Abertawe Bro Morgannwg: Trusted to Care?

(Pic: Wales Online)

Back in May, an independent review into care standards at two hospitals in the Abertawe Bro Morgannwg (ABM) Local Health Board – Princess of Wales Hospital, Bridgend and Neath Port Talbot Hospital – reported back to the Welsh Government (Trusted to Carepdf).

The review – led by the University of Sterling’s Prof. June Andrews and The People Organisation – was prompted by highly-publicised failures at both hospitals to provide good quality care to elderly patients. It was set up in 2013 at the request of Health Minister, Mark Drakeford (Lab, Cardiff West), concentrating on four areas:

  • Care of older patients on medical wards.
  • Administration and recording of medicines, in particular relating to patients who might be considered difficult or impaired.
  • Standards of nursing, and how ABM responded to lapses in standards.
  • Complaints procedures, how ABM responded to these complaints and how ABM held staff to account for failings.

This was hard to write (for obvious reasons) and I was tempted to pass on it, but it was too important to ignore.

This is a very emotive topic in Bridgend – on both sides – and I’m well aware of the seriousness of the allegations made with regard neglect at hospitals in the wider region.

I know there are calls for “heads to roll” over this, but you have to realise that all I have to go on is whatever’s presented in the report itself. I refuse to chuck anyone under a bus without hard evidence. So – for once – sod the politics.

The Review’s Findings

Vulnerable patients are sometimes difficult to handle – For example, “nil by mouth” is a standard medical practice which may result in what many would consider neglect, especially if a patient becomes dehydrated or is unable to take medication because they can’t swallow it. Because of staffing pressures, there wasn’t always someone available to assist patients with basic things like going to the toilet or washing, with horrifying examples given of patients being left in their own excrement. It’s unacceptable to relatives, politicians and the media (pretty much everyone to be frank), but is a sad reality of the modern NHS.

The culture of care was “muddled”– Some failings were completely avoidable if the right training were given. Nursing and medical staff at the Princess of Wales Hospital didn’t know how to help address common problems facing frailer, elderly patients (dementia, hygiene, fear etc), while ABM’s board haven’t paid enough attention to problems these patients face. A patient is quoted as saying that nurses are sometimes unable to look them in the eye because, “they know it’s (what they’re doing is) wrong”. It’s even said little things like the revolving door main entrance to the Princess of Wales Hospital places a specific challenge on elderly patients that’s been overlooked.

Poor management of public expectations
– The review said there was often an “uncritical faith” amongst the public in local hospitals. Care standards in hospital often aren’t the same as the more focused one-to-one care elderly patients might receive in a care home, or even in their own home. This is why there’s such a push to provide more care “in the community” because it genuinely would be better for them. Some relatives even wanted to be warned beforehand that what they might consider poor care is “something that might happen” in hospital. This would allow them to put arrangements in place themselves, like helping at mealtimes. Because ABM carefully managed information to stop rumours getting out of control, their own lack of openness on the standards of care patients could expect to receive meant some relatives came to suspect criminal neglect or harm – regardless of whether or not there was hard evidence supporting those claims.

Care for the dying was poorly handled – The report says around a third of all patients admitted to hospital are a year from death. There were rumours of euthanasia – which didn’t happen – but because ABM had developed a reputation for “covering things up”, or not being upfront about its own failings, it got out of control. Where patients were nearing the end of their lives, death wasn’t properly communicated to the relatives by medical staff, their handling of the issue being described as “unsophisticated”.

There were serious failings in administering medicines to patients – Some patients never got their medicines on time due to how medicines were managed, while anti-psychotics and sedation were used on patients with suspected dementia without a proper risk assessment. Sometimes medicines were simply left out for patients to take themselves, even if they couldn’t do so without assistance. The review team said they were “dismayed at the extent by which….staff….knowingly tolerate this hazardous, prohibited and unjustifiable practice”.

Failings in nursing leadership – The nursing management structure at the Princess of Wales Hospital, and across ABM generally, is described as“complex and difficult to understand”. There are too many nursing job titles, a large number of newly-qualified nurses replacing experienced staff, and above average sickness levels (a sign of poor morale in my book). Individual nurses worked well, but many lacked the confidence to work outside of their specialist area, taking a “not my problem” approach to certain patients. Because of a lack of doctors, nurses were often left to explain things to relatives, creating the impression that problems were a result of nursing standards alone when poor management was a bigger issue. Poor management of shift patterns also created an inflexibility where nurses often weren’t available in the right place at the right time.

ABM Local Health Board : too many managers, nobody taking responsibility – Lapses in nursing standards “have not been picked up early enough” by ABM. It’s difficult to understand what the health board are actually doing, with one interviewee criticising the “endless jargon and meaningless statistics”. Due to over-staffing at middle and senior level, ABM’s management structure is over-complicated, and as a result created confusion over who’s responsible for what. Meanwhile, lay board members often had to deal with “indigestible volumes of data with little serious analysis by the executive staff to help them understand”.  Managers were also under pressure due to budget issues.

Complaints procedures were slow and bureaucratic – Before the review there was an ongoing backlog of complaints. Most complaints regarding the two hospitals focused on Bridgend, and were mainly in relation to elderly, frail patients. Relatives were upset with how complaints were handled, often taking months to get through the system. These delays led to those who submitted complaints becoming increasingly angry, subsequently threatening legal action or complaining in a vexatious (annoyingly frequent and unjustified) manner. Because ABM were seemingly fobbing families off, it made concerned relatives come to think they had a “case” or were “victims”. But in some circumstances all their complaints needed was a simple explanation that was never forthcoming from ABM (an example’s given of failing to explain something as simple as a ward transfer).

ABM’s Community Health Council (CHC) failed to do its job – The CHC didn’t “provide an active and powerful voice on quality or safety issues” within ABM. Few people making a complaint realised what the CHC (or things like the Public Services Ombudsman) were set up to do because the information wasn’t easily available to them. Large chunks of the negative publicity is a direct result – alluded to in the report – of the complete failure of ABM’s CHC (of which 18 of its 36 lay members are appointed by the Welsh Government) to represent the interests of patients and act as an advocate.

I’ve said it a million times, but Local Health Boards are accountable to nobody and Community Health Councils are a complete and utter joke. Also for the million time, I’ll just leave this here.

As a result of the CHC’s failure, campaigners “turned complaints into causes and missions” – The veiled attacks on the ABM support group were completely unfitting a serious report. The campaign is described as “divisive public comment” and “debilitating”which “made it difficult to recruit staff and affected staff morale”.

It’s a result of a combination of anger and wanting answers – which, believe me, is a completely natural part of the grieving process, but can leave you vulnerable. Because neither ABM, its CHC or the Welsh Government bothered to listen or address concerns to their satisfaction, the only way the support group could get their voices heard was through journalists, tentative legal action, public meetings and opposition AMs.

Just because it’s mostly anecdotal evidence for now that doesn’t mean it’s not true, but selective and sensationalist reporting will create the impression that things are worse than they are and subsequently make those under accusation more defensive. So it would be fair to say that at times it did turn “complaints into causes and missions” and has damaged the reputation of both hospitals, perhaps permanently.

That doesn’t justify the attacks on the integrity of the campaigners. As far as I’m concerned, the families were left with no choice. Judging by their experiences, if I were in their shoes I would be doing the same thing.

The review came up with 18 recommendations – which ABM accepted “without reservation” in their entirity – summarised as:

  • ABM should set clear standards for care of the elderly in A&E, general and surgical wards within three months of the report’s publication.
  • ABM should ensure staff have the right skills to meet obligations of elderly patients – including things like dementia and care for the dying.
  • There should be a “zero tolerance” approach to improper administration of medicines.
  • ABM should overhaul their complaints procedures to rebuild public trust and “put local citizens at the heart of everything they do”.
  • The Welsh Government should ensure basic care (washing, hydration etc.) is seen as important on hospital wards and should review care of the elderly, undertaking an independent review within a year of the report’s publication.

What the report DIDN’T say
This is as important as the review findings themselves:

Both hospitals are“unsafe” Nobody should be afraid to go to the hospitals, and the vast majority of patients will continue to receive a high standard of care. That needn’t gloss over the fact that some patients and families have been let down, but it’s the exception rather than the norm.

Poor care contributed to patient deaths It’s unclear, but I’d give it a cautious “no” until it’s proven otherwise. The report suggests some of the affected patients were nearing the end of their lives, but because ABM have done their best to avoid being open, it’s led to suspicions and accusations of wrongdoing. However, at the very minimum the palliative care they needed to make them comfortable fell well short of standards relatives expected from the NHS and that’s distressing enough in itself.

Problems are widespread throughout the hospitalsNot really, but the investigation was narrowly-focused on a few areas of care over a certain period of time – specifically care of the elderly on ordinary wards. There were no investigations into any other hospital departments and nothing that led the review team to consider doing so. There’s currently a criminal investigation into falsification of blood tests and patient records at the Princess of Wales Hospital that could be directly or indirectly related – three nurses are due to appear in court at the end of the month – but it’s best to reserve judgement on that for the time being.

This is aWelsh Mid Staffs scandal No, but that’s not to let ABM off the hook. The report and the Welsh Government’s response draws clear parallels to “Mid Staffs”, but luckily for ABM it hasn’t snowballed to the same level. Sadly, care of elderly people in hospital – especially those with conditions like dementia – has been on a downward spiral for years across the whole of the UK. It’s completely unacceptable, but nothing that’s happened in ABM is on anywhere near the same scale as Stafford Hospital. It would be more correct to describe this as a “Mid Staffs aftershock” or a “final warning” to ABM to sort itself out.

Getting an apology from the Welsh Government is often like getting blood out of a stone, so managing to do so was significant by itself and underlines just how serious this was.

I don’t subscribe to view that there should be a full public inquiry (for now); as long as the recommendations are fully implemented and properly monitored we shouldn’t need one. ABM should report back regularly, outlining what steps they’ve taken to address the issues raised in the report,  keeping the affected families fully informed and involved.

Unfortunately, a running theme in Welsh health stories is that Local Health Boards don’t work like that. Promises and reviews have been broken or ignored before, making a full public inquiry at some point in the future unavoidable unless things dramatically change in the near future.