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Hospital compromised safety of its patients, report says

BMJ 2006; 332 doi: (Published 26 January 2006) Cite this as: BMJ 2006;332:198
  1. Adrian O'Dowd
  1. London

    A medical directorate at an NHS trust that failed to protect the safety of its patients is being completely overhauled, after a highly critical investigation was published this week.

    The report into the Mid Cheshire Hospitals NHS Trust by England's health regulator, the Healthcare Commission, made 21 recommendations and insisted on four urgent actions.

    The investigation followed the conviction in 2004 of a former ward sister, Barbara Salisbury, on two counts of attempted murder. Ms Salisbury, who was given a five year jail sentence, was convicted in relation to incidents at Leighton Hospital in 2002 that involved the inappropriate administration of diamorphine to patients.

    In its report the Healthcare Commission said there were serious lapses in the care of elderly people at the hospital. The trust had failed to meet adequate standards of care, and the safety of patients was compromised by a combination of poor leadership and management, staff shortages, and a failure to learn from complaints.

    Often patients were not helped to take their drugs or with eating and drinking. Staff showed a general lack of attention to patients, and there were numerous examples of drug rounds being late and of drugs being left on tables out of patients' reach.

    The report's urgent recommendations include that the trust:

    Recruit additional frontline nursing staff to provide acceptable and safe standards of care

    Improve governance and management of the medical directorate, and

    Investigate and address the cause of poor clinical outcomes in the medical directorate,

    Marcia Fry, head of operational development at the Healthcare Commission, said: “There is no excuse that allows the care and dignity of patients to be compromised in this way.

    “This report has highlighted serious problems, some of which go right up to the most senior level at the trust. We are pleased that the trust has already taken some urgent action to improve the service for patients. It must continue on this path and make every effort to implement all of the recommendations in this report.”

    The trust, which has a new acting chief executive, announced this week that it had already taken several steps to address the recommendations, including:

    Recruiting an additional 44 nursing staff

    Introducing a new approach to handling and learning from complaints

    Agreeing new contractual arrangements for clinical directors

    Redefining the directorate manager's role, and

    Ensuring that senior staff in the medical directorate now audit the care of patients and identify and measure areas of poor clinical performance.

    The acting chief executive, Stephen Eames, said: “It is important to note that even before the report was received, the board had identified and initiated the major restructuring that was necessary to strengthen management and reporting systems to ensure the highest quality of care for our patients.” The report is at

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