Liverpool Care Pathway - From “Nightingale To Nightmare”

‘Up to 1,200 “excess deaths”…’

Excess deaths…?

This public inquiry has proceeded in the public gaze and yet the scrutiny has been almost imperceptible and inscrutable as to pass unnoticed, hiding in plain sight.

‘Up to 1,200 “excess deaths”…’

These are people. Is there no outcry?

Nightingale to nightmare. That describes it all perfectly. That is what we have come to...

 Mr Street, a former care-home manager, said : “All I was interested in was looking after Gill. Had it not been for Stafford Hospital I would have made that my life task.” Nursing in the NHS had gone from “Nightingale to nightmare”, he said, and “rampant complacency” among the regulators had resulted in trusts neglecting their duty to patients while focusing on hitting targets.                                                                                                                           

This is The Independent -

Neglected: lessons of fatal error in NHS care

Public inquiry chairman says Mid-Staffordshire did nothing – even after a mistake killed a patient

JEREMY LAURANCE 

 SUNDAY 27 JANUARY 2013

In his final summing up to the public inquiry into the Mid-Staffordshire Foundation Trust, the biggest scandal in NHS history whose report is due to be published next week, the chairman, Robert Francis, quoted the case of a diabetic patient who died because nurses forgot to give her insulin.

A police investigation was launched into the act of gross negligence in 2007 but no prosecution was ever brought. A manslaughter investigation by the Health and Safety Executive is pending and two nurses involved in her care are awaiting disciplinary hearings before the Nursing and Midwifery Council.

Ron Street, 79, the “close friend, soulmate and carer” of Gillian Astbury, who was 66 when she died, spoke for the families of hundreds of other patients today when he said he wanted people held accountable for her death.

Up to 1,200 “excess deaths” occurred at the trust from 2005-8 as a result of horrific standards of care which left de-hydrated patients drinking from flower vases and others screaming in pain. In a letter to the inquiry,  Mr Street wrote: “I am not here for myself. I am here for Gillian and the rest of the dead. When they took Gill away from me they took away my contentment. I don’t want anyone else to suffer that. Bereavement comes to us all but it is how it comes to you that is important.”

Mr Francis, QC, told a seminar on organisational culture at the inquiry, that despite its gravity, the gross error that led to  Ms Astbury’s death had failed to trigger remedial action.

“A report on the incident by the in-house solicitor said there had been several systemic failures and it was clear similar issues in other cases were occurring regularly. That never registered with the trust board or with the strategic health authority. One then asks this: what about accountability?” he said.

Mr Street has waited six years for the report, the most extensive inquiry ever held into the NHS and one of the most eagerly awaited which is examining how regulators allowed the scandal to happen. That it will make uncomfortable reading for all involved, from the most junior healthcare assistants to senior ministers and officials in the Department of Health, is a given.

Ms Astbury was admitted to Stafford Hospital with a fractured hip following a fall at home on  1 April 2007. After repeated instances in which Mr Street had found her lying in soiled bed linen, with meals left out of reach and bloody tissues discarded on the bedside table, she died  10 days later in a hypoglycemic coma after she  had been transferred to a new nursing team who had not read her notes and learnt she needed regular injections of insulin for her diabetes.

Mr Street, a former care-home manager, said : “All I was interested in was looking after Gill. Had it not been for Stafford Hospital I would have made that my life task.”

Nursing in the NHS had gone from “Nightingale to nightmare”, he said, and “rampant complacency” among the regulators had resulted in trusts neglecting their duty to patients while focusing on hitting targets.

“There is a culture problem. It is about people’s attitudes. There is a lack of responsibility and a lack of compassion.

“I am not a vindictive person but I would like the people at Stafford held to account. I don’t necessarily want them clapped behind bars but I do want a message sent out across the NHS that you cannot do this with impunity,” he said.

They may ‘take learnings’ from this...

but they can and they will.