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Tragedy puts skills deficit in the spotlight


The case of an agency nurse mistakenly turning off a disabled patient’s ventilator is symptomatic of the increasing dilution of skills in overstretched community nurse teams, senior nurses have warned.

They said a shortage of sufficiently trained community nurses, combined with growing workloads, was leading to reliance on less well qualified staff and nursing agencies to cover increasingly complex cases.

Royal College of Nursing primary care adviser Lynn Young told Nursing Times: “We simply don’t have enough community nurses. We bring in agency nurses – quite rightly – but how do we know quickly if they have the right skills?”

“Nationally we have lost our grip on what’s happening in community nursing.”

Rosemary Cook

As widely reported last week, tetraplegic Jamie Merrett was left with severe brain damage after agency nurse Violetta Aylward switched off his ventilator for 20 minutes in January 2009. She is suspended while a Nursing and Midwifery Council investigation is being carried out, although it has been confirmed she will not face criminal charges.

When the incident occurred, Ms Aylward was working for the nursing agency Ambition 24hours, which had a contract with NHS Wiltshire.

Ms Young said that, although Mr Merrett was an exceptional case, it illustrated how the “number one” priority for improving patient safety across the NHS was to invest in community nursing, which had missed out on investment over the last decade.

Latest data from the NHS Information Centre shows the number of registered district nurses fell 31 per cent between 1999 and 2009, from 13,475 to 9,327.

Although that was slightly offset by the employment of 1,654 community matrons, it still represents a declining workforce at a time when successive governments have championed moving services out of hospitals into community settings.

Nursing Times’ analysis of Department of Health figures shows that the number of patient contacts carried out in the community increased by about 9 per cent between 2006 and 2009.

However, the DH stopped collecting specific data on community nursing patient contacts in 2004.

Queen’s Nursing Institute director Rosemary Cook told Nursing Times the lack of government data made workforce planning and commissioning training places difficult. She said: “You can’t plan at anything other than the very local level.

“Nationally we have lost our grip on what’s happening in community nursing.”

Although government data was no longer available, she said it was clear the community nursing workload was increasing.

Ms Cook cautioned that community teams were becoming less skilled as the workload increased, while the size of the specialist workforce shrunk. As a result, the gap was being filled with less qualified nurses and healthcare assistants, Ms Cook said.

“They all have a role in the team, but it’s unfair on them to be expected to deal with a situation that may be stressful.”

Ms Young agreed, saying: “Over the last few years, the number of nurses having access to health visitor and district nursing programmes has diminished, so we have a diluted skill mix at a time when patients’ needs are increasing.”

She noted that Mr Merrett would not have been cared for in his home 30 years ago, saying: “If this is becoming the norm, we’ve got to be absolutely confident our nurses are up to it and acknowledge they are working in isolation and can’t get help in five seconds.”

The case has also raised questions about the regulation
of nursing agencies, which the Care Quality Commission took over from the Commission for Social Care Inspection in April 2009.

CSCI had rated Ambition 24hours as excellent and awarded it the maximum three stars in October 2008, a rating that the CQC upheld in December 2009. A CQC spokesman said the regulator would “continue to monitor the services provided by Ambition 24hours and will act immediately if required in response to any further concerns”. 

Health minister Anne Milton described Mr Merrett’s situation as a “tragic and deeply distressing” case.

She said: “The Department of Health expects all NHS trusts to ensure they employ appropriately qualified and supervised locums and agency staff as well as providing the correct staffing levels to ensure patient safety at all times.”

Both Ambition 24hours and NHS Wiltshire declined to comment on the case for legal reasons.


Readers' comments (19)

  • This situation will only get worse as staff are down banded and leave due to lack of confidence and trust in their employers to managethem as trusts implement Transforming community services.
    Many with the skills needed to maintain highly skilled and technical nursing are chosing to leave the profession

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  • was this nurse so desperate for work that she took this shift. didn't the agency ask what her skills were.although i have not long been qualified i know my limitations and if i was to be asked to do something i was not comfortable with i just would say no i am unfamiliar with this sorry.

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  • I have met staff from care agencies with name badges saying 'nurse' and 'Sister' when neither were qualified nurses.

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  • I blame the District Nurse in charge for this unfortunate incident. He or she should have allocated one of her team members to visit this patient or The DN should have visited this pt as he or she is familiar with his care.

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  • “I blame the District Nurse in charge for this unfortunate incident. He or she should have allocated one of her team members to visit this patient or The DN should have visited this pt as he or she is familiar with his care.”

    Ok so the Trust commissioned the Agency – The agency employed the nurse, who quite obviously was out of her depth- and yet it is the DN team fault!! Are you for real?????

    The Trust should have ensured the agency could provide adequate staff (depending if the Trust had a half decent contract and a commissioner with half a brain cell- few and far between), the agency should have provided adequate staff and the agency should have checked the Nurse credentials and obviously the nurse has a duty not to practice out with her limitations.

    This is a horrific incident, I am sure it is by the grace of God it doesn’t happen more often. Agency Nurses are often told they are going to a place to carry out in one specialised area only to be faced with something completely different when they get there.

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  • To be honest I don't know nearly enough about this individual case to comment on it, when were the Nurses skills last updated? Was she even a qualified Nurse? Were skills checked by the trust before hiring? Too many variables.

    I will say though that although it is absolutely up to us to ensure our skills are up to date, the trusts themselves (and I can imagine it is worse in the private sector and/or for agencies) are failing us all by not providing enough or adequate training in an effort to save money.

    It is a simple fact that people of any rank can deskill quite quickly if those skills are not constantly practiced or used over a long period, and updates are always important to keep up with changing best practice, so why are constant training and quals available to us on demand? Why can't we say 'It's been a while since I've done 'X' skill, can I have an update?'

    This is a very important issue I feel hasn't really been touched on in this debate.

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  • Mike "Why can't we say 'It's been a while since I've done 'X' skill, can I have an update?"

    We can, it is very clear in our Code that we are accountable for our practice and should acknowledge any limitations in knowledge and competence and decline any duties unless able to perform them in a safe and skilled manner. We can therefore refuse to do a task until we have had appropriate training. Also if our employer expects us to perform certain tasks then they are obliged to provide us with that training.
    After seeing the documentary about this tragic incident it was apparent that turning off the ventillator was not a mistake as the off button needed to be pressed twice, and immediately afterwards when asked what she had done the nurse answered that she had "turned this thing off" It was also apparent that she had no idea how to connect the ambubag to the patients trachy. She was totally out of her depth and should have realised that when she arrived to start her shift at the very latest.

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  • why is a patient on a life support machine being nursed at home without adequate supervision 24/24 from professionals who are qualified in this area? it is far too dangerous to do otherwise.

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  • Anonymous | 2-Nov-2010 2:29 pm

    I wasn't exactly clear in what I meant there, sorry. I know we CAN, and I know it is part of our code, but that does not mean our trusts or workplaces are going to be forthcoming with it.

    It is sometimes an uphill struggle to get updates and training, (especially if we ask for it within our working week!) and it is by no mean guaranteed, even if our employers are obliged to do so.

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  • This is what happens when we have numerous care providers operating outside of NHS governance in the past he would have had considerable support from a DN team.
    many private providers do not deliver a good enough standard of care and this will only get worse as the government unleash many more providers onto the market with no one single agency in charge.
    PCT commissioners cannot hope to monitor many providers.

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