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Clinical Negligence Solicitor Paul Sankey on The Mid Staffordshire Healthcare Inquiry: Lessons for the NHS

The Inquiry into poor care at Stafford Hospital between January 2005 and March 2009 will be published next week and is likely to castigate managers at the hospital from the Chief Executive downwards, health professionals, regulators and the Department of Health. In advance of their findings here are 3 lessons drawn from our Clinical Negligence team’s experience of acting for people injured by negligent medical care.
1. There is a culture to change
Culture is sometimes defined as ‘the way we do things round here’. The culture at Stafford Hospital was to be defensive about complaints, to conceal, not to investigate and to turn a blind eye. This happens far too much. Doctors have a professional duty to tell patients when they have made mistakes but this is not legally enforceable and other staff - administrators and managers - do not. All too often when patients make written complaints they do not receive an open and honest response. The worse example I have experience was a young father left paralysed, brain damaged and in need of 24 hour care when failures in care led to a stroke. The response to his complaint was, ‘Looking back we think there was nothing different we could have done’. This was entirely untrue.
Without taking complaints seriously, hospitals fail to learn lessons from past mistakes. ‘History repeats itself first as tragedy, then as farce’ said Karl Marx. In healthcare it certainly repeats itself but only as tragedy.
Robert Francis QC, who chairs the Inquiry, may well recommend introducing a duty of candour. With its current track record the government is unlikely to do so.
2. Weekend care needs to improve
Too many of our cases concern patients neglected at weekends. I have recently acted for:
• The family of a woman who died after gall bladder surgery. She deteriorated over the weekend. Nobody noticed. By the time they did – on late Monday afternoon – it was too late.
• A man who had to undergo an above-knee Amputation after staff had failed to realise that the blood supply to his leg had been obstructed. The tissue in his leg gradually died and he developed Sepsis during the weekend. Nobody noticed until late Monday afternoon by which time it was too late. He recovered damages of £1.4m.
• A man who had a stroke after the failure to treat an infected hip. Like the others he deteriorated during the weekend, developed Sepsis, went into Atrial Fibrillation (abnormal heart rhythm) and developed a blood clot (Thrombosis) which went to his brain.

The common thread is clear. Better care is needed at weekends.
3. Administration needs to improve
There are far too many cases of people ‘lost to follow up’. I have acted for people who have lost kidneys because they were not monitored, had feet amputated because they had to wait too long for appointments, not told that they had Cancer and not called back when x-rays or scans revealed a fracture which had earlier been missed.
Whilst I have some hope of seeing some change in the culture and perhaps even with weekend care, with an increasingly fragmented and privatised system, I have little doubt that the scope for administrative chaos will only increase.