NHS trust in special measures after patients died waiting for heart treatment

An NHS trust has been placed in special measures after some hospital patients were found to have died after waiting too long for heart treatment while others were left to go blind.

NHS Improvement took action against the Royal Cornwall Hospitals NHS Trust after inspectors from the Care Quality Commission (CQC) found services were failing across several departments, including surgery, maternity and cardiology.

Among their findings were patients waiting too long for treatment and suffering harm as a result, operations being cancelled, including for cancer, patients with sepsis not receiving antibiotics in time and a sewage problem in a bathroom not being dealt with for more than three years.

In cardiology, from December 2016 to June 2017, 554 patients suffered delays while waiting for appointments, the CQC inspection report said.

Inspectors added: “We were informed of two patients who had died of cardiac related causes while delayed on the waiting list.

“While it is not possible to say the deaths were directly linked to the delay, the trust reported it was highly likely.”

Inspectors also found a backlog of around 150 heart monitoring tapes going back to March that had still not been reviewed.

This backlog was a “particular risk because if any cardiac anomalies were present in the tapes, the patient would remain unaware of this”, inspectors said.

In ophthalmology, 6,503 patients were delayed in having their appointment, with 1,200 patients waiting for treatment for the condition wet age-related macular degeneration at the time of the CQC inspection.

Patients with this condition had therefore not been reviewed within a safe timeframe, inspectors said, and this delay to treatment had caused harm to at least four patients “who had suffered partial loss of vision or complete blindness as a result.”

Inspectors also reported “significant levels of cancellations” of planned operations across the trust. This included 12 patients with cancer between January to May 2017, with seven cancelled on the day of their operation.

Three of these patients were women with breast cancer whose operation was put back due to a lack of high-dependency beds.

The trust was also found not to have acted on a coroner’s report dating back to 2014, which highlighted the risk that emergency surgical patients are not seen quickly enough.

Meanwhile, while the trust was good at identifying patients with sepsis, only 37% to 65% with severe sepsis received potentially life-saving antibiotics within an hour as set down in national recommendations.

Inspectors also found serious problems in maternity, including not enough midwives to provide safe care at all times, and midwives not having up-to-date neonatal life support training.

Inspectors added: “We could not be assured that community midwives had the necessary equipment to manage obstetric or neonatal emergencies in the community in the event that the ambulance was delayed.”

Furthermore, women who were admitted for monitoring after reporting that their baby’s movements had reduced, indicating potentially serious problems, could not always be seen on the same day.

Too many women were also being induced on some days, indicating a risk to safety, and there was “no process to ensure that there was always a nurse or midwife on duty with the necessary competencies to manage high dependency women”.

Overall, the trust was rated inadequate for safety, while surgery, maternity and gynaecology and outpatients and diagnostic imaging were rated as inadequate.

The CQC’s Chief Inspector of Hospitals, Professor Ted Baker, said: “The people of Cornwall are entitled to services which provide safe, effective, compassionate and high quality care.

“During this inspection and in our previous visits to the Royal Cornwall Hospital we have found persistent evidence of care that falls below those standards.

“As a result patients have been let down and some have been placed at risk.

“It is clear that these are not isolated lapses.

“I am concerned that the management systems to assess, monitor, and deal with risks to patients have not been operating effectively and the Board has not had the oversight that is required.

“Throughout our inspections, we have invariably found the staff to be caring and compassionate.

“Despite their best efforts Royal Cornwall Hospitals has a history of poor performance, with a failure to make improvements over a number of years.”

Announcing the hospital trust was being placed in special measures, Jennifer Howells, NHS Improvement’s regional director for the South West, said: “The lack of improvement between inspections at Royal Cornwall Hospitals NHS Trust is disappointing and it is important that the trust now makes rapid progress to maintain and restore the confidence of local people.”

Kathy Byrne, chief executive of the trust, said good, safe care was a priority.

She added: “We take the CQC report very seriously and I want to apologise to any patient who has waited too long for treatment or not received the very best care.

“We have now established a stable senior leadership team and we want good clinical leadership to be at the heart of our quality improvement programme.

“Everyone who works in our hospitals is committed to making the changes our local community and regulators want to see.”

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