Mid Staffordshire Investigation

March 20, 2009



What were the reasons for the failings at the trust?

“It is the view of the Healthcare Commission that there were deficiencies at virtually every stage of the pathway of emergency care. This can be illustrated by following the patient’s pathway.

When patients arrived in A&E, they were usually assessed by reception staff with no clinical training, before waiting in an area out of sight of the staff in reception. There was no regular check by nursing staff of the patients in the waiting room. Some essential equipment, such as cardiac monitors, was missing or not working. Assessment and treatment were often delayed.

There were too few doctors and nurses, alongside poor training and supervision, and junior doctors were put under pressure to make decisions quickly without advice and support from more senior doctors. Doctors were moved from treating seriously ill patients to deal with those with more minor ailments, in order to avoid breaching the four-hour waiting time target. Patients were moved to the clinical decision unit to ‘stop the clock’ but were then not properly monitored, since this area was not staffed. Patients had to wait for medication, pain relief, wound dressings and antibiotics. There was only a relatively junior doctor available after 9pm to give advice on surgical patients. There was no specialist trauma team. In summary, the care and assessment of patients fell well below acceptable standards.

Sometimes patients were rushed to the emergency assessment unit (EAU) without proper assessment or discussion, and without appropriate specialist care. The EAU was a large ward with a poor layout. It was busy, noisy and sometimes chaotic with too few nurses. Many of the nurses did not understandthe cardiac monitors and did not always carry out observations adequately to identify whether a patient’s condition was deteriorating. There were many instances of patients not receiving the medication they needed.

There were too few beds for patients who had had a stroke, not all patients with heart attacks went to the acute coronary unit, there was no non-invasive ventilation on the respiratory ward, and critical care beds were not always available. The medical wards on floor two were seriously understaffed and there were grave concerns about the standards of nursing care.

There were too few theatre sessions at weekends and consequent delay in getting to theatre, especially for trauma patients, and some patients did not get essential medication. Post-operative complications were not always recognised.

Surgical practice was idiosyncratic, relationships were poor and there was little multidisciplinary team work. There were concerns about the level of cover by medical staff at night and at weekends.

Across the trust, there were shortcomings in resuscitation and arrangements to avoid potentially fatal blood clots were inconsistent. There was a shortage of critical care beds and concern about access to medical advice from critical care specialists.

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