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Major nursing overhaul at Royal Sussex after patient deaths


The Royal Sussex County Hospital has introduced "major changes" to its nursing care after a coroner said a catalogue of failings led to the deaths of two patients, its chief nurse said today.

Brian Waller, 72, died after falling out of bed at the Brighton hospital in April last year, while a month later Edward Warneford, 66, died in the same ward after choking on his false teeth.

Mr Warneford's sister, April Moss, said staff did not even realise he was wearing dentures when he choked on them as he ate, causing him to have a fatal heart attack.

She said today: "His care notes had been made but not adhered to, or only partially completed. Some of them were virtually illegible.

"We still can't get to the bottom of the last 25 minutes of his life. He was supposed to have been fed as he was in there in the first place to get him to eat properly but it seems that he was alone."

Mrs Moss, 62, from Gosport, Hampshire, said her brother, a former engineer who lived in Hove, was admitted to hospital due to his alcohol problems.

She added: "We were concerned from the day he went in. The only time something was done for him was when we complained.

"We met with hospital staff yesterday and they did their best to assure us things were changing and they were addressing their shortcomings. We only hope they do change things so these sort of mistakes don't happen again."

Mr Waller, who was being treated for heart problems, fell out of his hospital bed despite wearing a wrist band with "risk of falls" written on it.

He landed on his head, breaking his neck and suffering a massive bleed on his brain which led to his death six days later.

It was later discovered one of the guard rails on his bed had been left down.

At inquests into the two men's deaths, coroner Veronica Hamilton-Deeley strongly criticised the Brighton and Sussex University Hospitals NHS Trust and said changes needed to be made at the hospital.

Sherree Fagge, chief nurse for Brighton and Sussex University Hospitals, admitted staff could have done better.

She said in a statement: "The circumstances surrounding the deaths of these two patients were very different.

"We are however profoundly aware that for both Mr Waller and Mr Warneford we could have done better and we have met with both their families to apologise, listen to their concerns and assure them that lessons have been learned."

"We have introduced some major changes focused completely on the quality of our nursing care.

"For example, every week, all of our most senior nurses including myself are working on the wards undertaking direct patient care alongside frontline nursing staff."

The nurse added: "What I see when I am on the wards is that the majority of our nurses are working hard and carrying out their duties with the kindness and compassion we would want for our own families but we are also using this as a way of teaching our less experienced nurses and picking up issues before they become problems."

Comments(16)

yorkie44 says...
5:10pm Fri 12 Mar 10

Another set of useless people think they can get away with this by saying "lessons have been learned". This is the new mantra that all public servants now think will just let them carry on as though nothing had happened. The staff concerned should be sacked. Those left will then perhaps learn the lessons needed to do their job properly before they go on duty again.

Tye says...
5:58pm Fri 12 Mar 10

have senior hospital managers tried to get the coroner the sack or tried to stop him pracising ?

thats what usually happens when people die because of THE MANAGERS incompetence (so long as it looks good on their scorecards - and as brucie said points mean bonuses) is not the issue but the fact that the news got out eh?

dea says...
7:31pm Fri 12 Mar 10

My husband was inthe Royal Sussex a while back. He is 64, also at risk of falls and twice fell out of bed, injuring himself. The food was disgusting, the cheapest possible and badly prepared. I took food in myself. Some of the staff could speak little English. Whilst some cared they were outnumbered by the total indifference of others. Clipboards and paperwork ruled over common sense. The toilet was dirty, there was urine all over the floor - twice I went in and cleaned it myself. He came home with C-dif. Gave it to me. He was rushed back into hospital. I was alone at home so could not collect him when they discharged him as I would have been a risk to others. They sent him home late at night in a taxi, confused, in hospital pyjamas, in the freezing cold with just a blanket round him. The taxi took him to the wrong address. I could go on. It was unbelievable. We've moved away now. I would not want to be a patient in that hospital for all the tea in China!

monstersharky says...
8:20pm Fri 12 Mar 10

It's ok to slag off the staff at the County BUT there are several things to remember:
1. Why is there few English speaking staff? Answer: because few English people want to be nurses nowadays! Nursing is in a state of chaos, mostly driven by the supremacy of ignorant managers but securely based in the FACT that young English people do not want to be nurses.
2. Emphasis (from these very same managers of course) is on a well written plan of care. Some of these are extensive BUT no-one actually takes responsibility for seeing that they are carried through. If you work on a busy ward, you just do not have time to read six book-like care plans before you give care!
3. Nursing is not rocket science but the "academic" training given to nurses these days NEGLECTS basic care in favour of academic nonsense & research stuff. The people who plan nurse training are managers & teachers - where is the ART of nursing when it those people who place such a low value on actual care.
4. Nursing assistants (whatever they are called these days) suffer from the "pay peanuts & get monkeys" issue.
The County, like every other NHS Trust needs to WAKE UP & realize that nursing care is not an academic subject NOR can it be left to the untrained. Well trained, experienced nurses are worth their weight in gold when it comes to looking after people. Plan:
a. bring back apprentice based nurse training & these problems will go away.
b. put real clinicians in charge NOT people who go into management to escape from the wards.
c. force all politicians (who seek to interfere in the NHS) to roll their sleeves up & do some work in the NHS!
That's my view, anyway

stan bailey says...
9:04pm Fri 12 Mar 10

dea wrote:
My husband was inthe Royal Sussex a while back. He is 64, also at risk of falls and twice fell out of bed, injuring himself. The food was disgusting, the cheapest possible and badly prepared. I took food in myself. Some of the staff could speak little English. Whilst some cared they were outnumbered by the total indifference of others. Clipboards and paperwork ruled over common sense. The toilet was dirty, there was urine all over the floor - twice I went in and cleaned it myself. He came home with C-dif. Gave it to me. He was rushed back into hospital. I was alone at home so could not collect him when they discharged him as I would have been a risk to others. They sent him home late at night in a taxi, confused, in hospital pyjamas, in the freezing cold with just a blanket round him. The taxi took him to the wrong address. I could go on. It was unbelievable. We've moved away now. I would not want to be a patient in that hospital for all the tea in China!
I have heard that care in Indian hospitals is better than ours now

joanne77 says...
11:01pm Fri 12 Mar 10

this hospital hasnt changed,my mum was left bleeding to death on a bed in the hallways,that was over 20 yrs ago,only after my dad had to stand there screaming for someone to help,we lived in lancing at the time and she was brought in by ambulence,we nearly lost her that night,my mother in law had a stroke,spent 3 days in a&e only to be sent home saying she had flu,had another bleed few days later,lucky she is ok,but usless staff,no-one know what each other is doing.

D Merrett says...
7:56am Sat 13 Mar 10

I have read many of the comments and I have believed for a long time that someone needs to stand up and stop defending the NHS as a protected institution, and start putting right the "ills" of this organisation at grass roots levels. When will this country wake up and realise that this patient is beyond recovery and needs to be let die in peace.

monstersharky says...
9:33am Sat 13 Mar 10

Sorry to disagree, D Merrett but free healthcare at the point it's needed CANNOT be left to die!! The "ills" are:
- too many politicians interfering.
- too many non-jobs & employment for the boys.
- too many managers making rules that are patent nonsense.
- too many people thinking they are entitled to get whatever they may want immediately.
Healthcare is expensive & so needs to be rationed in a sensible way. Are smokers & drinkers entitled to life-saving treatments if they refuse to give up their self-destructive habits? What about drivers who speed? Are they entitled?
I don't have the answers but these & other questions which need rational debate. Personally, I want the NHS to help me stay healthy while I can enjoy life & then to leave me alone when it's my time to pop off. I don't want spin, superficial nonsense & the reams of propaganda which is thinly disguised as "patient information".

saveHOVE says...
10:50am Sat 13 Mar 10

Next time a major development is proposed anywhere in Brighton, Hove or in the immediate area, remember this story and remember these comments.

The truth is that too much is expected of the RSCH over an above the PC rubbish that everyone there hides behind. Too many patients and too many of those patients are visitors or short-term residents unattached to the area in a meaningful way.

And, yes, the too-grand-to-nurse attitude is rife. They all want to be seen as "nurse practitioners" (fake doctors in the same way that a PCSO is a fake policeman).

20 years ago that hospital had a working kitchen in which it produced food from scratch that was recognisably food and not artificial pap or worse. Now a boiled egg is forbidden and only scrambled from powder is allowed.

Broken Britain produced one scary mess in the hospitals area full of PC hysteria, layers and layers and layers of management and agency nurses with their middle finger in the air.

We have a major infrastructure problem in relation to the overdevelopment of this area. When next anyone wants to scream about needing more housing in Brighton & Hove, think about those who are not getting what is needed in the RSCH NOW!

And think how awful the daily lives of people working in that hospital must be. Oh, and ask yourself why only the PCT (GP and dentist provision) are asked for a view when developments are proposed. Why isnt hospital use a consideration?

oxenbee says...
11:23am Sat 13 Mar 10

it pains me to comment but i feel i must,i lost my son in there,the night before we lost him, he had to have a procedure,that should have been simple,but the africain doctor that was doing it ,had done it wrong,and admitted it,and then blamed it on tiredness,i was fuming as it was 3am,i was tired too as was my son, but i knew the incompetent fool didnt have a clue ,we kept telling her,but she wouldnt listen,i felt like knocking her head off,in the end i told her to get out and find someone to could do the job without a fuss,useless idiot ,how she became a doctor is a mystery.there are to many foreigners working their,whose english is appaling,the royal sussex needs a complete shake up,or knock it down.

The Real Phil says...
2:48pm Sat 13 Mar 10

Lessons have been learned at the RSCH. When my elderly aunt fell out of bed last summer the staff quickly bundled her back in and simply did not make a single reference to it on her care plan or fill in an incident report, leaving them free to deny that any incident had occurred. However, when all of the patients can tell the relatives exactly the same story, you just know that the staff are not only incompetent, but also unprofessional liars.

Tye says...
7:22pm Sat 13 Mar 10

PLEASE

Will The Argus take up some of these cases?

Will the reporters act like proper reporters rather than wait for the next press release from their communications director?

I know its easy to accept "we cannot discuss individual cases due to confidentiality concerns" the hospital will spout as a first line of defencre BUT It must be easy enough to contact some of these people here and get their OK?

Rita Snatch says...
7:40pm Sat 13 Mar 10

Nursing fell into decline when Universities became the training ground for nurses, rather than the actual real wards that many of us good nurses experienced as student nurses.

Cleanliness on the wards disappeared when contract cleaners were employed and supervised by their own managers rather than the fussy ward sister.

I weep as I continually hear of patients injured or dying as a result of nursing negligence now-a-days.

Nurses need to be trained on the wards with patients, not in remote buildings. It is all very good 'knowing' what to do, it is very different being 'skilled and able' to allow that practice to be delivered.

SRN and proud of it.

Pretty Vacant says...
10:09pm Sat 13 Mar 10

it's with a heavy heart I read the above comments - Im a nurse at the RSCH. Myself and my colleagues work incredibly hard, often missing our unpaid breaks to ensure patient care is met. Staff sometimes go home in tears if they feel they have "failed" their patients, by giving timely appropriate care - with the best will in the world we cannot be in 3 places at once. But most of us try, we really do. Supposedly I'm a "to posh to wash" breed of nurse - what nonsnse.
What we do suffer from is understaffing , WE know we need more nurses to look after our patients safely, but the money isn't there, so we just have to do our best.
Sadly that always isn't enough..

Amora says...
10:22pm Sat 13 Mar 10

On Monday night I have been invited, as a local resident to the RSCH, to a public meeting about the redevelopment of the hospital site. I understand that over the course of ten years, they will knock down the most of the current hospital and replace it with a 15 storey monolith at a cost of some £70 million.

Perhaps before they send in the demolition crews they should think long and hard about whether this is the right location for a major trauma centre for the entire region. Replacing old buildings with glass and concrete is not going to fix the underlying issues that have been addressed here.

Argus - I think it is time for you to do some proper investigative journalism and determine what the real priorities are for the Trust's senior management. The kudos of new buildings and a medical school or providing excellent healthcare facilities for the local community. As a city we deserve better.

Cass says...
11:08pm Sat 13 Mar 10

As a relative of someone in the RSCH at this moment in time (I couldn't agree more with "Amora, Brighton") and I also lost my Father a short time ago in there. I have been on both occasions pushed past frustration with nurses who don't listen and I hate to say, appear to quite simply, not care. Information from relatives/friends is sometimes the best information they can get but do they listen, absolutely not, and those that do at the time forget or don't pass it on, they certainly don't write it down. Asking questions seems to be nothing but a bore and time wasting, it's written in their faces, family commitment feels like an intrusion to their profession. I for one am heartily sick of being patronised for caring. It is about time the whole place was given a good shake up, and lessons will never be learnt, (horrid expression) until the staff stop acting on the defensive. They are sometimes wrong and should admit to it.
As for the location of what is now a huge hospital and apparently due to get bigger, it is a joke. Thursday evening at visiting time, 7 to 8pm, the car park sign said, full, with a waiting time of 60 minutes. That is ludicrous when you consider most people race to get there for that time anyway. Car parking in all the streets around the hospital is a dead loss, I feel for those who live nearby. The whole place needs relocating to the outskirts of town where it can be well planned in every aspect. Pity so much effort went into the new stadium, now that location would have been ideal but I guess a football team that makes you sick takes preference over those who already are.


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