CQC inspectors forced to intervene as staff did not react to choking patient

Health inspectors had to intervene as staff at an under-fire hospital did not react when a patient started choking.

Two staff from Queen Alexandra Hospital in Portsmouth were in close proximity to a patient when they started choking on their meal “but did not attempt to help the patient”.

Inspectors had to intervene to ensure the safety of the patient, the Care Quality Commission (CQC) said.

CQC officials also witnessed a member of staff ignoring the pleas of a patient with dementia calling out for assistance – as a result the patient was incontinent.

The CQC said there was a “culture of poor care” in some of the medical services at the hospital.

Inspectors also observed patients living with dementia becoming upset and agitated and staff not acknowledging them or providing reassurance.

Meanwhile, inspectors also raised concerns about some patients not being assisted with their meals, even though some had been identified as being at risk of malnutrition.

“We found there was a culture of poor care and behaviour which had become normalised for staff within the AMU (acute medical unit) and some medical services,” the inspection report stated.

Inspectors said that staff did not feel listened to or connected to senior management amid allegations of bullying and harassment.

They also raised concerns about a number of infection control processes, including night nurses eating pizza at a nurses station.

“Staff eating on the ward could pose an infection control risk,” the report added.

Medical care at the hospital has been rated as “inadequate” overall.

Inspectors also said that too many beds in the hospital were taken up by people who were medically fit but unable to leave hospital until social care became available.

They described one case where a patient was medically fit for discharge but could not be sent home due to lack of availability of care packages in the community. The patient died of hospital acquired pneumonia before being discharged.

A separate CQC report into the trust which runs the hospital, Portsmouth Hospitals NHS Trust, criticised safeguarding issues.

“We were concerned by the high prevalence of safeguarding events being reported and investigated,” the report stated.

“At the time of the inspection there were three serious allegations of physical abuse between staff and patients under investigation by the police and local authority.

“There were three cases of where a patient with a learning disability had died as a result of poor care, documentation and decision making.

“These were going through a serious case review at the time of our inspection.

“There was a case subject to police investigation in relation to wilful neglect of patient care.

“We were not assured that the processes for safeguarding children were effective within the emergency department.

“We were informed of two cases that occurred in the week prior to our inspection where children under the age of one-year-old were sent home despite bruising of unknown origin being found.”

The CQC has ordered the trust to make significant improvements to protect patients using medical care services at Queen Alexandra Hospital.

It has issued a warning notice requiring the trust to improve safety, patient consent, dignity and respect, safeguarding and overall leadership following two separate inspections earlier this year.

“During our inspection in February 2017 we found that the quality of care on the medical wards was very poor especially for the most vulnerable patients, whose needs were not being dealt with properly, and who were at risk of avoidable harm,” CQC’s chief inspector of hospitals, Professor Ted Baker, said.

“Such was the level of our concern that we took enforcement action instructing the trust to implement improvements.

“We undertook a follow up inspection in May to look further into the wider culture, governance and leadership within the trust.

“It is a matter of concern that on this return inspection we found the trust had still not effectively got to grips with these issues.

“There was a distinct lack of management oversight. The board appeared to have no real understanding of what was happening on the wards: we concluded that the trust leaders were not giving sufficient attention to many of the concerns we identified or the concerns of their own staff.

“Portsmouth Hospitals has been under pressure for some time, too many beds are taken up by patients who are medically fit for discharge but unable to leave hospital until social care becomes available.

“This in turn creates further pressure on the wider healthcare system.

“All local system leaders must help resolve this issue.”

Trust chief executive Mark Cubbon said: “The report makes for difficult reading and we have fallen short in some key areas; but I am confident that we can and will do better.

“In the four weeks since I have been here, I am convinced that we have the skills, dedication and ambition to address all the issues raised by the CQC and ensure we give the best possible care we can to every patient.

“Since the inspections in February and May the Trust has made some significant and important changes, including strengthening the joint working of our doctors and nurses in the emergency department, urgent and medical services.

“We have also seen very significant improvements for vulnerable patients, including those who have mental health issues, we have active, early risk assessments in our ED, a Mental Health Liaison Team, working much more closely together and much stronger cross-organisation working with colleagues from partnership organisations.”

He added that the trust would be publishing an action plan on how it would deliver better care.

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