Page last updated at 18:07 GMT, Tuesday, 16 February 2010

Grim toll as NHS trusts miss patient safety alerts

By Paul Burnell
File on 4

intravenous drug
Some 80 trusts in England have not complied with 10 or more alerts

Peter Cameron died a "tortured" death - a nasal-gastric feeding tube wrongly inserted filled the cavity around his lungs with two litres of liquid food.

"It had gone straight through his lung and speared him," his widow, Heather, told BBC Radio 4's File on 4 programme.

The trauma of his death, while under the care of the Cambridgeshire-based Hinchingbrooke Healthcare NHS Trust, was compounded by the discovery a vital safety check called for after 11 similar deaths, by a patient safety watchdog, could have saved his life.

Freedom of information requests from the patient safety charity Action Against Medical Accidents (AvMA) have found 80 trusts in England may have failed to comply with at least 10 patient safety alerts.

A further 300 trusts have yet to comply with at least one patient safety alert, and 200 trusts have not complied with an alert dating back five years.

His body looked so horrible, it shocked me
Heather Cameron

The first indication Mrs Cameron had something was wrong with her husband's treatment was his sudden sore throat.

Warning sign

She said she had been told by a friend, who was a nurse, that this could indicate the feeding tube had been inserted in lung.

Staff dismissed this idea, but within 36 hours Mr Cameron, 75, was dying.

"His body looked so horrible, it shocked me," said Mrs Cameron.

"He looked absolutely tortured. He was pretty thin as it was.

"He had absolute agony on his face."

Vital test

The National Patient Safety Agency (NPSA) had issued a specific alert about the right way to test the position of feeding tubes, the year before Mr Cameron's death.

And Hinchingbrooke Healthcare NHS Trust said its staff had followed national and local feeding-tube guidelines in his case.

But File on 4 has discovered evidence the trust failed to update fully its own policy in the light of that national advice.

An internal inquiry into Mr Cameron's death, seen by File on 4, said the trust's own guidelines were "not fully compliant to the National Patient Safety Alert issued in 2005 - the trust policy therefore requires updating and reissuing".

The 2005 alert had called for a type of testing paper to be used on fluid from the feeding tube to establish whether it was in the right place.

Mrs Cameron's solicitor, Richard Follis, said the trust had not implemented that policy even though NPSA had drawn attention to 11 deaths caused by misplaced tubes.

He added: "The most worrying feature is that the guidelines themselves do not appear to have been implemented by staff on the coal-face."

Hinchingbrooke Health Care NHS Trust would not comment in detail on the specific case for legal reasons.

It said: "The trust has a robust system to ensure that alerts are completed within set timeframes."

Patient 'overdosed'

But according to AvMA, robust compliance systems are lacking in many hospitals in England.

In another medical mistake, at the Birmingham Heartlands Hospital, cancer patient Paul Richards, 35, was given a five-fold overdose.

He and another man died at the hospital on the same weekend due to the same medical mistake.

Four months before his death in March 2007, a NPSA alert had focused on the need for tighter precautions on a range of injectable medications including the drug administered to Mr Richards.

Trusts had been given a year to comply.

A further alert issued after his death brought the compliance deadline forward.

But the widow of Paul Richards, Lisa Richards-Everton, has discovered through AvMA 10 hospitals had not complied more than two years later.

"How many more people have got to die and go through what I'm going through now and be in the same situation?" she said on File on 4.

'Shocking' system

AvMA's chief executive Peter Walsh said he was shocked by the failure of scores of trusts to comply with the alerts.

"There is actually no system in place to systematically monitor compliance and follow-up with the trusts," he said.

The Department of Health said it expected all NHS Trusts to comply with safety alerts and "record and action them".

It added: "The department will shortly be issuing all NHS organisations a formal reminder of their obligations to do this."

It said from April the Care Quality Commission would have improved powers to monitor incidents and ensure compliance with alerts.

File on 4 is broadcast on BBC Radio 4 on Tuesday, 16 February , at 2000 GMT, repeated Sunday, 21 February, at 1700 GMT. You can listen via the BBC iPlayer or download the podcast.

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