Heart surgery boy died 'due to staff shortages'
BANK holiday staff shortages were partly to blame for the death of a seven-year-old boy at Bristol Children's Hospital, a report has found.
Luke Jenkins was expected to make a full recovery after successful corrective heart surgery at Bristol Children's Hospital. But an investigation found that a catalogue of avoidable errors led to the death of the Cardiff youngster on April 7.
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Luke Jenkins died within a week of heart surgery at Bristol Children's Hospital
Put together by an investigative team at University Hospitals Bristol NHS Foundation Trust, which runs the city centre hospital, the report found that junior nursing staff lost vital time because they did not know where to find resuscitation equipment on Ward 32, where Luke was placed. The emergency team was also unfamiliar with the equipment because cardiac arrest was rare in the ward environment.
The fact that Luke suffered a cardiac arrest on Good Friday meant that the duty surgeon was at home when he collapsed and had to be urgently called in to attend hospital, although he was treating Luke within 19 minutes.
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Luke's heart stopped for 43 minutes before he was resuscitated, after which he underwent exploratory surgery. He died the following day.
Luke was born with a congenital heart defect and had already had two other corrective operations.
He was initially put into intensive care but was transferred to Ward 32 after several days.
Low staff levels had been a problem on the ward for at least two years, the report found. A risk assessment identifying "low and unsafe" nurse staffing and high dependency patient monitoring following a high-risk incident in October 2010 had not been dealt with and there had been eight separate patient safety incidents on the ward since January, all of which were linked to problems of low staffing levels.
The report also found that alarms on Luke's monitoring equipment were re-set because Luke was frequently triggering them after his arrival on Ward 32.
"Triggering the alarms did not appear to trigger a medical review," the 40-page report said.
Luke's parents Stephen, 30, and 27-year-old Faye, say the report itself contains errors and questioned an assertion that he had undergone an x-ray the day before his death.
"If he had had an x-ray they would have found what was wrong with him and he would still be here now," said Mr Jenkins. "But we were with him all day and we know that it never happened.
"There have been eight other incidents since January 2012. They cannot tell us who the people were but that should be made public."
UH Bristol acting chief executive Deborah Lee said: "We extend our deepest sympathy to the family for the loss of their child. We are aware of their concerns about the care their child received and are investigating those concerns. We are in contact with the family. Incidents do occur in a complex specialty such as paediatric cardiac services, where we are caring for some of the sickest children in the region. Each incident, no matter how minor it may appear, is recorded, rigorously investigated and actions taken forward as part of our clinical governance process.
"We provide highly specialist care for children with a range of complex cardiac problems from South Wales and the South West and our reported cardiac outcomes are amongst the best in the UK."
Comments
by Bristol
Wednesday, October 03 2012, 3:44PM
“Bristol Children's hospital is fare from a centre of excellence; Children have died due to the poor standards of care. Outside of PICU Bristol does not have a high dependency unit. Bristol Royal Children's Hospital is misleading families into believing their children are cared for in high dependency beds on ward 32. Low level of staff are putting vulnerable children at risk. http://tinyurl.com/9yzq726”
by Bristol
Wednesday, October 03 2012, 3:43PM
“Bristol Children's hospital is fare from a centre of excellence; Children have died due to the poor standards of care. Outside of PICU Bristol does not have a high dependency unit. Bristol Royal Children's Hospital is misleading families into believing their children are cared for in high dependency beds on ward 32, ward 32 does not have high dependency beds. Low level of staff are putting vulnerable children at risk.
http://tinyurl.com/9yzq726”
by 780715JVB1
Monday, September 10 2012, 3:47PM
“"And where is the Evening Post and other media outlets looking into this scandal and really challenging the Trust that runs the BRI to explain why staff numbers and costs on the ward are being cut? The Evening Post is toothless and gutless."
Just to point out - it's also suffering from the same lack of staff due to budget cuts ....”
by dp98765
Monday, September 10 2012, 3:39PM
“UH Bristol acting chief executive Deborah Lee said: "We extend ..... and actions taken forward as part of our clinical governance process."
Then how come the '.. "low and unsafe" nurse staffing and high dependency patient monitoring following a high-risk incident in October 2010 had not been dealt with .. '
So Deborah was the action taken forward to do nothing? Will the actions to take forward from this be more of nothing?”
by raldred
Monday, September 10 2012, 2:29PM
“This wont be an isolated case, hospitals up and down the country are short-staffed due to cuts and staff off sick with illnesses caused by poor working conditions. Junior staff thrown in the deep end because there is not enough senior medical staff to give guidance. I don't doubt that many children on high dependency & ICU wards have died and will die due to improper staffing.”
by stevebris7
Monday, September 10 2012, 2:01PM
“I agree 1000% with Hartman81. I always feel realyl helpless when I hear of things like this, my mum goes into hospital occasionally and the quality of staff can be dreadful, checking forms to see what duties they can perform. Heaven forbit a patient wants to go to the toilet but the person they ask to help them dfoesnt have that on thier duty list. It's an absolute joke!”
by Hartman81
Monday, September 10 2012, 1:45PM
“Unfortunately there will be more like this, for adult heart patients as well as children. The Trust is forcing wards to cut back on staff costs rather than make savings elsewhere. Of course Trust management and the army of office staff and bureaucrats remain unaffected. Nursing staff numbers should not be cut in any way under any circumstances. The sad incident in this article happened on a bank holiday. No surprises to know that this is when staff get a higher rate of pay so more junior staff are scheduled to work on these days to save money. The staff shortages mentioned were entirely self-inflicted and planned.
Currently, nurses are completely over-worked and wards under-staffed of experienced nurses. The Trust and BRI senior management (bean counters with little or no clinical experience) think it is about numbers of people on the ward rather than ability. More Nurse Practitioners and Nursing Assistants, with fewer trained Nurses, is having a direct impact on patient safety. How many deaths will it take for the Trust to ring-fence ward staff costs and make any cuts elsewhere?
And where is the Evening Post and other media outlets looking into this scandal and really challenging the Trust that runs the BRI to explain why staff numbers and costs on the ward are being cut? The Evening Post is toothless and gutless. There is no investigative journalism any more. Just re-hashing of stories you can find elsewhere and freedom of information requests.
Like I said, this death will not be the last if things continue like they are and the 'cartel' looking at cutting staff costs further will make it even worse as many staff will simply quit and work elsewhere. The Trust needs to focus on what a hospital should be – somewhere that makes ill people better. That's all. Focus on that, hire MORE trained nurses and cut all the other stuff. Stop running the hospital like a business – it isn't one – and ensure all board members and senior management have clinical experience, so they know what they are doing rather than just seeing people as numbers on a spreadsheet.”