Nurses raising concerns about “dangerous” staffing levels at Mid Staffordshire Foundation Trust were repeatedly ignored, an analysis of 940 incident reports has revealed.
The National Patient Safety Agency study, which was carried out for the ongoing public inquiry into the failure of regulators to spot problems at the trust, looked at all incidents related to staff shortages logged with the agency’s reporting system from its introduction in 2004 until March this year.
The reports, many of which relate to night shifts and early mornings, complain of nurse to patient ratios as low as one to 12 in acute areas, patients receiving medication hours late and inexperienced staff regularly being left in charge of wards.
Other reports detail resuscitation frequently being manned by only one nurse at a time. One nurse reported being told to “ignore” her cardiac arrest bleep if it went off after she raised concerns that she would be unable to answer it without leaving her patients unattended.
One member of staff told how they “found” a patient on their ward who had been left unmonitored since being transferred there three hours earlier while another report details an elderly patient left shouting for help for hours in an unmanned clinical decision unit.
The reports detail staff informing management but nothing being done.
One writes: “This staffing level at night shift particularly in ward 2 [is] seriously dangerous and this incident form I have done many times. No action no feedback. I am very unhappy about patient care.”
Inquiry counsel Tom Baker described the reports as “a cry from staff who appear to be being ignored”.
In her evidence to the inquiry, NPSA’s director of patient safety Suzette Woodward said staff shortages were not something the agency usually looked at as it was expected it would be dealt with locally.
She said: “The incidents associated with this report, infrastructure and staffing, are deeply distressing for both patients and staff who are clearly wanting someone to listen to them.
“I would not expect that to have to reach a national agency… for those issues to have been dealt with.”
The study also compared Mid Staffs to 23 trusts of a similar size, and found it to have an above average level of incidents reported relating to a lack of suitably trained or skilled staff. However, it did not have the highest level of incidents. However, the inquiry heard there were various factors which influenced reporting including whether staff felt they were listened to or what they perceived to be a normal level of staffing.