report was subject to a number of further information requests prior to the SI Panel, and discussed at length at the SI Panel in August. Our assessment was that there was evidence in the report that the environment in theatres at the time of the incident was not conducive to safe surgery and that there should be further detailed analysis to identify the reasons why staff did not adhere to the swab count policy. The SI Panel also noted that the lessons learned and actions were weak and needed further review by the Trust. The report was not approved, and a revised report is expected for the September SI Panel. 6.2.3 The SI reports have identified a number of issues to be addressed, such as reduced staffing compromising safety; that there was a lack of explicit leadership within the theatre; and that there is no mandatory training for swab counting or formal competency assessments for new and existing theatre staff. However, the actions to prevent recurrence are more statements 147 of intent (such as “there must be adequate staffing throughout every operation in Theatres” which will form part of the internal quality walk around audit). The reports do not consider the pressure that staff are under to cover both elective and emergency surgery, and the lack of leadership from medical staff to ensure that all staff are in attendance at the beginning of the operation, and to support and enable nursing and junior staff to follow the swab counting protocols. There are also concerns that operations are being carried out without a full complement of staff, as staff are leaving the theatre to scrub for emergency operations. It is anticipated that the Trust will provide assurance of the actions in place to prevent these potential care failings happening again when the revised reports are submitted. 6.2.4 Two of the reports indicate that junior staff present during the operations knew that swabs had been retained, but did not feel that they could challenge senior medical staff, which reflects a low safety culture which must be improved on. 6.2.5 The AfPP report states that Anaesthetics do not have any theatre education posts (these posts have not previously existed) and there is not funding for this within the existing theatre staffing establishment. These posts are key to supporting a formal structured induction for new staff and to standardise competency assessments and the delivery of simulation training sessions alongside clinical practice. The report notes the cost pressure and that there is a strategic outline case developed and to be submitted to identify potential funding. If this is not funded by the Trust, there is a risk that junior staff will find themselves in a position whereby they are made responsible for swab counting when they have not receive training nor been competency assessed, and these Never Events could recur. 6.2.6 Challenges to the AfPP report will be made at the CQRM on 11 September, and outstanding concerns will be escalated to the SPR. 6.3 BHRUT -
Delayed and Missed Diagnosis 6.3.1 Over the past few months we have seen an increasing number of serious incidents coming through specifically related to missed or delayed diagnosis for cancer. In addition to the SIs being declared by the Trust the GP Alert system has also recently identified a case of potential clinical harm as a result of delayed reporting and the Trust not acting on the radiology results. 6.3.2 Whilst we have sought and been given assurance that BHRUT are managing this quality risk and have an improvement plan in place for radiology services, at both the external clinical harm review panel and the CQRMs, from the information available the level of risk has now escalated. This has been added to the CCG risk register. 6.3.3 Concerns have also been raised by HM Coroner, which issued a Regulation 28 against the Trust on 10 March 2017 for similar concerns. 6.3.4 Although the Trust has given assurance that they are managing the risk, the level of risk has now escalated which is very concerning. The full details of the serious incidents presented to the Committee in the report and were discussed in detail. JH advised that an unannounced quality visit had taken place and that the Trust had failed to demonstrate their capability in managing their own alerts. 6.3.5 At the next CQRM, the Trust will be giving a presentation on radiology improvements and what their top topics are and following that a discussion will be held with the Trust at the Service Performance Review (SPR) meeting. The Quality and Safety Committee were not assured by this and require evidence as to how robust the Trust’s action plan is. 6.3.6 The QSC considered a detailed paper outlining the details of all the reported never events and have made recommendations for further assurance which will be progressed through the CQRM and SPR.
Below is one of the press reports as a consequence of the CCG report
2 - Is a Telegraph Extract referencing never events
3 – The guarantee given to NE London Residents which should be honoured
4 Examples of senior NHS staff speaking out against cuts – which is what the closure of King George A&E is