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Mid Staffs nurses' concerns ignored

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.

Readers' comments (13)

  • This is not new news, it was known even at the time. But what use is this news? The idiots in charge STILL have not learned any lessons from this. Many, many hospitals and care homes are in a similar position now, with staff concerns about staffing levels and many other things being completely ignored, and are only accidents waiting to happen. Yet still, they will not learn.

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  • tinkerbell

    I was rebuked by a manager once for using 'inflammatory wording' in an incident form, i put that the staffing levels were dangerously low. Apparently the word 'dangerous' was inflammatory. Hey ho. Copings not the same as caring is it?
    This old chestnut has been rumbling around for decades, what's new. Nothing has really changed, as usual all rhetoric.

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  • What worries me in these situations that are obviously spread far and wide, is that when patients have incidents ie falls, drug errors....whatever. It all falls upon the poor staff who are doing their utmost to keep the place afloat at a safe level....when there isnt a safe level! Staff are stressed out, exhausted and god forbid at risk each time of losing their hard earned registration when a major incident occurs.
    This all appears to be going round in circles.....again
    Come downunder....:)

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  • michael stone

    Change the 'complaints system' for this type of incident ! Involve the PUBLIC whose treatment is being compromised by these resourcing issues - how many times, is it necessary to point out that complaining to management, about management, will often not work !

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  • Can you imagine how much stress the staff have been under, even completing incident forms takes time and probably kept them after shift finnished. When events happen there is a blame culture by management sat behind a desk asking why was this and that not done - er it could be due to lack of staff and all the extra paperwork that nurses are being burdened with, but they do not want to know this they are happy with pointing the finger at already exhausted staff. We are under the same pressure. Complaints by staff fall on deaf ears.

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  • This report raises three broad issues.

    Firstly what did any of the nurses who raised concerns do when no notice was taken of concerns raised. Did they raise them individually or collectively with their manager and/or with their professional bodies or trade unions?

    If not why not?

    If they did what did their trade unions and professional bodies do to pursue those concerns?

    Secondly what did the managers do once they were aware of those concerns having been raised?

    If they did not take those concerns further why not?

    If they did, where is the evidence and what consequences followed for them as individuals in an organisation where fear was an element of the management culture?

    Finally, what steps has the NMC, HPC, GPC or GMC taken to hold to accxount those registrants who by their acts or omissions failed to comply with their professional duty to raise concerns?

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  • Managers! Managers! Managers! What action will be taken by the Dept of Health and the Minister of State for Health at this disturbing report, repeated many times previously as comments observe.
    No progress! No progress! No progress!
    Instead staff get targeted if they become too vocal and are then silenced. I speak with authority as the recipient of emails from devastated staff who have dared to speak out often and have been silenced. It is a great relief to them to find they are not alone, through the website www.suspension-nhs.org. Roger Kline’s question about what happened to these people at Mid Staffs if they did keep speaking out, is very pertinent. What indeed. Don’t ask the Dept of Health. They don’t have a clue. And as for the staff who kept quiet and did their best and got out as soon as they could, how wise.
    And the unions Roger are often too close to management to be of use. Our small study on our website showed major failings, for example - two thirds of union officers failed to respond to telephone calls or emails for significant periods of time and seemed to believe the member was guilty in some way. Now members have the right to legal representation at disciplinary hearings if their job is in doubt, but the unions are usually refusing to supply such help.
    We’ve been campaigning for 8 years now and see the same manager malfunctioning in what has been described as toxic organisations. Poor patients and poor staff. Organisations, stop blaming the staff and sort out the managers please.
    Julie Fagan, founder member of Campaign Against Unnecessary Suspensions and Exclusions UK (CAUSE)

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  • This report raises three broad issues.

    Firstly what did any of the nurses who raised concerns do when no notice was taken of concerns raised. Did they raise them individually or collectively with their manager and/or with their professional bodies or trade unions?

    If not why not?

    If they did what did their trade unions and professional bodies do to pursue those concerns?

    Secondly what did the managers do once they were aware of those concerns having been raised?

    If they did not take those concerns further why not?

    If they did, where is the evidence and what consequences followed for them as individuals in an organisation where fear was an element of the management culture?

    Finally, what steps has the NMC, HPC, GPC or GMC taken to hold to accxount those registrants who by their acts or omissions failed to comply with their professional duty to raise concerns?

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  • RE nurses' warnings and Icident Reports of poor staffing, near misses, unsafe care / work environments (...etc etc) being ignored by management et al, and staff being "groomed" / "occupationally socialised" / "counselled" regards their use of terminology to highlight risk!!

    Wake up management and trade unions!!!!!!!!!!!!!!!!!! Time to listen to those "in the thick of it" - or be held to individual, legal account for inaction, ignorance, passivity and collusion.

    The Health Select Committee and NMC met recently - the unpublished minutes are available...as expected, very sadly, no REAL, MEANINGFUL change action to prevent Mid Staffs again!

    Regards the comment from Roger Kline - he asks what has been done about individual nurses who failed to act. Rightly so BUT...similarly and fairly, no-one ever asks what has been done to the individual nurse / non-nurse managers, executives and individual trade union officials who failed to act on what WAS reported (God forbid we should ruin their little empires).........scapegoating at its best

    One worrying thing about the article - it took a public inquiry for the NPSA to analyse 940 reports submitted, which then retrospectively triggered alarm bells, hmmmm. Proactive NHS...NOT.

    When does "a cry from staff who appear to be being ignored" (inquiry counsel comments) become a scream??? (can't scream though, because then you get vilified, denigrated and labelled as unstable, mad, unprofessional, unable to influence others or work as others "in the fold"...etc...and employers are legally blessed to dismiss you for SOSR’ some other significant / substantial reason’....got you - for those of us who do have courage that is

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  • At one point we were short staffed and I felt it was a risk to both staff and patients I did complete incident forms to highlight it, all I got a thank you for pointing it out but also do not fill one out if you are short staffed but only if an incident happens because of it. Nothing was done

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  • With reference to Klein’s comments: the RCN’s Peter Carter denied all knowledge of what was going on at Mid Staff’s!

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  • It would appear that, no matter what happens and no matter how much reporting of untoward/dangerous incidents, there is only action when it becomes public knowledge through the media, followed by a public enquiry.

    We nurses, therefore, have one course of action. Only blow the whistle to the press/TV/radio.

    The Rcn has become as ineffectual as management.

    I was horrified when Peter Carter denied knowing of problems at Mid Staffs. I will never believe that there are no Rcn stewards there who would have brought in their regional officers. Word travels fast and I am sure it would have reached the ears of Peter Carter.

    The Rcn is fast becoming a waste of time. I hope they have the "balls" to represent the nurses who have their heads on the chopping block. And even more to bring out the big guns for managers who condoned this practice and were directly resposible for the untimely deaths of patients.



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  • There but for the grace of god. A few years ago we had a situation where we were staying late to fill out incident forms after every single shift, our ratio was usually 1:16 (acute setting!) and it was terrifying. We set up an 'overtime' book. In ONE MONTH we racked up over 1000 hours of unpaid overtime.
    Senior staff resigned in disgust, I and many other juniors left.
    The situation came about because of non-nursing management deciding that the way to meet budget targets was to cut nursing staff, but the chief exec still took a big fat bonus. How that person sleeps at night I shall never ever know.

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