A hospital trust chief executive has admitted his hospital did not act quickly enough after concerns were raised over patient deaths.

Matthew Kershaw, CEO of Brighton and Sussex University Hospitals NHS Trust, apologised to the families of the patients involved and said the standard of care they received was “nowhere near good enough”. The apology came as the father of Stephen Palmer, who died in 2013, spoke of his fury at what happened to his son.

The Argus exclusively revealed yesterday how serious flaws in the care of five patients in the acute medical unit (AMU) at the Royal Sussex County Hospital in Brighton contributed to their deaths.

Brighton and Hove coroner Victoria Hamilton-Deeley issued emergency notices over 14 months ordering the trust to take action following the patients’ inquests.

Mr Kershaw said improvements had been made, including recruiting more staff and cutting the number of beds at the unit.

However, he acknowledged the hospital’s response had not been quick enough.

Mr Kershaw said: “I am extremely sorry that the standard of care the five patients received was nowhere near good enough and that whilst work was done we did not act quickly to make enough changes when issues within this area first came to light.”

In a joint statement, the Brighton and Hove and East Sussex branches of the Healthwatch watchdog said the hospital’s plan to eradicate incidents had not seemed to resolve the problems.

They called for a fundamental rethink about the purpose of the AMU. Its role is to take patients from A&E who need to be assessed further and to monitor them.

The trust’s patient safety ombudsman at the Royal Sussex, Delilah Hesling, said the issue was highlighted by her internally and the Care Quality Commission (CQC) over the last two years.

She also shared concerns with local MPs and the Brighton and Hove Healthwatch group, which went on to carry out its own investigation.

Staff shortages and a lack of available beds are said to have contributed to the pressures faced at the hospital, which can sometimes have an impact on the care and treatment patients receive.

Sue Huggins, a senior officer at the Royal College of Nursing, said: “Due to the bed occupancy situation in the Royal Sussex, patients have not been able to be moved out of the department on to hospital wards.

“This results in staff needing to deliver care for an excessive amount of patients who should be on wards, not in an emergency department, and so impacts on the specialised A&E staff who have a responsibility for those new patients requiring emergency care coming through A&E.”

 

FATHER-of-two Stephen Palmer was a deep sea fisherman who had worked hard all his life.
The 57-year-old was taken to the accident and emergency department at the Royal Sussex County Hospital in Brighton with severe abdominal pains.
He was given a scan but the life-threatening split in his aorta was not picked up and Mr Palmer was “inappropriately” transferred to the acute medical unit.
He remained on the unit for 12 hours before being taken to theatre for surgery but he did not survive.
At Mr Palmer’s inquest, Brighton and Hove coroner Victoria Hamilton-Deeley said he should have stayed in A&E or gone to a surgical unit.
She said: “There was a failure to prepare him for surgery and a failure of the CT scanning service at the hospital, which meant his condition went undiagnosed.”
Mr Palmer’s father Gerald, 86, from Bevendean, Brighton, said he was “incandescent” about what happened to his son.
He said: “He was waiting around for 12 hours and they did nothing. He was left in limbo.
“I am absolutely furious. Stephen would be here now if he was given a chance but he was never given that chance.”
Mr Palmer said the family was taking legal action against the hospital. He said he was shocked to learn other incidents at the unit had also been highlighted by the coroner.
He said: “Obviously there are times when people come in and there is nothing that can be done for them, but these are unnecessary deaths.”
Mr Palmer died in July 2013.
As revealed exclusively by The Argus yesterday, Mr Palmer was the first of five patients whose deaths over a 14-month period resulted in emergency notices being issued by the coroner.
The Regulation 28 notices ordered the hospital to take action to prevent further deaths but the incidents continued.
The most recent case was 89-year-old Evelyn Kennedy, who was so badly neglected and the treatment she received so chaotic that her death in October 2014 was accelerated.
Her death came just a month after the hospital received a notice about a patient who had died from pneumonia in June 2014.
The coroner said poor care meant chances to diagnose were probably lost.
And there were two further deaths where concerns were flagged before that – those of Herta Woods, from Horsham, who died in August 2013, and Linda Rignall, 55, from Peacehaven, who died in May 2014.
Hospital chief executive Matthew Kershaw admitted the trust should have done much better for the five patients.
He said the trust had carried out its own investigations into the deaths and the process was still continuing.
Mr Kershaw said staffing shortages across the trust were a factor on the pressure of the unit but said the trust had recently recruited more than 250 nurses and these were starting to have an impact.
The number of beds at the AMU has now been reduced from 36 to 27 but still has the same number of staff, so patients are getting a higher level of care.
The extra space created by reducing the size of the AMU is now being used by those patients who would otherwise be inappropriately placed on the unit.
Mr Kershaw said the focus was now to make sure the AMU was used for what it was created for – a short-stay assessment unit with patients staying for a maximum of 48 to 72 hours.
He said: “We should have done much better for these five patients and the undeniable failings in their treatment and care are unacceptable and inexcusable.
“We have accepted responsibility for those failings and said sorry to the families of the patients affected.
“I am extremely sorry that the standard of care they received was nowhere near good enough and that whilst work was done, we did not act quickly to make enough changes when issues within this area first came to light.
“We have made some real and lasting improvements in AMU, which are having a positive impact on the
quality of care provided and patient experience.
“But there is still a lot more that we can and need to do, and as is the case with all of our challenges, we will continue to be open and honest about both what needs to be done and what we are doing about it.
“We cannot undo what has happened nor can we ever guarantee that we will eradicate all mistakes or errors in judgement.
“But we can look forward, keep striving to do better and do our utmost to ensure these failings in care are not repeated. And that is what we need to do and are doing.
“The issue over bed availability and capacity is something we are continuing to work on with the help of our partners to ensure there is enough support in the community for patients ready to be discharged and keep the flow of patients going through the hospital.”
The Brighton and Hove and East Sussex branches of the watchdog group Healthwatch carried out an unannounced visit to the ward in January this year.
Inspectors were told the majority of patients on the unit were
inappropriately placed there.
Healthwatch said they would continue to monitor the situation.
They said: “We recognise the trust has taken significant action to improve the situation, particularly putting in extra staff, providing more training and expertise, and reducing the number of beds in the ward.
“The recent death of Mrs Kennedy is a tragedy for her family and those who were very close to her.
“Mrs Kennedy did not receive the basic care she should have been assured of in any hospital ward.
“The AMU’s role is to provide immediate high level medical care and assessment so the person can either go home or be transferred to another ward.
“Instead, this very elderly lady with many problems was not given basic attention and seems to have been forgotten in the high pressure environment of the AMU.
“Similar problems have occurred in the AMU in the recent past, and plans put in place to eradicate further similar incidents do not seem to have resolved the situation.
“This indicates the need for a fundamental rethink about the purpose of the AMU and the model of care it provides, as well as an improvement in its relationship with other hospital wards and departments.
The hospital’s patient safety ombudsman Delilah Hesling, pictured left, said she had raised concerns with the trust itself, local MPs, the Care Quality Commission (CQC) and Healthwatch over the past two years.
She said patients continued to be harmed and her heart “goes out to them and their loved ones”.
She said: “Staffing levels at the trust have been raised as a contributory factor to our patients’ poor experiences for a considerable time.
“I am awaiting feedback on my more recent ongoing alerts.”
Sue Huggins, a senior officer at the Royal College of Nursing, said: “We have continued to raise concerns about the pressures that staff
are under in the A&E Department and the associated AMU at the Royal Sussex.
“Due to the bed occupancy situation in the Royal Sussex, patients have not been able to be moved out of the department and on to hospital wards. This results in staff needing to deliver care for an excessive amount of patients who should be on wards, not in an emergency department, and so impacts on the specialised A&E staff who have a responsibility for those new patients requiring emergency care coming through A&E.
“The RCN have witnessed improvements regarding communication and documentation but until the bed occupancy rates within the hospital improve and staffing levels recover to allow the department to function appropriately the existing staff will continue to remain under this pressure.”

 

MP reaction
BRIGHTON Pavilion MP Caroline Lucas said it was vital that any problems leading to preventable deaths at the Royal Sussex’s Acute Medical Unit were resolved immediately.
“My heart goes out to those who have lost loved ones because of what the coroner had identified as a medical unit that’s not fit for purpose, and we must ensure others do not suffer in the same way in future,” she said.
Brighton Kemptown MP Simon Kirby said: “Avoidable deaths, such as those recently described at the AMU, are always tragic and are unacceptable.
“But I know the vast majority of staff at the Royal Sussex do a fantastic job in often difficult circumstances, and it must be remembered that thousands of patients are successfully treated every week by skilled, dedicated staff.
“We certainly need to keep a close eye on the situation and the ultimate solution is for a much improved hospital.”
Mr Kirby said while the £480 million planned redevelopment of the Royal Sussex would make a huge difference for patients and staff, it was not just a new building and improved facilities that were needed.
He said new structures needed to be in place to ensure people received the best healthcare and this was something the trust was trying to do.