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The Healthcare Commission today (Tuesday) publishes an investigation report criticising Mid Staffordshire NHS Foundation Trust for significant failings in emergency healthcare, leadership and management.

The report states that there were deficiencies at "virtually every stage" in the care of people admitted as emergencies.

The investigation examined the care of emergency patients across their entire hospital visit, from the time they arrived in A&E, care on the Emergency Assessment Unit (EAU) and subsequent admission to a surgical or medical ward.

Problems identified by the Commission included low staffing levels, inadequate nursing, lack of equipment, lack of leadership, poor training and ineffective systems for identifying when things went wrong.

Receptionists who were not qualified to do so carried out initial checks on patients arriving in A&E, heart monitors were turned off on the EAU because nurses did not know how to use them, there were not enough nurses to provide proper care to patients on wards, and the board did not routinely discuss the quality of care.

The investigation found that these problems put patients at serious risks that undoubtedly resulted in poor outcomes for patients.

Sir Ian Kennedy, the Commission's Chairman, said: "This is a story of appalling standards of care and chaotic systems for looking after patients. There were inadequacies at almost every stage in the care of emergency patients.  There is no doubt that patients will have suffered and some of them will have died as a result.

"The investigation found there were too few doctors and nurses, vital equipment was not available when needed, patients did not receive the care they deserved, and the trust had no systems in place to spot when things were going wrong.

"When we expressed our concerns to the trust formally in May 2008, it responded positively and began to take action. Our unannounced inspection of the A&E department in the last few weeks assured us that the service has improved. Our visit raised no immediate concerns about the safety of patients.

"However, despite the recent improvements that have been made, the regulator will keep a close watch in the coming weeks and months to ensure that the trust continues to improve care."

He added: "Trusts must always put the safety of patients first.  Targets or an application for foundation trust status do not lessen a board's responsibility to its patients' safety.  We look regularly at rates of mortality across the NHS.  Any concerns such as those at Mid Staffs would be acted upon swiftly."

The Commission launched its investigation at the trust in March 2008 in response to concerns from local people and when it became clear that the trust stood out statistically in terms of the high death rates of patients admitted as emergencies.

The Commission regularly scans rates of mortality in trusts across England and became aware of an unprecedented 11 occasions when the trust's performance deviated statistically from what would have been expected between July 2007 and November 2008. The statistical analysis served as a trigger - it raised questions which the investigation sought to answer.

In response to our requests for an explanation of these rates, the trust supplied insufficient evidence to support its claim that the statistical trigger could be explained as a problem with the coding of data.

In response to the investigation, the trust has already improved the way it assesses patients arriving in A&E and has increased the number of doctors and nurses.

As part of the investigation, the Commission's investigation team, including senior NHS managers and clinical experts, conducted five visits of up to three days and two shorter ones to the trust to observe wards and clinical care. These included unannounced and night visits.

The team also interviewed over 300 people, including current and former employees at the trust, patients and their relatives. There was an unprecedented response from patients and relatives.

The Commission also analysed more than 1,000 documents and over 30 sets of case notes of patients who died.

Findings from the investigation include:

• Assessing the priority for care of patients in A&E ("triage") was routinely conducted by receptionists, who were not qualified to do so. The report cites examples of where this resulted in poor care for patients, such as an individual with an open fracture of the elbow waiting for over 4 hours covered in blood with no pain relief. Triage should be conducted by a trained clinician. Since October 2008, triage has been performed by a nurse between 10am-10pm, after which time patients are booked to see the next available nurse or doctor.
• There were too few consultants in A&E to provide on-call cover all day, every day and junior doctors were not adequately supervised. For example, between March and May 2008 there was only one consultant in A&E. The Commission told the trust to take immediate action to address this issue. There are currently four consultants in post, the number recommended by the College of Emergency Medicine for a department of this size.
• The trust had two clinical decision units (CDUs) which staff said were used as "dumping grounds" to avoid breaching the four hour target for being treated in A&E, one of which was not allocated any staff. Patients who were unwell were placed in the smaller CDU without a dedicated nurse to care for them. Patients should not be admitted to CDUs for any longer than 24 hours, after which time a decision should be taken about the best course of treatment or to discharge. Some patients were in the CDUs for three days or more. The smaller CDU was closed by September 2008.
• There were not enough nurses at the hospital properly to care for emergency patients. A review of staffing levels in A&E in 2007/08 found the trust was short 120 nurses, of which 17 were needed in A&E, 30 were needed in the surgical division and 77 on the medical wards. Although there has been a net gain of 97 nurses and healthcare support workers since January 2008, in November 2008 they were still 40 nurses below establishment.
• Nurses, particularly in the emergency assessment unit (EAU), had not had enough training. For example, some had not been trained to read cardiac monitors and, in any event, these were sometimes turned off. Patients sometimes did not always get the correct medication. Some nurses on the unit also did not know how to use the intravenous (IV) pumps correctly, which meant patients not receiving the right dose of IV fluids and medicine at the correct rate. On wards, nurses were not always able to identify when patients were deteriorating after an operation, for example, by monitoring vital signs.
• Insufficient nurses on wards meant patients did not receive good care. For example, call buttons were not always answered when patients were in pain or needed the toilet, particularly on medical wards. Some relatives claimed patients were left, sometimes for hours, in wet or soiled sheets, putting them at increased risk of infection. Patients at risk of developing pressure sores did not get appropriate care. In one ward, 55% of patients were found to have pressure sores when only 10% had sores on arrival.
• Delays in operations were commonplace, especially for trauma patients at weekends. There was no system in place to give priority to cases for emergency surgery at weekends. This means that trauma cases, such as patients with a fractured neck of femur, were often delayed to give priority to general surgical or obstetric emergencies. Sometimes a patient's operation might be cancelled four days in a row, and they would receive ‘nil by mouth' for most of the day, four days running.
• There was often no experienced surgeon routinely in the hospital after 9pm at night. Often, only one foundation year one doctor (the most recently qualified) would be responsible for covering all the surgical patients. The resident surgical officer was often quite inexperienced and was responsible for admitting up to 20 patients a night. These surgical officers might also be required to go to theatre or be called to A&E. Junior doctors have now been reminded to contact more senior surgeons if they need advice.
• The trust was found to have poor systems for the prevention of deep vein thrombosis, a major cause of death in patients following surgery. The drug warfarin is one that is commonly used to dissolve and prevent blood clots that can lead to deep vein thrombosis and pulmonary embolism. However, an audit conducted between January and March 2008 found that only 10% of the relevant patients in Cannock Hospital and 30% at Stafford Hospital were given the drug in line with the protocol of best practice.
• Essential equipment was not always available or working. For example, there was no non-invasive ventilation on the respiratory ward to help to support breathing in patients with lung disease. In February 2008, there was no or only limited portable suction available to patients who had suffered a cardiac arrest. Suction is important in clearing the airways of secretions that may be blocking them.
• An analysis of the trust's board meetings from April 2005 to 2008 found discussions were dominated by finance, targets and achieving foundation trust status. There is little evidence that poor standards of nursing care were identified and discussed.  The investigation found that poor results of surveys of inpatients or staff were not discussed in public. It found that a doubling of the rate of C. difficile infection in the early months of 2006 was not released to the board nor the public.  The investigation also found that in 2006/07 the trust set itself a target of saving £10 million. This equated to about 8% of turnover. To achieve this, over 150 posts were lost, including nurses. This was in a trust that already had comparatively low levels of staff.
• The trust was poor at identifying and investigating when things went wrong and had poor arrangements to manage risk. The trust had no effective system for monitoring outcomes for patients and so failed to identify or understand what might be the cause of the higher than expected death rates among patients admitted as emergencies. It was poor at identifying, reporting and investigating serious untoward incidents. Some serious errors happened more than once. It had high levels of complaints compared to other trusts, but information provided to the board was at so high a level of generality that the board could not determine this or how serious the complaints were. The trust was also poor at auditing clinical performance. The relevant committee did not meet for a year prior to June 2007.

The Commission has written to Monitor, the organisation responsible for managing the performance of foundation trusts, to highlight the significant failings, stressing that they must be addressed urgently.

The Commission has made a series of detailed recommendations to the trust. These include the need to continue to recruit and train additional nursing and medical staff to ensure that care provided to patients, including at night and weekends, is safe and meets acceptable standards. The trust must also ensure an adequate number of theatre sessions are available and that equipment used in relation to resuscitation of patients and cardiac monitoring is also available.

The Commission says that the findings of the investigation are potentially relevant to the whole NHS, in particular:

• Trusts, from the board to the ward, need to have reliable comparative information on care, including rates of mortality and other outcomes, and to ensure that patients receive proper care when admitted as emergencies.
• Primary care trusts need to develop more effective mechanisms to learn about the quality of care, the actual experience of patients and the outcomes of care in services that they commission (purchase), and give more priority to this aspect of commissioning.
• There are lessons to be learnt about ensuring emergency care is provided to a high standard across the patient's pathway of care from the accident and emergency department to whatever ward they are ultimately treated on.
• A poor standard of general nursing care has been a recurring theme in the Commission's investigations.  Shortcomings have related to hygiene, provision of medication, nutrition and hydration, use of equipment, and compassion, empathy and communication.  

Investigation into Mid Staffordshire NHS Foundation Trust

Investigation into Mid Staffordshire NHS Foundation Trust: Summary report  

Investigation into Mid Staffordshire NHS Foundation Trust: Terms of reference

Notes to editors:

The trust has set up a helpline that patients and their relatives can phone if they are concerned about the quality of care at Stafford Hospital - 0800 783 4310.

Information on the Healthcare Commission
The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services. 

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.
The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.

For further information contact Creina Lilburne or Sarah Robertson on 020 7448 9313, or after hours on 07917 232 143.