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Queen Elizabeth the Queen Mother Hospital in Margate

Change needed to improve patient safety in east Kent hospitals

Canterbury and Whitstable MP Rosie Duffield has written to Prof Ted Baker, the chief inspector of hospitals at health watchdog the Care Quality Commission calling for an urgent inspection of east Kent’s hospitals. This is the text of her letter. It is entitled “Request for Supplementary Inspection Regarding Patient Safety at East Kent Hospitals University NHS Trust”.

Dear Professor Baker,

I write to request consideration of a supplementary inspection by your team following three separate reports of safety problems at the east Kent trust between February 28 and April 11, 2018.

All have been reported in the Health Service Journal and give grave cause for concern.

You will recall that the last all – services inspection by your team, dated December 21, 2016 rated the trust as “requires improvement” in the domains of “safe” and “well led”.

Canterbury and Whitstable MP Rosie Duffield

The three newly reported incidents were not referred to specifically in that report or alluded to in general comments about systems and processes in those inspection domains.

I therefore regard them as new and requiring immediate consideration by the Care Quality Commission inspection team.

The most recent, brought in to the public domain by an HSJ article on 11th April, relates to 5,000 mismatches of patient data in the two radiology systems being run by the trust, one containing patient record data and the second containing only images.

It is said by the HSJ report that the mismatches were discovered during routine investigation and maintenance of the system, but some go back as far as the year 2007.

There are a number of potentially critical system failures identifiable across all three major hospitals in the Trust, as follows:

• First, the fact that some mismatches were undetected for up to 11 years, indicating that routine checking processes may have been defective.

• Second, as some images were not directly related to the patient identifiable information which could have triggered call in of the patient or information being sent to the referring clinician, it may be that some patients were not informed of the results and/or their referring doctor was not so informed;

• Third, there is the possibility that some images were not reviewed appropriately by a radiologist and the review recorded on the system within the time window accepted as appropriate, and then transmitted to the patient and referring clinician.

• Fourth, the large scale of these errors over time suggests a strategic failure to undertake routine matching of data between systems which is itself serious and disturbing.

The HSJ report suggests that checking is ongoing but that it is being undertaken internally.

This is not acceptable and there should be an independent element to this based on an Inspection by your team and/or a review by an outside consultant radiologist nominated by the Royal College.

It is possible that significant harm may have been done to patients by missed diagnoses and failure to pick up progression of disease, and there is also the possibility that absence of disease may not have been communicated to patients in the way that would have been expected.

The second disturbing report (April 7 HSJ) relates to six babies in the Neo Natal Intensive Care Unit at the Queen Elizabeth the Queen Mother Hospital Margate who were found to have colonised MRSA, later identified as having been linked by contact with infected staff.

As you know, the NNIC is defined as a high-risk unit in the DH screening assessment report of 2014 and it appears that
screening and checking procedures appropriate to the unit’s treatment of vulnerable young patients may not have been in place during the January-March 2018 period when the infections occurred.

The Special Care Baby Unit was also suspected of being infected. These facts are of particular concern given the
medical director’s report to the board in April 2018 stating that the trust still had a problem with infection prevention and control.

The third case relates to findings made by the Central and South East Kent Coroner in respect of five deaths at the William Harvey Hospital Ashford and reported in HSJ on February 28.

The coroner stated that risk assessments of patients were “inadequate, incomplete, not reviewed or not enforced” and that the five deaths took place from falls where such risk assessments were not undertaken properly.

It was also the case that the inquests for some patients had been delayed to allow the trust to show progress on improvement activity but that this had not been completed by the time that the inquests proceeded.

The common theme in these different cases, which have been reported in the last two months, but which cover longer periods of time and different services within the trust, is a sloppiness regarding the implementation of patient safety policies and a failure to put measures in place quickly when incidents occur.

There is also a failure to record incidents, problems and risk assessments and my own work as an MP has convinced me that systems holding patient data in the trust are in some cases inflexible, inaccurate and confused, and top management unresponsive when questions are raised.

I am very conscious that the trust has been through a difficult time over the past few years, with multiple changes of top leadership and interim managers in place, and with serious financing pressures, but it is important in my opinion that the Care Quality Commission takes appropriate inspection action to kickstart the changes necessary to radically improve patient safety at the Trust.

This can only help the new management team to gain top level advice based on a comprehensive assessment of data
systems and safety controls.

Looking forward to your response as a matter of urgency

Best wishes,

ROSIE DUFFIELD MP

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