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University Hospitals Bristol Foundation Trust

Children's cardiac ward where patient died was understaffed


Management at University Hospitals Bristol Foundation Trust have been criticised by the Care Quality Commission for failing to address long running staffing issues on a ward for seriously ill children.

The CQC inspected ward 32 at Bristol Royal Children’s Hospital in September following complaints from parents whose children had died there.  

It issued the trust with a warning notice after finding patients were being put at risk by inadequate staffing on the ward, which regularly admits children following cardiac surgery.

Inspectors found the ward was operating as a high dependency unit but was staffed as general paediatric ward with half as many registered nurses as required.

In its report, published today, the CQC said the trust had been aware of the “inherent risks” posed by low staffing levels for a “considerable amount of time” but failed to address them effectively.

A root cause analysis of the death of seven-year-old Luke Jenkins highlighted that risks posed by inadequate staffing had been identified following an incident in October 2010 but had still not been addressed at the time of his death in April.

The analysis, completed in June, found low staffing levels were a “contributory factor” in Luke’s death as well as six other patient safety incidents that had occurred on the ward since the beginning of the year.

In a statement, the trust said it had bought forward plans to establish a cardiac high dependency unit and secured commissioner agreement to recruit additional specialist nurses.

Two beds have been created on the paediatric intensive care unit for cardiac children who require high dependency care and nurse to patient numbers have been improved.

Chief executive Robert Woolley said: “As a result of these actions, I believe we have addressed the issues leading to the warning notice and I would welcome a return visit from the CQC to confirm this.”


Readers' comments (8)

  • I have asked the NMC to determine if Alison MOON , the "Chief Nurse" for the University Hospitals Bristol NHS Foundation Trust is fit to practise.

    It is reported that staff attempted to draw attention to dangerous staffing levels on more than 10 occasions extending over some seven months

    It is time for Ward Staff to be listened to and for "Management" to cease putting patients and staff at risk.

    Make it clear in your trust that Nurse Management failures will no longer be tolerated and that fitness to practise referrals will be made to the NMC in the event of patients being put at risk as the result of management action/inaction .

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  • Hi Jenny,

    Have you made a formal referral? I would like to find out more. Could you drop me an email to or give me a call on 02077283746.



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  • until nurse managers are called to account nothing will change. everywhere is short-staffed, no-one listens because all they want is to save money. the government have put us all in this impossible position - money, money, money.

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  • It's not just front line clinical staff shortages that affect care, the less visible functions of admin support, portering, even postal delivery which has been halved in my place of work can have major impacts on patient safety in terms of communication of important pieces of information. Notes kept off site, important letters and results not filed and so not available to the current clinician - the outcomes are obvious. Above all the message is that management only listen and take action after people die.

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  • Sarah and Jenny
    Hpe that you are successful, may make a few more people take notice. Surely there is some legislation already on the books, Health and safety for example, for prosecuting these individuals under the guise of deliberate negligence ( corporate manslaughter perhaps?)

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  • all wards are under-staffed, the management, whoever is responsible needs to sit up and take notice. fine those trusts that are under-staffed, they are putting patients lives at risk every day and also the welfare of their staff. stop them referring nurses to the nmc for 'incompetence' when they are the cause of most of the incompetence.

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  • tinkerbell

    Jenny Jones | 1-Nov-2012 10:58 am

    Well done Jenny. Let us know how you get on. This is so important because it is an absolute disgrace that these situations are allowed to continue that put young patients lives, at risk. What kind of a society are we that tolerat these corrupt practice/ managers. This is criminal behaviour.

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  • Back in the 80s I represented theatre nurses at a private hospital. They were ordered to care for patients [from their hospital] in a nearby neuro ITU. They were scared as they did not feel competent.

    As a CoHSE rep [Unison] I wrote to the Chief Exec and Chief Nurse pointing out that my members were drawing attention to the fact that they were not competent to undertake the role and pointing out that if they were coerced into doing the job I would refer the Nurse to the NMC and inform the Press.
    The order was rescinded within minutes.

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