- Reviewers linked extended length of stay to higher mortality rates
- Review was commissioned by trust’s CEO, who joined in January
- Trust has since improved its medical examiner system and launched complete workforce review
An independent review into mortality has exposed serious workforce problems and a failure to learn from deaths at a hospital trust.
Although inspectors reviewing more than 200 deaths from 2017 to 2019 at Worcestershire Acute Hospitals Trust found most were due to irreversible disease, interviews and observations revealed several “conflating factors” linked to an increased risk of death at the organisation.
The review, commissioned by chief executive Matthew Hopkins, linked compromised senior decision-making, large trainee caseloads and poor relationships between specialty, emergency and acute clinicians to delays in care and discharge.
Patient flow was a key area of concern, particularly in the overcrowded emergency department. The review identified “an intolerable level of wait” in the emergency department and acute medical unit, with many patients on trolleys for 24 hours.
The workloads of junior doctors were found to have caused delays to care. The review noted junior doctors were “busy and often overstretched, [which] resulted in complaints of ‘bullying’ from nurses on the wards”.
Although consultants performed reviews during routine ward rounds, other medical reviews and decisions about care were generally performed by trainees. Sick patients were almost never escalated to consultants on an emergency basis.
Inspectors wrote: “Particularly after the acute phase of care the overall strategic oversight about an individual’s care seemed to lose focus.”
Specialist doctors were criticised for focusing on their area of expertise when patients had complex, multisystem disease. Interviews revealed a lack of perceived clinical ownership in the care of patients not on defined treatment pathways. Patients were often handed over with no consultant responsible for their overall pathway.
The report noted a dearth of elderly care doctors who could fulfill this role.
The probe also criticised the trust’s learning from deaths processes. Although individual groups of staff performed mortality reviews, some did not feel they led to learning across the organisation. At the time of the probe, there was a backlog of more than 800 reviews.
Inspectors also noted:
- Poor handover notes and, in some cases, a lack of available do not resuscitate forms in cases where CPR was not performed;
- Slow patient flow saw some patients deteriorate after being declared medically fit for discharge;
- Poor recognition of patients’ capacity to recover; and
- Approach to nutrition and feeding seemed “non-uniform” and merited further review.
The trust said it is working to shore up its workforce and improve its medical examiner system, following the review which took place over the summer.
Chief medical officer Mike Hallissey, who began his role in July, told HSJ: “The mortality review process that was in place before I came was immature, shall we say.
“Now that’s changed dramatically. We’ve significantly increased the number of reviews that are going on, and they’re all starting to feed back into the monthly mortality review meetings.”
Mr Hallissey hopes the trust will be performing mortality reviews in real-time by early next year.
He also explained he’d launched a complete review into the trust’s workforce to identify gaps and work out how best to fill them. As well as recruiting more doctors, Mr Hallissey said the trust would bring in more physician associates and other allied health professionals.
A small increase in junior doctor numbers, he added, already seemed to be improving relationships across disciplines. A Health Education England spokeswoman told HSJ it was working with the trust, alongside other organisations, “to help support staff and improve both the education and training environment and quality of care for patients”.
Mr Hallissey said the trust was working with NHS Professionals and the University of Wolverhampton to secure more clinical staff.
NHS Improvement, he added, was helping the trust to improve professional standards for consultants.
He said: “We have some workforce gaps at the consultant level that lots of trusts have, that we’re desperately trying to fill — especially around elderly care.
“We recognise that we need to make the experience for the patients as good as we possibly can, and that’s what I aspire to do.”
The trust’s June board papers also refer to bullying complaints, with trust chair Sir David Nicholson asking ”whether the issue of junior doctors being bullied by nurses has been resolved”.
HSJ Provider Summit
The HSJ Provider Summit, taking place at the Crowne Plaza, Stratford-upon-Avon from 22-23 April 2020, unites 120+ board members from provider trusts across the country with those shaping national policy, to share best-in-class initiatives in delivering cost-effective and high-quality care for their local populations.
Held under the Chatham House Rule, attendees will co-develop solutions to their local challenges with colleagues from across the country. The summit is free to attend for board-level NHS leaders.
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Trust board papers, information obtained by HSJ