Premature baby left to die alone in sluice room, report reveals: A looming patient safety crisis in the NHS?

By John Tingle

BBC News reported, 24/11/2016 on the Pennine Acute Hospitals NHS Trust review of its Royal Oldham and North Manchester General hospitals which identified several ‘unacceptable situations’. The BBC news item states that the review document

“…described how a premature baby had arrived “just before the legal age of viability” – at 22 weeks and six days – but staff did not find “a quiet place” for the child’s mother “to nurse her as she died and instead placed her in a Moses basket and left her in the sluice room to die alone”.

The report goes on to catalogue a number of other shocking events that occurred.

“It also condemned staff attitudes which led to “unacceptable situations”, including another mother’s “increasing deterioration” being wrongly attributed to mental health issues – a misdiagnosis which saw her eventually die “from catastrophic haemorrhage.”

“Other cases included a baby dying because a mother’s rare blood type was not identified and a woman needing a colostomy because her condition was missed three times.”

The review report also highlighted high compensation pay outs for death and injuries. The hospitals patient safety problems revealed in the BBC news item are very shocking but similar problems have occurred before in the NHS and are well chronicled in a number of reports of NHS patient safety failures,Mid Staffordshire and Morecambe Bay to name but a few. The NHS does not appear to learn from the errors of past events.

Things seem to be getting worse, patient safety wise

The Care Quality Commission (CQC) which is the independent health inspectorate for England paints a gloomy and worrying picture for health quality and patient safety in its latest report on the state of health care and adult social care in England, 2015/2016.

Budget cuts, financial constraints are stretching hospital budgets further and with a growing elderly population with more complex health care needs resources are in many cases being stretched to breaking point. The CQC point to considerable variation in quality of health care services between and within hospitals and in location.

“The safety of care is our biggest concern (10% of NHS Acute trusts were rated inadequate for safety). Ensuring consistently safe care remains the single biggest challenge for hospital providers… (p.22)

The reader can gain a very real sense, when reading the report that a ‘perfect storm’ is brewing in the NHS where more patient safety crises are going to develop.

The NHS does appear to be stuck between, ‘a rock and a hard place’. There is an almost infinite demand for NHS health care but only finite resources available. Tough budgetary choices have to be made, the NHS cannot fund everything .It should be remembered that the NHS in England remains free at the point of use for all UK residents. This currently stands at more than 64.6 million people in the UK and 54.3 million people in England alone. The NHS in England deals with over 1 million patients every 36 hours.

The CQC are very concerned about patient safety in the NHS. When the NHS system begins to creak under resource pressure then patient safety crises will appear.

The NHS can try to save money by exercising better resource governance but if more adverse patient safety incidents occur it is also going to lose money by having to pay out for more clinical negligence compensation claims. NHS policy managers have a very delicate balance to tread here.