A damning report into accident and emergency departments in and around Edinburgh has identified a breakdown in trust between nurses and doctors, and a culture of bullying.
The report for the Scottish government was sparked when a whistleblower revealed that waiting times of more than four hours at A&E departments in NHS Lothian were not being correctly recorded.
“Clinical involvement and engagement appeared disjointed”
The four-month investigation by the Academy of Medical Royal Colleges and Faculties in Scotland looked at three sites – the Royal Infirmary of Edinburgh, the Western General Hospital and St John’s Hospital.
The document – titled Review of Whistleblowing Allegation Final Report NHS Lothian November 2017-March 2018 – found a series of failings in management and the existence of a blame culture.
“Patient flow is not owned by everyone and largely left to nursing teams to manage,” the report stated. It found an “apparent lack of a clear and robust governance structure” and clinical leadership that was weak and not fully engaged “in the bigger picture”.
Bullying was another problem identified at the health board. “Concerns were raised by some staff who felt bullied and harassed at two sites, which appears to have been exacerbated by the lack of robust management structures and governance at site level,” said the report.
“NHS Lothian has had a previous review into its culture and, despite action being taken, we felt that this had not yet been fully embedded at all levels of the organisation,” it added.
“Patient flow is not owned by everyone and largely left to nursing teams to manage”
In particular, nurses felt blamed for the mis-amendment of breach times, the report said. At the Royal Infirmary of Edinburgh the investigation found a clear breakdown in the relationship between medical and nursing staff in the emergency department.
Attempts by senior management to resolve it were either “unsuccessful or detrimental”, it said. Staff felt it did not affect patient care but the report said this had not been formally tested.
The report also revealed that consultants said they had been “told off” for “blaming the nurses” for the data recording inaccuracies of breach amendments.
“Clinical involvement and engagement appeared disjointed with medical and nursing teams having separate fora,” the report stated.
At St John’s Hospital based in Livingston the report noted how nurses found the safety huddle “oppressive”. There was “no opportunity for challenge” in the huddle and unrealistic expectations were sometimes placed on them.
Staff in general felt unsupported, some felt “individually blamed” and there was evidence of “bullying and harassment of some individuals”, the report said.
The Western General Hospital fared better. “Staff spoke highly of the site director and director of nursing. The culture felt more positive on this site,” the report said.
In relation to the flow of patients, the report said: “Flow was felt to be the responsibility of the nursing teams. Clinical staff felt that their judgement on what was best for their patients was sometimes over ruled by non clinical management.”
“Staff have also come under intense pressure and for these failings I’m really sorry”
The report recommended work be done to change the culture at NHS Lothian, with sessions on “culture and values, particularly for the site leadership teams, the site and capacity and senior nursing teams”.
Jim Crombie, interim chief executive of NHS Lothian, said: “We have recognised from the outset that mistakes were made and accept the findings of this review.
“It’s clear not all was as it should have been. Staff have also come under intense pressure and for these failings I’m really sorry,” he said.
The organisation accepted that in some circumstances waiting times of more than four hours were not being correctly recorded as breaches of the standard.
In relation to bullying, Mr Crombie said: “We share the Scottish Academy’s concern about bullying behaviour as reported by staff at many levels during the review, while recognising that there was no evidence of bullying and harassment at board level.
“In the face of intense and sustained pressure working relationships can sometimes be fraught and plainly we have not been doing enough to support our frontline staff,” he said.
“We will ensure that it is absolutely clear that NHS Lothian does not tolerate bullying behaviour”
Mr Crombie said that the trust was working on practical ways to reduce pressure across the system and undertaking a programme to improve leadership.
“As part of that work we will, through all mechanisms, ensure that it is absolutely clear that NHS Lothian does not tolerate bullying behaviour,” he said.
“We are also clear that the job of ensuring patients travel swiftly and safely through the system does not rest with just one team or department. It is a ‘whole system’ responsibility.
Work was being done on patient discharge, which have a significant impact throughout the hospital system, he said.
He also noted that NHS Lothian carried out its own internal review that was approved at a public meeting of its board in February 2018.
The organisation said improvements from that review were already taking place and would be monitored through NHS Lothian’s revised governance framework.