University Hospitals Bristol Foundation Trust
Children's cardiac ward where patient died was understaffed
Management at University Hospitals Bristol Foundation Trust have been criticised by the Care Quality Commission for failing to address long running staffing issues on a ward for seriously ill children.
The CQC inspected ward 32 at Bristol Royal Children’s Hospital in September following complaints from parents whose children had died there.
It issued the trust with a warning notice after finding patients were being put at risk by inadequate staffing on the ward, which regularly admits children following cardiac surgery.
Inspectors found the ward was operating as a high dependency unit but was staffed as general paediatric ward with half as many registered nurses as required.
In its report, published today, the CQC said the trust had been aware of the “inherent risks” posed by low staffing levels for a “considerable amount of time” but failed to address them effectively.
A root cause analysis of the death of seven-year-old Luke Jenkins highlighted that risks posed by inadequate staffing had been identified following an incident in October 2010 but had still not been addressed at the time of his death in April.
The analysis, completed in June, found low staffing levels were a “contributory factor” in Luke’s death as well as six other patient safety incidents that had occurred on the ward since the beginning of the year.
In a statement, the trust said it had bought forward plans to establish a cardiac high dependency unit and secured commissioner agreement to recruit additional specialist nurses.
Two beds have been created on the paediatric intensive care unit for cardiac children who require high dependency care and nurse to patient numbers have been improved.
Chief executive Robert Woolley said: “As a result of these actions, I believe we have addressed the issues leading to the warning notice and I would welcome a return visit from the CQC to confirm this.”
31 October 2012