Nurse staffing pressures were a major factor in why some patients received poor care, an independent review of children’s cardiac services in Bristol has suggested.
Nursing staff on a key cardiac ward were “regularly under pressure, both in terms of the numbers available and the range of skills needed”, according to the Report of the Independent Review of Children’s Cardiac Services in Bristol.
The report, published today, warned that this had “led on occasions to less than good care for children and poor communication with parents and families”.
“Nursing staff were regularly under pressure, both in terms of the numbers available and the range of skills needed”
However, the independent review found “no evidence” of a repeat of the level of failures identified in the high profile public inquiry of 1998-2001, which found 35 babies died and many others were left with brain damage at Bristol Royal Infirmary during 1991-95.
The latest work was commissioned in June 2014 by Sir Bruce Keogh, NHS England’s medical director, after he was contacted by a number of families whose children had died in recent years following cardiac surgery at University Hospitals Bristol NHS Foundation Trust.
The resulting review, chaired by Eleanor Gray QC, was contacted by 237 families whose children were treated at the Bristol Royal Hospital for Children. It also analysed over 6,000 documents and had 50 meetings with staff.
Mandie Sunderland, chief nurse at Nottingham University Hospitals NHS Trust, also acted as one of two expert advisors to the review.
Much of the review, which covered the period from March 2010 to July 2014, focused on the hospital’s ward 32.
The report noted that “one reason” why the review was set up were parent concerns that “numbers of nurses on ward 32, and their skills, were not adequate to provide proper nursing care to the children on the ward”.
Some of these parents had been instrumental in triggering an inspection of the ward by the Care Quality Commission in September 2012, it stated.
The review highlighted that the number and needs of children on the ward called for a “high level of nursing care”, and it potentially had the highest level of acuity in the hospital.
Demand for nursing care was further increased by the fact that a large percentage of patients were babies or very young children with cardiac problems and that there were a large number of small rooms or cubicles on the ward. Staff also had to respond to the needs of children who attended the ward for a day, or less, for short reviews, as well as non-cardiac patients with “less familiar” needs.
“Overall, there was evidence that suggested that ward 32 was under heavier pressure than other wards, because of the circumstances of its patients,” said the review.
It noted that senior nurses said that, at the time, a lack of validated tools for measuring acuity meant there was a “heavy reliance on professional judgment and discretion” to assess the daily staff numbers and level of nursing needed by the ward.
“We do not doubt the sincerity and good faith of all those staff made those judgments. But we do consider that they needed better tools to be developed, to support them to make them,” said the report.
It highlighted that, in recent years, “much work has been done on ensuring safer nursing levels”, including the development of tools for measuring patient acuity, with one for paediatric patients soon to be available.
“We emphasise the importance of the early use of, in particular, a nationally recognised paediatric staffing tool for acutely ill children,” it said.
“When available, this should be utilised, together with the professional judgement of senior nurses responsible for the care of the patient, to review the basis of the current nursing establishment on the cardiac ward,” said the review report.
“On a number of occasions, the care was less good and that parents were let down”
It went on to note that during the review period, the “most appropriate sources” on levels of nursing staff were the Paediatric Intensive Care Society’s 2010 standards and 2003 guidelines from the Royal College of Nursing, which nurse managers said had “limitations”.
The report stated: “In the light of the numbers of patients, their ages, their need for specialist care and the increasing acuity of patients, the review felt that the nursing numbers would have fallen below the recommended levels on a reasonably frequent basis, and that there was a clear risk of harm as a result.
“Further, heavy reliance on Bank and agency nurses to maintain staffing levels is not consistent with providing an appropriate quality of care,” it added.
The report went to say that case reviews showed staff worked hard to ensure children received “proper attention”, such as hourly observations, but lacked time to reflect on trends in clinical status, for example the ability to identify children whose condition was deteriorating.
By late 2011, the review suggested there was growing evidence that low staffing levels were affecting patient safety on the ward.
Details of incidents relating to “low” or unsafe staffing, expressions of concern voiced by the trust’s cardiac clinical governance committee and by a consultant paediatric cardiologist suggested a “need for careful review of the existing care”, said the review.
During 2010 and 2011, the funded establishment for ward 32 was three registered and one unregistered member of staff during weekdays, and two registered and one unregistered overnight and at weekends.
By spring 2012, a number of incidents had prompted further consideration, both of the staff’s ability to recognise children whose condition was deteriorating and of the adequacy of levels of nursing staff.
Steps to increase these levels – to four registered and one unregistered member of staff during the day on Monday to Sunday, and three registered and one unregistered overnight – were outlined in an email from the matron in April 2012. “Shift patterns were said to have been changed to free nursing resources,” added the report.
The review described the proposed changes as “reasonable” but found no evidence that a planned audit to ensure they occurred had taken place and there was a “dearth of information about exactly when the changes described took effect, and their efficacy”.
“Against that background, the CQC found that there was non-compliance with, in particular, its staffing standards, when it inspected the ward in early September 2012,” added the review.
Overall, the review has made 32 recommendations requiring action by the trust, NHS England and the Department of Health.
In response, NHS England said it would set out plans for reconfiguring congenital heart disease services next week.
Sir Bruce said: “Quality is not just about survival, it is about many other things. These families’ experiences tell a very powerful story not just for Bristol but for the rest of the NHS in terms of compassion and how we treat people in their darkest moments.”
Trust chief executive Robert Woolley said: “We fully accept the findings of these reports and welcome their publication as a way to learn from mistakes.”