In early July the Care Quality Commission (CQC) released their report on the failings at North Middlesex University Hospital. Swift intervention and change was promised – what has happened since then?
Urgent and emergency care at the London hospital was rated ‘inadequate’ by the CQC following serious concerns about staffing. Medical care was also reported to be requiring improvement. The report followed an unannounced inspection on 14th April and further inspections of the emergency department on 4 and 5 May.
The inspection found that there were long delays in patients accessing care because of a shortage of doctors, and on one occasion a patient shockingly lay dead for up to four and a half hours before being found.
Sir Mike Richards, the chief inspector of hospitals, said: “People going to the emergency department at the North Middlesex University Hospital NHS Trust are entitled to a service that provides safe, effective, compassionate and high quality care. When we inspected, we found that patients were waiting for a long time to be seen, without being assessed by a doctor in the first place.
“North Middlesex University Hospital is one of the busiest A & E departments in London – so it is worrying that we found that there were not enough experienced doctors on call to deal with demand. We have strongly encouraged the Trust to engage with other organisations across the local health and social care system to resolve this challenging issue.”
The report found that in February 2016, only 67.2% of North Middlesex patients were seen and treated within four hours against a national standard of 95%.
Patients were initially assessed by a receptionist who was not medically qualified and had to wait up to two hours, instead of the recommended 15 minutes, for an assessment by a nurse.
The ratio of nurses to patients in the cubicle area was meant to be 1:4 but was up to 1:10, with patients placed in the corridor. In January and February 2016, levels of absence among nursing staff were between 8% and 9%, compared to a national average of 3-3.9%.
Middle grade doctors were left in charge overnight, sometimes with just one or two on duty, and there was a culture of not calling consultants past 11pm. Middle grade doctors were unwilling to make decisions, sometimes left patients in the emergency department instead of a ward overnight, and had their competency questioned by some staff.
There were waits of between 38 and 41 minutes for patients to be handed over from ambulance staff to medical staff, again against a target of 15 minutes.
The report also said that there were poor relations between different teams. Emergency department staff saw Trust management as “oppressive and overbearing” and did not feel comfortable raising concerns with them. Worryingly, the Trust had failed to learn from ‘never events’.
Patients were treated with “a lack of respect and dignity” and inspectors found omissions in their assessments, inconsistency and inaccuracy in completing their care records and observation charts, and inaccuracies in their food and fluid charts.
What has happened since then?
The chief executive of North Middlesex left the Trust following the release of the CQC report, and has been replaced by a senior executive at another London hospital on an interim basis.
The Trust has now appointed a new clinical director and nursing lead in the emergency department and gained five additional middle grade doctors and consultants on loan from other London hospitals. In June, its performance against the four-hour waiting target reached 77%.
Sir Mike said that the CQC carried out another inspection which showed that the emergency department “has turned a corner, but there is still much more that needs to be done”.
The CQC has issued a statutory warning notice on the Trust requiring it to improve care of emergency patients by 26 August, and will conduct a full inspection in September.
Dr Cathy Cale, North Middlesex medical director, said: “We are extremely sorry for the current problems in A&E and for the long waiting times for some patients. We are committed to getting back to the standards that we and our patients expect and, working with our health partners, are taking all the necessary steps to address the concerns raised, particularly the shortage of doctors which lies at the heart of it.”
Andrew Hines, NHS Improvement acting interim executive managing director for London, said: “North Middlesex University Hospital is facing complex challenges and it will take time to put improvements in place. However, the CQC have recognised that progress is already being made and working with the Royal Free London will provide staff and patients with additional support to make and embed further improvements.”
Healthwatch Enfield, which promotes patient views on NHS services and attends all meetings with the board running North Middlesex, says it will do all it can to make sure services improve and are maintained.
They say that “Overwhelmingly, people have expressed strong views that they want a local hospital, which provides not only a quality Accident and Emergency service, but also exceptional care throughout its other departments.”
Healthwatch Enfield said they “repeatedly raised” concerns on behalf of patients over the A&E performance with both Enfield Clinical Commissioning Group and the CQC.
North Middlesex University Hospital Trust faces a significant challenge to turn around a clearly dysfunctional A&E department. It is clear that whilst staffing is at the heart of the problem, a cultural change is also required for a lasting improvement to be made. As the CQC’s deadline approaches, many will be watching and hope that standards are raised for the safety and benefit of patients.