The Health Care Commission Report into Stafford Hospital (Mid Staffordshire General Hospitals NHS Foundation Trust) has been published. The report was prompted by an analysis of mortality which indicated an apparently high mortality rate for specific conditions or operations at that hospital.

The consistent high mortality rate could not be explained by data errors. The Standardised Mortality Ratio (SMR) would be 100 for similar hospital trusts. Between 2005 and 2008 the SMR for Stafford Hospital was between 127 and 145.

The report lists numerous failings which include:

 A failure in the Accident & Emergency Department to have clear protocols and pathways for the management of patients admitted as emergencies

 The Department was poorly equipped

 Too few Nurses to carry out immediate assessments, leaving this work to be carried out by Receptionists who had no clinical training

 Lack of essential equipment such as defibrillators for every resuscitation trolley

 A & E Nurses not specifically trained

 Leadership weaknesses

 Patients waiting for medication, pain relief and wound dressings

 Most senior surgical Doctor after 9 pm was often a junior and an inexperienced Doctor

 Too few Consultants

Further findings were that:

 When patients were admitted to the medical wards there was sometimes poor communication with the handover from the emergency assessment unit.

 Care of patients was not acceptable, examples being:

 Failure to answer the call bells
 Tablets or nutritional supplements were not given on time
 Doses of medication were missed
 Patients being left in wet or soiled sheets
 Water bathrooms and commodes were not always clean
 Failure of Nurses to conduct observations and identify patient’s deteriorating condition

For patients admitted as surgical emergencies it was found that:

 General Surgeons did not work well together and there were few agreed protocols in surgery
 There were not enough Doctors on duty out of hours
 There was only one list for surgery theatre at weekends

The report is also critical of the hospital board’s management in failing to identify many warning signs, including:

 Routine reports on performance that did not identify failings in care of patients
 Information on complaints was incomplete.
 Discussion by the board of matters were in private, so that for example, an outbreak of Clostridium Difficile (known as C-Diff) in the Spring of 2006 was not reported or acknowledged in public.

The report concludes that since March 2008 there have been improvements at the hospital, including:

 An increase of 46 qualified Nurses
 51 Health Care Support Workers
 Matrons increased from 3 to 12
 Improvements have been made in the Accident & Emergency Department
 2 new Consultants have been appointed
 There is a programme of training for junior and middle grade Doctors

Recommendations have been made to address all of these concerns and specific directions to the hospital board to assist in overseeing the quality and safety of clinical care within the Hospital Trust.

A copy of the report is available from the Health Care Commission at www.healthcarecommission.org.uk