Diary of Events

Sunday 15th March

Dad discharged from I.T.U. to Baily Ward at approximately 6.45pm  Was without drip and oxygen for a couple of days before move.

During the first visitation to the ward , Victoria was informed that they were about to administer pain relief (tablets resembling paracetamol).  When she questioned what they were, she was informed they were co-codomol – to relieve the pain in his knees.  Victoria requested they desist from this course of action and directed the nurse to check the red wristband on Dad’s arm where it clearly stated that he should not be given paracetamol.  Victoria went on to explain how it would cause him to have a crash in blood pressure (as happened in I.T.U.) and require noradrenalin to re-stabilise him.  She explained how ibuprofen also had a similar effect.  The nurse then checked with I.T.U. who confirmed this.  There is no documented record of this incident.

Monday 16th March

Dad very unhappy.  Reported he has been treated very roughly by nursing staff.  When Victoria arrived, drinks, TV and nurse bell were all behind him – out of reach.  Dad was slumped against side of bed (supported by medical notes) and Victoria had to reposition him as the staff were “too busy”.  When Emma visited later that same day, the TV and nurse bell had been moved out of reach again.

Dad back on drip.  No information from nursing staff as to why this was the case. Victoria asked the HCA who said she didn’t know, she then asked to speak to the staff nurse and was told that the nursing staff were too busy to talk to her.  There are no medical notes explaining why.

Tuesday 17th March

Dad in pain again, unwashed and unshaven since arriving on the ward (there is no personal care core plan until 18^th March contravening Core Care Plan 1, point 4 “Offer patient assistance with personal care at least daily”).  Drinks and TV out of reach.  Pain relief not administered because (according to staff nurse S) the fact that he hadn’t taken the tablets himself, meant he had refused them.  Victoria explained that he was unable to take them himself – that he needed the tablets to be put into his mouth for him.  Victoria administered the tablet (there is no drug chart to support whether or not the drugs were administered – nor is the fact that Victoria administered the tablet documented).  Dad was slumped in the bed again and Victoria had to reposition him.  He was miserable.  Back on oxygen (which was directed at his eye instead of his nostrils and causing further discomfort).  Victoria asked the HCA why the oxygen was again necessary, she didn’t know.  Victoria then asked to speak to the staff nurse, and waited….and waited.  Some time later she asked the HCA again, and also a passing staff nurse but left with no further information (there is no information about this in the care plan or medical notes (they assume he had always needed oxygen).

Wednesday 18th March

Cannula hanging out of arm – dripping and bleeding onto bed.  This had been the case for a while judging by mess (not in care notes).  Photo evidence. 8/3/2009. 20:27

Concerns about Dad’s level of nursing care since his arrival on the ward prompted Victoria to contact the Patient Advice and Liaison Service.  There was no improvement in Dad’s care, he was miserable, often without TV, drinks and nurse bell as they were constantly out of reach   Victoria discussed our concerns and requested that Dad was moved to another hospital before the stay on Baily ward kills him.  She was told that PALS would take up the case with the head nurse of the ward (P A) and that he was ultimately responsible for making the decision regarding Dad’s move.

After talking to P, PALS rang Victoria back and informed her that P was disputing that Victoria was Dad’s main carer and next of kin so would be unable to make anything happen.  Victoria requested to speak to P directly and was put onto the phone with him.  He then said he didn’t dispute her main carer/next of kin status.

Victoria told P of her fears that if Dad were to remain on the ward he would die there due to the abysmal standard of basic care.  He challenged this comment and suggested a face to face meeting.  He also said that Victoria should have spoken to him directly in the first instance instead of going through PALS.  He agreed to relax the visiting hours for the family (they were too restrictive and were considered detrimental to Dad’s care) and a meeting with him was arranged for the next day.

Thursday 19th March

Prior to meeting with P the registrar updated Victoria, Samantha and Emma on his medical care.  Amongst other things he confirmed that although Dad’s heart rate was still high, a pacemaker would not be necessary (this is backed up by the medical notes and a direct contradiction to the opinion of P in the meeting that followed).

During the meeting with P we discussed the following points:

• The level of Dad’s care

• often unwashed and in dirty pyjamas
• Nurse bell often out of reach
• Fluids out of reach
• TV and phone out of reach
• Drugs were impossible for him to pick up and take and because of this it was put down as a refusal of medication
• Possibility of liquid form meds

• Where Dad’s rehabilitative care would take place – East Sussex v West Sussex.
• The possibility of Dad moving to another hospital
• We requested a meeting to be arranged with Dad’s consultant (Dr C) in order to discuss the big picture of Dad’s care with her.

Outcome of the meeting:

• P was embarrassed at our complaints about the level of care.  He excused the fluids being out of reach by stating that if they were put on Dad’s right side (which was the arm he couldn’t move), his thirst would motivate him to move it.  He agreed that fluids would be put on the other side from now on. Regarding the other issues, he promised to look into our concerns and ensure Dad’s needs were better met in future.
• We were informed that in order to get Dad released into a West Sussex rehabilitation centre, since the long term aim was for him to live with Victoria in Shoreham, we should change his address now to reflect this move.
• P stated that it was currently impossible for Dad to move to a different hospital.  He said the reason for this was because Dad had to have a pacemaker fitted.  We questioned why this was necessary – especially since the consultant had told us one was not required just minutes earlier.  P explained that it was the only way to slow Dad’s heart rate to make it normal.
• P agreed to arrange for us to have a meeting with Dr C – date to be confirmed
• P said he would get dad’s meds all prescribed in liquid form

Unspecified date (sometime around 24^th March)

Victoria visited Dad one day and when she asked to see the care plan, she was informed by F that she could not.  She was advised that if she wanted to see it, she had to apply in writing.  Just after this, in order to find out some information and since none of the staff nurses or HCA’s would/could offer any help, Victoria barged into P’s office.

During her discussion with P, she was provided with a detailed description of Dad’s medical notes – that he was being treated for infection, that they thought he may have tuberculosis etc..  When asked why Dad’s drugs were still being provided in tablet form (instead of liquid form as was requested) she was informed that the pharmacist was off sick.  There was no response from P when this poor excuse was challenged.

When asked about the future plan to fit Dad with a pacemaker, P denied having said this – even though having a pacemaker fitted was his primary reason for Dad not being able to be moved to another hospital.

Victoria asked about the meeting which he was going to arrange for us with Dr C – he said he was on the case and would let her know when he’d spoken to her.  (We now know he never mentioned anything to her about a meeting, or any of our concerns or complaints (Dr C told Victoria this herself on the night Dad went into resus)).

She was still not provided with any details of care plan.

Ongoing issues – unspecified dates

Dad constantly covered in handling bruises

Waiting 30-40 minutes for help to open bowels and was then roughly treated.  When he complained of rough handling Dad was told “they save lives at this hospital!”.  Staff Nurse G requested that Dad move his legs to roll.  He was unable to do this due to neuropathy from I.T.U.  She called him a “poor old sod”.  Dad was offended (this contravenes Core Care Plan 1, point 9 “Maintain patient’s dignity and privacy during all personal care interventions”).

Dad constantly left, uncomfortable and unable to attract the help required to go to the toilet (this contravenes Core Care Plan 14 – Risk of Falls, point 9 “Respond to requests for toilet facilities with urgency (max 5 mins”).  His bell was always out of reach and staff always too busy.  When Victoria or Samantha visited they were regularly asked by Dad to help him with the bed pan.  This became a routine – they would assist him with his toileting, clean him up afterwards and dress/undress him themselves (a repeated contravention of Core Care Plan 1, point 4 “Offer patient assistance with personal care at least daily”).  If left without visitors Dad would be unwashed and in dirty pyjamas (he hated wearing the gowns).  In addition, Victoria and Samantha administered Dad’s pain relief on a daily basis (there are no notes detailing this – there was no pain relief until they arrived).  They were often made to wait around (for at least 20 minutes) for the nurses to get the drugs in order for them to give them to Dad.

Nurse F was unhelpful on various occasions.  Most times she ignored Victoria, but there were other occasions (when she visited with Auntie Eileen for example) where, after waiting an hour to speak to her she said that she was busy with other patients who took priority.  She was overheard discussing the Waller family with another staff member called S in a public corridor.  Detrimental statements such as “all Mr Waller’s daughters do is moan and complain” were witnessed.

Friday 27th March

Dad had bronchoscopy.  He went down at 9am.  The family were not informed until Victoria visited some time after 11am.  Upon questioning, the HCA said it’s not routine to inform family of procedures such as this.  Given how badly Dad reacts to anaesthetic (as seen on itu) we had expected to be told of any and all investigative procedures undertaken.  Dad could not have been fully aware of what he was signing – his signature is evidence of this, as well as the Neurological Observations sheet which consistently state he was confused) .

The staff had expected dad to be back on the ward by the time Victoria arrived but he wasn’t. When she asked that they check on his wherabouts it transpired he was still in recovery. Victoria then left the hospital but on return that evening her and Samantha discovered that just after returning to the ward after his bronchoscopy Dad had gone to have a chest scan.  Again no-one was informed of this.

Tuesday 31^st March 2009

Dad not being given his puffer as unable to administer it himself, and when Victoria and Samantha arrived at the hospital he was desperate for them to do it for him.  When the HCA was informed she went to see staff nurse S, who said Dad was required to ask to have it administered.  When asked how he can ask for it when his nurse’s bell is always outside his reach she replied that he could shout.  Victoria asked how she thought Dad could shout when he is short of breath and requires a puffer?  The nurse then said that she would get the notes changed so that Dad’s puffer was offered regularly (this has not been documented).  He was still not given a nurses bell.

Wednesday 1^st April

Dad was moved into a side room off the ward.  When asked why, Victoria was informed that it was because they needed the other bed (F later (7/4/2009) told Emma it was due to MRSA).

Whilst in this room, Dad had a heart attack (1/4/2009) and was moved to the cardiac wing in the middle of the night.  Victoria was informed of this development at 7.15am (not at the time of the incident).  Dad was put on blood thinning drugs (which were continued even after the fall until Dr P had examined him and stopped it)

Monday 6^th April

Dad prescribed Vancomycin for MRSA.  Although Dr  P explained this and discussed Dad with Victoria (Dad could simply be a carrier of the disease at the back of the nose, or he’d developed the infection in his chest during his time as an inpatient (although Microbiology reports make no mention of MRSA prior to Baily).  No advice was provided regarding MRSA visitation procedures.

Dad back to normal, playing with grandchildren and interacting well.  When Victoria left the hospital at 1.30pm, he was in bed with the cot sides up happily watching TV.

Upon arriving back at the hospital at 7.30pm, Victoria was informed by Dad that he’d fallen out of bed.  He was pleased that Victoria had arrived so soon after he had asked the nurse to ring and tell her about the fall.  No-one had rung her.  He then explained what had happened:

His feet were cold.  He could see his slippers on the bottom of the table but could not reach them.  He didn’t have a bell (it was again out of his reach) and his shouts for help were repeatedly ignored. The person who had administered his PIC line earlier that evening had (apparently) left the bed elevated and the cot side down (despite Dad’s wristband stating that there was a “risk of falls” (photo evidence).

When Dad leant on the table to reach for his slippers, it moved on its wheeled feet across the floor.  With no restraining bars on the bed (because the cot side had been left down), Dad fell completely out of the bed and onto the floor.  He landed on his head and neck.

Nurse G, (the same nurse who had called Dad “a poor old sod”) confirmed what Dad had said and that it had happened at about 6.50pm.  When Victoria arrived he was visibly shaking with shock, he had a massive bruise and swelling to his head, and further bruising to his hands and arms.  G stated that the bruise on his head and the shaking were not unusual – that the bruise had always been there and that Dad was always shaking.  This is not true.

Victoria demanded that his neck be immobilised.  The nursing staff informed her that there was no neck brace available.  She suggested going to the A&E department and borrowing one, but this suggestion was refused.  Instead, they rolled up two towels as a make-shift brace.

Victoria complained about the lack of action concerning the accident.  Dad was clearly in shock and pain and not being treated for it.  He was then given oxygen.  No crash team had been called on the event of the fall, Dad was not seen by an emergency team, nor was he was immobilised on the floor until a trained team had evaluated whether it was safe to move him.  He was simply scooped up off the floor, put in bed and left alone. No obs were carried out that evening (whilst either Victoria or Daniel were with Dad).

An X-ray was planned to check the placement of the PIC line.  Since Dad didn’t want to be left alone, Daniel remained with him throughout the night and accompanied him to X-ray.  His X-ray took place some time after 1am the following day with no nurse present during the transfer or five hour wait (despite Dad being given oxygen).  A CT scan was NOT organised or planned.

Tuesday 7^th April

Victoria visited Dad and was accompanied by her two children (since there was no information or advice provided to the contrary regarding MRSA and children’s visitation (Thomas’s gastrostomy) she presumed this was OK).

10.30 Upon arrival at Dad’s room Victoria witnessed a nurse trying to give him a drink.  She was shocked to see him forcibly spitting it out.  Victoria took over from the nurse and asked Dad what was wrong.  His words were slurred but she thought he said he couldn’t swallow.  She told him she was going to ask him if he could swallow – and just to answer yes, or no. Can you swallow? He said no.  This set alarm bells ringing with Victoria as she understands this to be a classic sign of brain injury.

Dad was evidently in a great deal of pain.  He was slumped in the bed with no neck support (the make-shift towel support had been removed) and was clearly uncomfortable. Victoria noticed he had developed a left sided droop.

Victoria demanded for a doctor to come and examine Dad.  She was staggered to discover that the nurse caring for Dad was completely unaware of his fall.  She had been told he simply had a stiff neck (the care notes were not read or they were written in retrospect).

When Dr P attended, Victoria informed him of the fall (he was also completely unaware – if the care notes were as they stand now, he would have known all about it) and of Dad’s slurred speech and inability to swallow.  The left sided droop was evident.  Upon examination of Dad, Dr P ordered an urgent CT scan.  He also identified that there was a vertebra missing from the X-ray of Dad’s neck and shoulder (the purpose of the X-ray had been to check positioning of the PIC line – not to assess Dad’s condition after the fall).  He ordered a further X-ray to include this sixth vertebra and for Dad’s neck to be immobilised with a brace.  He then demanded a complete investigation of the fall.

11.30 Emma arrived and Dad was dozing – or so it seemed.  He never regained consciousness again.

Various HCAs (took observations (blood pressure and eye reactions) at half hour intervals throughout the day.  Many of these were inexperienced – in fact one named W admitted she didn’t know what she was doing).

Dad looked uncomfortable and became increasingly non responsive throughout the day.

Around lunchtime, because we were so concerned about the events which had led up to the accident, Emma contacted PALS about getting Dad transferred to another hospital.  She was passed to the Social Services Department, who when informed of Dad’s fall discussed a “safeguarding Adults” investigation.  She was eventually put through to N W (the discharge nurse) who organised a meeting between herself, Emma, F (since P was on holiday) and one of the regular nurses to discuss Dad’s care in detail.  The meeting took place and covered the following points:

• The level of Dad’s care experienced so far

• Nurse bell often out of reach
• Fluids out of reach
• TV and phone out of reach

• The catalogue of events leading up to the fall which had allowed it to take place.  The negligence of everyone involved
• The aftercare since the fall
• Our concerns about Dad’s deteriorating condition and lack of urgency regarding investigative procedures since the fall
• The possibility of Dad being transferred to another hospital

Outcome of the meeting:

• Nurse apologised for Nurse bell, fluids and phone/TV being out of reach
• F embarrassed that accident had happened – admitted cot side down and bed elevated
• Informed by F that room change was due to MRSA (although still not provided with guidelines or advice regarding visiting). This contradicted what Victoria had been told about the reason for the room change being because they needed his bed.
• Nursing staff to chase up CT dept and ensure X-ray was completed with urgency
• Wait for Dad’s condition to stabilise and then N would help champion a move for Dad to another hospital

4.15 Dad taken down for CT scan.  Emma was told he should be finished by 5pm and that a nurse would accompany him throughout.  Dr P would either ring Victoria with results before he left at 5.30pm or she would be updated by the nursing staff upon her arrival that evening.

6pm Victoria arrived at hospital and Dad was not in his room.  She asked F where he was and she didn’t know.  The ward then received a call informing them that Dad was in Resus. F accompanied Victoria and Samantha down to resus (she had to ask a porter for directions to get there) During the journey she said ‘ lots of things must be running through your mind’ to which Victoria agreed and said “yes, if some idiot hadn’t left the cot side down and Dad had been looked after properly we wouldn’t be going to resus”.  F said nothing more.

Matron at resus explained that CT had called her down because of Dad’s unresponsiveness. She and her team went there to collect him.  Victoria explained the events of last night and today.  She agreed he had no gag reflex and that what Victoria thought (massive brain injury) was likely to be correct.  She said that Victoria had to be a good advocate for Dad.  She said that she’d informed the Chief Executive and that Dr C was coming in to see Victoria. She also said that once Dad was intubated and stable, CT could be carried out.

The eventual CT scan showed that Dad had had a catastrophic brain haemorrhage due to a blow to the head.  He’d also broken his neck.

When DR C arrived, she was horrified that this had happened. She told Victoria that she was unaware of our concerns over Dad’s care and had NOT been informed of our request for a meeting.  She agreed that Dad wouldn’t have to go back to Baily ward, she arranged for him instead to be cared for in Millenium Wing where he finally received the care he deserved.

Dad died less than five days later at 6.25 on 12^th April.  According to the coroners report, his death was a direct result of the brain haemorrhage.

(Which we now know as narrative from the jury at inquest was caused by the fall due to the cot side down, the bed elevated and no nurse call bell.

poor dad)

Core Care Plan 14 – Risk of Falls, point 17:

If patient falls:

• • • Stay Calm
    • Check for obvious injury and take first aid measures
    • Make patient comfortable
    • Return to bed/chair (use lift aids as indicated)
    • Inform medical staff
    • Inform family/carers
    • Complete Safecode – WM to review asap

Photographic Record

19:37 06/04/2009

Taken when Victoria arrived

At approximately 18:50 dad fell out of bed due to the cot side being left down. His nurse G said the person doing the picc line left it raised and cot side down. Dad agreed. Bell was out of reach all day. He wanted his slippers, couldn’t call so tried to get them himself.

19:38 06/04/2009

® arm and wrist painful after fall. Dad thought it was broken.

Victoria was not called to be informed of the fall.

19:45 06/04/2009

Dad in extreme pain in neck area,® side arm and wrist. Shivering all over in shock, cold pale and clammy. Was alone after injury. Victoria got dad an extra blanket. Head not immobilised. Nurse would not take on Victorias concerns to call a DR

20:30 06/04/2009

Approx 50 minutes after fall. Neck immobilised after Victoria asked why it wasn’t seeing as it hurts him so much.

Went to x-ray well after 9pm. Finally done by 2am. Was told x-ray was for picc line placement purposes.

12:39 07/04/2009

Victoria arrived at 10:30 am. Saw Dr Price who had not been informed of the fall. Dad had no neck brace on my arrival. Brace was put on around 12:30 by staff nurse and HCA just before this photo was taken. They admitted not knowing how to put it on.

15:06 07/04/2009

Orthopaedic team came in around 14:50 and added the red blocks. They did not secure tape to the bed, just dad’s head.

Inquest into my Fathers Death.

The Inquest was fair, full and fearless. The jury did an excellent job of taking the evidence into consideration and reaching a verdict.

There will be a Rule 43 ‘coroners recommendation’ made, which has a national impact and details on that will be available later.

The verdict was Accidental death with Narrative.

Basically this said his cause of death was subdural and intracerebral haemorrhage resulting from the fall which occurred due to the bed being raised, the cot side being left down and no call bell being within reach.

We are happy with this verdict

My sisters and I issue the following statement.

The standard of care throughout our fathers stay on baily ward, at the Royal Sussex County Hospital was Abysmal.

There was a complete lack of dignity and respect for our father. There were also major failings in communication and a total disregard for any of our concerns.

Our Father was placed in a dangerous situation in an isolate room with no nurse call bell and therefore no way of attracting help. It was an accident waiting to happen.

His bed was elevated and the cot side left down in error despite evident ‘risk of falls’ wrist band. He fell out of bed sustaining a broken neck and fatal head injury.

The catalogue of errors immediately following his fall included appalling management, lack of basic training, miscommunication, flawed decisions and a failure of appropriate prioritisation when it was clear our father was gravely ill.

The recommendations from the coroner as a result of the inquest will hopefully prevent a repetition of the issues our family have experienced. No one should ever be subjected to such diabolical treatment and care in any hospital.

BBC South news coverage on Dad’s inquest can be found on the link below approx 3:34 mins into the programme.

http://www.bbc.co.uk/mediaselector/check/england/realmedia/southtoday/southampton/southtoday?size=16×9&bgc=C0C0C0&nbram=1&bbram=1&nbwm=1&bbwm=1

Patient Safety meeting

Yesterday was a bit of a stressy day to do with the aftermath of my poor Dad’s death and ensuring there is never a repeat. I still can’t go into too much detail because as I’ve said before, there is an Inquest pending.

Anyway, my sisters and I had a meeting with the ex deputy chief medical officer regarding an update to our first meeting where we outlined our concerns and these concerns were taken on board.
This meeting looked at the implementation of the new patient safety guidelines drawn up after our first meeting, covering a variety of bases. We also had a discussion surrounding the use of NICE guidelines and whether they should be formally challenged so that they are applied on an individual patient presentation led basis and not just as a money-saving tool, which is the primary purpose currently. This is currently being investigated.
Overall the meeting went well and I do feel progress is being made, we are scheduled another meeting just before Christmas.

All this stuff always make me sad though, it hurts to think about dad, about the way he died, about the circumstances that led up to his death and obviously because he should still be here.

After the meeting we went to visit the tree on the edge of the wood where we sprinkled dad’s ashes back in May.

Anyone ever done this? there’s no sprinkling of ashes that gently whisp off and curl in the breeze to be carried off forever… no, you open the pot, gently tip and it all goes ‘ thunk’ to the ground and resembles cat litter. Not what we were expecting I assure you. Although all three of us instantly looked at each other and laughed, hard.
I’ve been to dad’s tree three times now since we sprinkled him in May.  Dad is still there, in a little mound. He likes it so much there he’s staying put.

Sweet dreams Dad x

Dad