• Review identifies eight deaths, with areas of concern over patient care in A&E unit
  • Review of 229 deaths at The Dudley Group FT finds the majority were unavoidable
  • Investigators find issues around delayed diagnosis in busy periods and the “appropriate observation” of patients
  • Reviewers find trust has improved on key concerns highlighted by CQC

A review has found “concerns” over the care of eight patients who died in a struggling emergency department.

The review of A&E deaths, occurring in 2016-17 and 2017-18 at The Dudley Group Foundation Trust, found in both years more than 90 per cent of the patient deaths were unavoidable.

However, the report, carried out by former national deputy medical director Mike Bewick, highlighted areas the trust should address.These included:

  • Ensuring “appropriate and timely referral to specialist opinion and management”;
  • Making sure there is “appropriate observation following triage”, especially for patients with significant but as yet ill-defined diagnosis (sepsis and abdominal pain as examples)”; and
  • Addressing individual error in assessment of diagnosis and escalation to senior specialist opinion by junior staff.

It also noted “delays in diagnosis were most apparent during long stays within the ED at times of high workload and demand”, and the current clinical record system, known as CasCard, was inadequate.

The eight patients’ families have been contacted and the trust is set to further investigate the issues the review identified.

The trust commissioned the review after the Care Quality Commission raised concerns about its emergency department last summer. The trust’s emergency services have since been rated “inadequate” and the CQC is due to carry out a full inspection of the provider this year.

At the time, the CQC highlighted concerns around the monitoring of deteriorating patients. According to the review, which was finished in October 2018, the trust has made improvements in this area.

Key areas of concern found by reviewers were that the ambulance triage unit was “uniformly busy” and that patients waiting for investigation or admission frequently waited for long periods.

The review also commented that staff within the ED were “working at the limits of their capacity”.

As part of the review, each patient cared for outside of the ED department was also reviewed and recommendations made for wider system improvement.

This included an “urgent review” of end of life care services in the community, “with an emphasis on reducing unnecessary conveyancing of patients with serious and life ending conditions”.

A review, carried out by law firm Capsticks, into whistleblowers’ concerns raised about the trust’s leadership team was also undertaken in November 2018. This review is yet to be published.  

Trust chief executive Diane Wake said: “I would firstly like to offer my heartfelt condolences to all families who have suffered the loss of a loved one and to thank those families whose loved ones’ care formed part of the review.

“We are absolutely committed to delivering the very best care to our patients and for those patients whose death is inevitable, it is paramount that they die with dignity and compassion.”