16 October 2007

How many deaths will it take?

The story about Maidstone Hospital shocked and appalled even me, cynic about state medical services that I am.

For some time I've been in little doubt that eventually, a medical system such as ours — without any effective consumer power — would descend to the level at which patients are left to lie in their own filth. I was however surprised last week to find that the NHS has in part already begun to reach that level.

In my opinion things can only get worse.

Consultations, reviews, reports, admonitions, penalties, more training, change of management, increased funding — none of these things can overcome a basic absence of incentive. Once a culture of efficiency and diligence has declined in a particular corporation or profession beyond a certain point, nothing can retrieve it. It basically has to be dismantled and you have to start again.

I wonder how much worse things will have to get before the penny drops, and people overcome their fear that without a nationalised medical service they will be at risk of receiving no decent medical care. And start considering the possibility that the risk is higher with a nationalised service.

Here are some highlights from the Report of the Healthcare Commission's investigation. ("CDF" = Clostridium difficile, the hospital-based pathogen responsible for 90 deaths at Maidstone Hospital and Kent & Sussex Hospital during 2004-2006.)

[In one-third of the 50 CDF cases which were investigated] the medical records did not indicate that doctors had regularly reviewed patients’ CDF infection after it had been diagnosed. ... In at least five cases, we could find no mention of CDF in the notes after it had been diagnosed. This was despite evidence of continuing symptoms from the infection, for example, diarrhoea or abdominal symptoms. [p.32]
In 22 cases, neither a microbiologist, infection control nurse, outreach clinician, nor gastroenterologist was involved in the care of the patient. In six of these cases, CDF infection was considered definitely or probably the main cause of death. [p.32]
35 patients were started on antibiotic treatment within two days of a positive result; five patients three or more days after the result became available; and 10 were not started on antibiotics, either because the diagnosis came too late, or for reasons not clear from the notes. In 12 cases there had been a delay of over one week between development of symptoms and starting antibiotic treatment for CDF. [p.33]
On at least two occasions, the reviewers concluded that a delay in starting treatment had occurred because of an initially negative microbiology result that was not repeated for several weeks despite persistent diarrhoea. There was evidence of serious deterioration in a manner consistent with CDF infection during this time in one of these patients. [p.33] [Moral: if a medical expert says you definitely haven't got a particular ailment, perhaps you shouldn't necessarily take their word for it.]
In general, there was little evidence that, once CDF had been diagnosed, patients were routinely and actively monitored for signs of severe CDF infection, particularly colitis. [p.34]
In at least seven cases, the reviewers were concerned that patients had not been managed in accordance with their resuscitation status. This was because these patients were recorded as being for “full active treatment” ... but did not receive fairly routine interventions such as nasogastric feeding or an abdominal X-ray, where it appeared that these were indicated. [p.35]
The overwhelming majority of relatives and patients who contacted the Healthcare Commission were not happy with the nursing care received at the trust. Words used by a few included “despicable,” “sickening,” “appalling,” “chaotic.” [p.39]
One family were very concerned that after the sister on the ward had reprimanded a nurse for a further error in giving medication to their relative, they were seen “laughing and joking” together five minutes later. This gave the impression that the matter had not been taken seriously. [p.39]
Some patients and families told us they thought that the trust was unwilling to acknowledge that patients had the infection, particularly in the early months of 2006. ... Some families were concerned that signs and notices relating to infection and isolation were inconsistent or missing. [p.40]
We observed 29 wards during our visits to the trust. Twenty wards at the trust were observed as having basins that were hard to reach or obstructed, either on the wards or in the utility room. There were mixed male and female patients on 15 of the wards we visited and three had unisex toilet facilities. Even when patients of the same sex could have been grouped together in a bay, this often did not happen. It was particularly unfortunate for patients with CDF infection to be with patients of the opposite sex, since they often had diarrhoea many times a day. [p.43]
Not only were there were very few hand basins on many of the wards, but some of these were difficult to use because they were next to beds. In 2004, the existing basins were replaced on the Nightingale wards at Kent and Sussex by mistake. The intention had been to add extra ones. This therefore led to no overall improvement in the number of hand basins. ... At Kent and Sussex Hospital the average space between the centres of beds was 2.3 metres, with some as narrow as 2 metres. [p.44]
We observed eight bedpan macerators (machines for the destruction of disposable bedpans) to be in a poor condition on eight different wards. They were dirty, rusty and leaking. These posed a potential risk as leaks could soil the environment ... On an unannounced visit in April 2007 we found bedpan washers at the Kent and Sussex Hospital that were not working, resulting in bedpans that had been washed still being visibly contaminated with faeces. [p.45]

Judging by this blog reaction*, the medical profession is in semi-denial about this scandal. How can it be the highly trained professionals who are at fault? To suggest so would be to raise the possibility that their motivation might not be as driven by lofty concepts like duty and sacrifice (as opposed to financial considerations) as they would like us to believe. Which would undermine their claims to be allowed to have power over patients on the basis that they alone are suited to judging 'best interests'.

I note from the BBC report that the Commission "began its investigations amid a string of complaints about cleanliness, and was particularly alarmed after the trust claimed no-one had died from the condition despite admitting there had been hundreds of cases. This seemed highly improbable given that the average death rate is between 6% and 7%." No doubt the trust thought it best not to generate unnecessary panic, or unhelpful scrutiny.

So do you still want to "trust your doctor" (or other health care professional)? Even though he/she is not really working for you, but on behalf of society?

* via The Last Ditch