Ward nursing standards; the decline of patient-centred care

There have been numerous scare stories about the poor standards in hospital. Maidstone lost its Chief Executive; Basildon has been pilloried; Stafford has been taken apart and a government report has castigated the care of the elderly[1]. In December 2012 the newspapers were full of tales exemplifying the “culture of cruelty” in the NHS. Are these unique cases? I fear not. For decades my consultant colleagues in my hospital have criticised the nursing numbers on wards. For decades we have been told that the numbers meet the norms (well, almost). That does not mean the norms are right. However the constant ignoring of doctors’ concerns – made all the worse by professional divisions that have seemed to allow nurses organisational autonomy that cannot be criticised – means that they have largely given up reporting them. When a report like that on Stafford comes out the politicians bleat “If you knew what was going on, why didn’t you say something”. When they do, they are accused of whistleblowing and threatened with disciplinary action. So they’re damned if they do and damned if they don’t.

I would not wish to be racist but it is an open secret that some nurses from overseas have a different attitude to sick people from me – and from many others. There is an authoritarian streak in nurses from some parts of the world that appears to be cultural and requires patients to do as they are told. One of my patients told me a story about her mother. She (the mother, that is) had been admitted with something or other and had been written up for her usual raft of medication. On the 6am drug round she was presented with her morning pills. She remonstrated mildly that at home she took them at 8. The nurse grabbed her hair with one hand and forced the tablets into her mouth with the other.

You may wonder why no complaint was made. So did I. My patient told me that she was too frightened to say anything in case the nurses took it out on her mother later. Perhaps this is an argument to close hospitals, but people in medical difficulty have to be looked after somewhere and the scenario could occur in a nursing home just as in an acute ward.

The most appalling example of bad care happened with one of my long-term rehabilitation patients. Let us call him James. He had had multiple sclerosis for many years and had slowly become quadriplegic. However he could drive his electric wheelchair with a chin control and led an active life, going out for meals (he could swallow normally, so only had to have food put to his mouth) and to the theatre and cinema. Indeed he led the life of a normal retired man.

James came into my unit for one week in eight to give his wife a rest. Both of them were into their seventies, so she found it difficult to manage 24/7 and our care gave her a much needed rest and enabled us to sort out any medical issues.

One Friday evening James was admitted through A&E. There were problems with his indwelling catheter and he had become unwell. Considering what happened, maybe it was no accident he was admitted on April 1st.

Patients with MS who “go off” should be presumed to have an infection until proved otherwise. They go off fast and bounce back just as quickly. But anyway James was admitted to an acute ward, although his relatives asked if he could be transferred to the rehab unit where he was well known. They also asked that he be put on a low air loss mattress; he had one at home, and with careful turning he had been kept free of pressure sores.

A mattress went up to the ward under the trolley. James was put into a bed in the acute bay (nearest the nursing station) without it. After a bit he became quite uncomfortable, so asked for help. Nothing happened so he began to shout. The response of the nursing staff was to put him in a side-room as he was disturbing the other patients. He was at least given a buzzer to communicate. Of course, being tetraplegic, he was unable to use it. Perhaps he would have been less uncomfortable if he had had some analgesia. Although he was on quite a lot at home, no-one had written up his drug chart.

The blood results from A&E suggested that James’ blood sodium level was low, so he was placed on a restricted fluid regime. Possibly no-one had considered the possibility of failure of his adrenals to respond to stress, or some weird effect on antidiuretic hormone (we see this low sodium problem quite often in MS patients). However, the regime was very restricted indeed; he was given a jug of water. His intake was recorded (it was actually short of what was suggested), but the level of water in the jug did not alter. Perhaps this was unsurprising, as he was tetraplegic. He passed enough urine either through or round the catheter for the sheets to get wet, but they were not changed.

Two days passed and James had developed pneumonia. He was, at least, on an appropriate mattress by now and he was given antibiotics but it was probably too late by then; the doctors perhaps had not appreciated the need for speed, indeed pre-emptive action, needed for MS patients. So he was now quite ill, probably septicaemic.

At this point one might ask why the medical team decided, without knowing any of his previous background, that he should not be resuscitated. They sprang the decision on the relatives who, taken by surprise and realising that he was very ill, thought that the doctors must know best. On the evening of the third day they asked if they could stay, but were told they had to leave at 11pm. On the fourth day when James’ son rang at 9am to ask how his father was he was told that he was unchanged. At 1pm a message came through that James was very sick and when he and his mother arrived his father took a deep breath, and then stopped.

James’ wife asked their son to fetch a nurse. He shot from the room and found one at the nursing station. She told him he would have to wait as they were about to do their shift handover.

As if all this was not bad enough, at 6.30 the grieving relatives were astonished by a knock on the door from the ward hostess, who asked “Would James like his dinner now?”

When James’ son came to see me two days later to report all of the above he was more angry than anyone I have seen. Indeed he said he could not trust himself to draft a complaint as he might do something silly.

I was pretty angry, too. So I wrote it.

Quite a cover-up ensued, but an independent review found that what is recorded above was essentially the truth. As it happened James’ district nurse had, unknown to me, written an equally damning report of his care. No-one lost their job, or was even subjected to a warning.

I was at a meeting with the Chief Executive a while later and the case came up in conversation. I commented on its dreadful nature and my concern about what followed. “Hmm” was the reply “There was rather a lot of Dr Bamji said this and Dr Bamji said that”.

Not many consultants have written formal complaints about their own hospitals. Perhaps, given my brush-off, not many will. But if a hospital’s response to the raising of serious concerns is this negative (or more so – one consultant was suspended for doing this recently, and took the Trust to court – and won) then it is hardly surprising that we have problems in the NHS. I do not know for sure, but suspect, that the consultants at Stafford knew exactly what was going wrong in their place but had either been cowed into silence or not bothered because they knew it would make no difference.

The day after I wrote about this case the “Daily Mail” printed another ghastly story, which I reproduce below.

Dying hospital patient phoned switchboard begging for a drink after nurses said ‘No’

A patient desperate for a drink of water had to telephone the switchboard of the hospital he was being treated in to beg to see a doctor.

Derek Sauter, 60, used his mobile phone to request medical attention after his pleas for help were ignored. But when the doctor arrived he was turned away by ward nurse Caroline Lowe, who said Mr Sauter was ‘over-reacting’ and threatened to confiscate his phone. Eight hours later the grandfather-of-three, who was suffering with a chest infection, was dead.

Rather than offering sympathy to Susan, Mr Sauter’s wife of 41 years, Miss Lowe later told her that he could have been prosecuted for harassing the doctor on call.

Yesterday his daughter, Ruth Sauter, 42, said she was appalled at the way her father, a former administrator for the Healthcare Commission, the former NHS watchdog, had been let down by the NHS. ‘My father went into hospital for a routine chest infection, but never came out,’ said Miss Sauter, of Thurrock, Essex. ‘His condition was not life threatening and the nurses had specific instructions to keep close tabs on him. ‘But their appalling lack of care, and cruel behaviour killed my father. He should not have died that weekend; it was not his time. ‘It’s so much worse knowing that he died alone, thirsty and scared on that ward.’

Mr Sauter was admitted to Queen Mary’s Hospital, Sidcup, in Kent, at 9am on June 27 2008. He was admitted to a ward and given intravenous antibiotics and oxygen, but at 8.30pm he telephoned Mrs Sauter, a midwife, in distress claiming nurses were refusing to give him any water because he had accidentally knocked over the first cup he had been given. A note scrawled by Mr Sauter and discovered by his family after his death said: ‘Asked for a jug of water at 6pm and again at 8.30, told to wait for handover. Said I knocked cup of water on floor.’ In another note Mr Sauter said he was ‘getting depressed’.

Some time between 9.30pm and 11.30pm Mr Sauter was moved to a side room where there was no monitoring equipment and, although he was supposed to be checked every four hours, no observations on his condition were made. At 11.35pm Mr Sauter, who had still not had any fluids, made his desperate call to the switchboard. The following morning, at 6.51am, a distressed Mr Sauter telephoned his wife to ask her to come back to the hospital. But he died of pneumonia brought on by the chest infection less than half an hour later – before Mrs Sauter, 60, arrived. She had not been able to see him before because the events had happened outside of visiting hours.

An investigation by the hospital revealed Mr Sauter’s oxygen levels, which should have been routinely monitored, were not checked for 11 hours and had dropped 35 per cent below the recommended level.

The report concluded that were it not for the failings of Miss Lowe Mr Sauter would have survived. She has since been sacked by the hospital, but has not been suspended by the Nursing and Midwifery Council, who are investigating. ‘It’s absolutely appalling that they haven’t struck the nurse off their register,’ Miss Sauter added.

Miss Lowe, who lives in Essex, said: ‘I am so sorry about what has gone on, but there are key facts the family haven’t picked up on. ‘He didn’t press the buzzer. We got him water, but then he spilled it, so we got him another glass. We got him a jug and everything. ‘I have been through such trauma with this. I am still traumatised by it.’

A spokesman for Queen Mary’s Hospital said: ‘The Trust would like to convey their sincerest apologies for the failings in care which have been revealed.’[2]

I should hope so.

The Francis Report on Stafford has come out, broadly confirming the problems that will arise when targets come before patients. I was surprised and appalled to read that a number of individuals had made contact to report that their institution faced many similar problems (as shown above, mine did, though I was not one of the correspondents). However such reports were deemed to be outside the scope of the Stafford enquiry. Oh dear. So what enquiry will follow these up? I am quite sure that many doctors are aware of major problems in their hospitals but have dared not speak for fear of victimisation or intimidation.

 

Names have of course been changed in my account

[1] Care and compassion? Report of the Health Service Ombudsman on ten investigations into NHS care of older people. http://www.ombudsman.org.uk/care-and-compassion/home

[2] Daily Mail, 29th March 2010 (http://www.dailymail.co.uk/news/article-1261457/Dying-hospital-patient-phoned-switchboard-begging-drink-nurses-said-No.html)

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