Colchester NHS Trust Patient Care
In November 2014 the Guardian reported that “The scale of the problems at Colchester hospital has been laid bare after the hospital’s chiefs admitted there had been 563 serious incidents over a two-year period”. The hospital refused to detail what the 563 cases involved at that time.
The CQC looks at events which are defined as those “causing or threatening serious harm to patients, staff, the public or the trust itself”. They include unexpected or avoidable deaths, serious harm requiring lifesaving intervention, serious hospital-acquired infection outbreaks, maternal mortality and allegations of abuse.
The Care Quality Commission report in 2015 showed that the Trust reported nine never events between May 2014 and April 2015. It also declared a further four never events between April 2015 and October 2015.
When talking about patient safety we refer to ‘Never Events’. These are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.
Hospitals are required to monitor the occurrence of Never Events and publicly report them on an annual basis.
The Never Events Annual Report 2009/10 provides an overview of the Never Events reported to the NPSA by NHS organisations in England from 1 April 2009 to 31 March 2010.
- Wrong site surgery
- Retained instrument post-operation
- Wrong route administration of chemotherapy
- Misplaced naso or orogastric tube not detected prior to use
- Inpatient suicide using non-collapsible rails
- Escape from within the secure perimeter of medium or high secure mental health services by patients who are transferred prisoners
- In-hospital maternal death from post-partum haemorrhage after elective caesarean section
- Intravenous administration of mis-selected concentrated potassium chloride
Colchester NHS Trust had the highest reported never event rates of any trust in England for 2014. It also had the highest declared rate of never event incidences in 2015 to date with 14 being declared since September 2014.
Where did the events occur in Colchester NHS Trust?
There were high incident report rates for administration and clerical functions, such as clinical coding, and also from clinical areas such as Accident and Emergency and the Emergency Assessment Unit.
Other incidents included a patient exceeded 100 days on the cancer pathway without treatment, shoulder dystocia to baby following delivery and a grade two pressure ulcer. These are wholly preventable. The CQC also found sepsis was not appropriately monitored and treated resulting in critical care admission.
In January 2016 the BBC reported that Norman Betchley died in 2009 after he was mistakenly fed a pill by an agency nurse. The CQC had found that the Trust was relying on ‘unsuitable’ agency staff. The BBC report stated that inspectors said the hospital demonstrated “poor leadership” and “only a limited capacity to improve”. Staff were let down by agency workers, who were not as committed and were “unsuitable in terms of their skills and knowledge”.
If you have been tretaed at Colchester NHS Trust and suffered poor care leading to harm then get in touch with us today. Our investigations are being conducted by Dr Victoria Handley who can be contacted on 0800 470 2009 (No win No Fee Agreements available) or firstname.lastname@example.org
All calls are confidential.