Hospital Scandals

These are two of the major hospital scandals that have occurred in the 20th century and highlight the importance of teamwork and communication within the NHS.

Definitions

Inquiry: A request for information.

Inquest: A judicial request for information that follows an incident or death.

Independent Investigation: An inquiry into potential misconduct by an external person/organisation. This is gold standard investigation as it is not subject to bias like an internal investigation.

Review: A formal assessment with the intention of establishing change. This often follows and inquest and investigation.

Whistleblowing: An employee who reports unlawful or unsafe activity within a public or private organisation.

Stafford Hospital Scandal

Between 2005-2007 “conditions of appalling care” (as stated by the Care Quality Commission) led to 400-1200 avoidable patient deaths:

  • Patients were not given food or water.

  • Patients’ calls for help were unanswered - some were left in soiled sheets or unwashed for months.

  • Misdiagnoses were frequent.

  • Medication wasn't given on time or at all.

  • Bandages became infectious as hospital staff didn’t replace them.

Causes of the Scandal

  • Chronic Understaffing.

    • Shortage of health care assistants and senior doctors.

    • Junior doctors were alone at night.

    • Receptionists had to triage A&E patients (determine the urgency of a patient’s condition; thus, the order in which they receive treatment) rather than a qualified triage nurse.

    • Low staff moral due to overworking and understaffing, leading to staff dropout.

  • Bullying of staff who tried to speak up.

  • The Mid Staffordshire NHS Trust attempted to save £10 million in 2006-2007 in order to get foundation status, taking even more money away from the hospital.

Who Failed The Patients?

The Francis report was published on 2013 and it examined the causes of this great failing of care:

It can be attributed to all the levels of care:

  • The doctors and nurses for not whistleblowing (however many who did were harassed and bullied).

  • The Trust for attempting to save money and hide unusually high death rates under “coding errors”. It also changed some data retrospectively.

  • Health Care Commission (which has now been replaced by the Care Quality Commission) for not investigating the hospital sooner, therefore, causing more unnecessary patient deaths.

In fact, the inquiry into the hospital only occurred after the “Cure the NHS” campaign. This was launched by Julie Bailey after she lost her mum in the Stafford hospital, and saw the abhorrent conditions and neglect of patients. When she spoke up about it, it encouraged many other to do the same

Outcomes From the Scandal

The Francis report made 290 recommendations for change. Outcomes included:

  • The mortality rates of all NHS hospitals have been made publicly available.

  • The trust lost its foundation status and certain departments were closed.

  • The Nursing and Midwifery Council held hearings about some nurses working in the Trust after allegations proposed they were not fit to practice. The NMC struck off several nurses.

  • Greater protection for whistleblowers.

  • Guidelines on staffing levels in the NHS and increased training of nurses.

  • New Revalidation schemes for Nurses from 2016 onwards (see: Medical Revalidation).

Shropshire Maternity Scandal

This involved two hospitals located in Telford: The Royal Shrewsbury hospital and the Princess Royal hospital. Donna Ockenden, a senior midwife, set up a review in 2017 which revealed 201 avoidable baby deaths and hundreds of other babies coming to harm in the two hospitals since 1979.

It was first flagged by the Stanton-Davis family in 2009 after Rhiannon Davies lost her daughter, Kate, due to numerous failings by the hospital including:

  • Her pregnancy wasn’t flagged as high risk.

  • Her condition was incorrectly monitored.

  • When born, Kate was anaemic and hypothermic yet a nurse placed her in an unheated cot.

Kate was found by a healthcare assistant in cardiac arrest and she was transported to Birmingham hospital but died on route. An inquest into Kate’s death came back as “unavoidable” so the parents challenged the NHS. The Stanton-Davies family and others wrote to Jeremy Hunt (the health secretary then) who ordered an independent investigation led by Donna Ockenden. This found systematic failings within the Shrewsbury and Telford NHS Trust.

Causes of the Scandal

  • There was a culture of bullying and harassment amongst the staff, preventing whistleblowing.

  • There was a breakdown of relationship between doctors and nurses preventing collaborative working across the disciplines.

  • 40% of stillbirths and neonatal deaths were not investigated and so errors were repeated.

  • Investigations for serious incidents were internal and “inappropriately downgraded” rather than thorough external investigations.

  • Parents were not listened to, and patients weren't treated with “respect and dignity”.

  • Many families were denied Caesarean sections even when they were considered safer (C-section are roughly £1000 more expensive for the NHS than vaginal births).

Outcomes From the Scandal

Ms Ockenden identified 60 specific improvements that could be made and seven immediate actions for all maternity services including:

  • More urgent investigations involving family inquiries.

  • Increased investment into the maternity workforce and training.

  • Increased accountability for the improvement of care among senior maternity staff.

On top of this, the Care Quality Commission rated the services of the Shrewsbury and Telford NHS trust as “inadequate”, placing them on special measures and under frequent observation.