Emergency department 'inadequate, chaotic and compromised safety'

An unannounced inspection by the Care Quality Commission in November found problems including a poor nursing skill mix, patients waiting in ambulances and delays in clinical assessments. It also found patients were not receiving adequate clinical care and were at risk from medication errors.

University Hospitals of Leicester Trust was served with a notice placing conditions on its registration by the CQC in December “because of concerns about potential risks to patient safety”.

In the inspection report, released on Thursday, the CQC highlighted problems with the nursing skill mix. “During our unannounced inspection we noted the most senior nurse in charge within the resuscitation area of the department was a band five nurse.

“We also noted one agency nurse, who had not worked in [the emergency department] before, had not received an induction to the department on the day of our inspection.

“The nurse in charge told us ‘it is common not to have the correct skill mix,’” it said.

These findings follow the publication by HSJ earlier this year of leaked National Institute for Health and Care Excellence guidance on safe nurse staffing in accident and emergency departments, which emphasised appropriate skill mix and minimum ratios of nurses to specific areas of emergency departments.

The guidance was completed but never published after NHS England and the Department of Health suspended NICE’s safe staffing work.

Other findings from the CQC’s inspection of Leicester Royal Infirmary included:

• Serious incidents at the department included raw sewage leaking through the ceiling of the resuscitation department causing the evacuation of six patients.
• Inspectors saw an agency nurse in the resus area administer an insulin infusion to a patient without having it checked by a second nurse and without checking the patient’s identification.
• A review of seven patients found four had triggered the criteria to be reported to a senior clinician as part of the sepsis pathway but this had not happened.
• Inspectors reviewed three patients in the majors department and found the time from arrival to initial clinical assessment varied between 75 minutes and 212 minutes.
• Despite incident investigations the CQC said it saw no evidence of on-going monitoring of action plans or any indications of the actions being signed off.

The CQC report said: “We observed the environment within the [emergency department] at the Leicester Royal Infirmary was chaotic and overcrowded during our unannounced inspection.”

It added: “Safety in the emergency department… was compromised. We found the delivery of services in the areas we inspected was inadequate.”

The CQC did not inspect the paediatric emergency department, the minors area or the urgent care centre.

The emergency department at Leicester Royal Infirmary was originally built for 100,000 attendances, but between November 2013 and October 2014 it saw 211,505 patients, and between November 2014 and October 2015 this increased to 217,832 patients.

Trust chief nurse Julie Smith said: “Since their visit we have reported back to the CQC every week on all three measures: time to triage, staffing and sepsis care.

“We have made real and sustained progress on time to triage and staffing. Identifying and quickly treating sepsis remains a key priority for us across the whole of our organisation and is a key part of our quality commitment for the coming year.

“The only element that we have not been able to address is the numbers of patients attending ED on a daily basis, which has continued to rise.”