"Detailed review of hospital stay in October 07"

About: North West Ambulance Service NHS Trust Royal Lancaster Infirmary / Gastroenterology

(as the patient),

Primary Care Stoma Service

I began to experience pain at my stoma site at about 11.30 a.m. on Thursday, Oct 18th. As I had had a similar pain on two previous occasions I was not very concerned. I used the contact number for the Stoma Service that I had been given but only got a recorded voice and a promise that the call would be returned when someone was in the office.

When I met the stoma nurse later in hospital I was told that the message had not been passed on.

GP Services

After a light lunch I went to bed. Previously this had always led to a quick recovery but the pain got worse so I was driven to the GP Surgery and asked to speak to a doctor. At this stage the request was not urgent. However, by 3.30 I was in considerable pain and made arrangements to see the duty GP. We discussed the situation and I was advised to get in touch with the Out of Hours GP Service if the pain had not eased by 19.30hrs. The GP was aware that I was very reluctant to involve secondary NHS services.

Out of Hours GP Service

By 19.30hrs I was feeling sick as well as in pain so I tried to contact the Out of Hours Service, as arranged. I discovered that BT’s Directory Service for disabled people (195) had a problem with this. They could not give me a number for “Out of Hours GP Service.”

The problem was solved by telephoning the number of my own GP service, listening to the recorded message (twice) and eventually getting the right number. (Old physically disabled people do tend to be slow) After that, once all the various levels of reception had been convinced of the seriousness of my condition I received a first class service. The doctor arrived at my home within the hour although, at one stage in the proceedings I was informed that, as a merely “Urgent” case there might be a delay of two hours before a doctor could get back to me by telephone. If my case were not urgent, it would take 6 hours.

In my view, the method by which the Out of Hours GP service is accessed needs urgent attention. It has the tone of a service grudgingly provided for people who are likely to misuse it.

Ambulance Service

The Out of Hours GP stabilised my condition, gave me something to ease the pain and sent for an ambulance. The ambulance arrived very quickly; certainly within 7 minutes of being called. The ambulance was manned by two technicians.

This was a good call. I do not believe that paramedics would have done any better.

Accident and Emergency

I received prompt attention in the A & E department. Of course I had to wait in a treatment bay but, although I was aware that the unit was busy, there was no sense of my case being ignored. After assessment by a doctor I was admitted to an assessment ward

The Assessment Ward

‘One part of the hospital where the management seem to have got it right’

All the people with whom I had contact: doctors, nurses in various coloured uniforms and other health professionals, were courteous as well as being efficient. The tests that needed to be done were carried out promptly. The surgical team were able to explain the options available and obtain my consent to do the necessary surgery, so that they, I and my family had time to prepare for the operation in full knowledge of the possible risks and benefits. It is true that the options were limited so that the choice was, in one sense, easy to make.

The need for the surgeons and other health professionals - however skilled they may be professionally - to gain the confidence of the patient is difficult to overestimate. However brave a person may appear, they are likely to be in an emotional turmoil both going into and recovering from surgery.

After the surgeon had explained the problem and obtained my consent for the operation, the anaesthetist came to see me. For pain control, following the operation I was offered the option of an epidural or patient controlled analgesia (PCA). I opted for PCA.

It was interesting to me that, in fact, neither epidural nor PCA was used. Adequate pain relief was administered, first intravenously and later, orally (morphine syrup and Paracetamol). I took this to be good news. That it meant that the procedure had not been as drastic as the surgeons originally feared would be necessary - but nobody explained the change of plan.

High Dependency Surgical Ward

Coming to consciousness on a high dependency ward was weird. Awareness of the pressures under which the nurses work cannot be avoided. Of the “Florence Nightingale” image of calm, efficient reassurance, if it ever existed, there was no sign.

Let nobody get me wrong. I am forever grateful for the excellent care that I received. Considerate, sensitive and skilful care was given to me by people in all the different uniforms as well as those who, for whatever reason, wear ordinary clothes. Often some of the best care was provided by people I knew to be least well paid. And therein, I believe, is a clue to the problem. The pressure of work and the seething discontent among the nursing staff was palpable. A person who openly declared to a colleague that they loved their job would also complain; about the management, other people not pulling their weight, the long hours of work and the so-called flexible working arrangements. Most people have heard stories of doctors and surgeons who hold conversations round the hospital bed and ignore the patient lying in the bed. Well, nurses do it too.

I can see how difficult it must be to get the balance right. Social chat is an important part of team formation. Small talk helps patients to recover and to feel normal but patients should not be upset by the process.

Patient Confidentiality

“Patient Confidentiality” Forget it! The beds are so close together that, if you are awake, you cannot help but learn a great deal about the patients in the beds near to yours. You would have to be quite deaf not to hear as doctors; nurses and other heath professional explain things to old men with hearing problems. So you know that the same conditions apply to you too.

Nurses

I would not be a clinical leader nurse for a footballer’s wage. They have clinical responsibilities to match that of doctors plus heavy managerial responsibilities. They seemed always to work longer than they were contracted to do; finishing off tasks left over from the previous shift.

Among what used to be called auxiliaries many work hard. Some are outstandingly experienced and skilful nurses who take on the bulk of the dirty and unpleasant tasks. Is there no way that such people could be properly promoted and rewarded?

Equipment

Most of the machines for recording blood pressure; temperature etc. seemed to be broken down for most of the time I was there. When I left two of them were still next to the nursing station awaiting repair.

Continuity

Shift hand-over seems to create real problems. Work with patients is interrupted. It can seem a very long time for patients when everybody disappears, treatment can be stopped in the middle of something and nobody responds to calls for bedpans or other essentials. Then someone arrives who has never seen you before and you worry that they may not be as understanding of your situation as the people who have just left.

Food

The general quality of the food was good.

I almost said there were no problems but of course there were - linked to the more general problems that exist around communicating information about patients. My progress from, “Nil by mouth” to the, “Diet for individuals who have had bowel surgery” was fraught with uncertainty because the instructions of the surgeon who was dealing with my case did not seem to get to where they needed to go.

One could not fault the efforts of the members of staff who gave out the meals. Once they were made aware of a problem they went to endless trouble to satisfy the patient.

Infection Control

Infection control measures were obviously in place. There were bottles of jell at the door of each bay and at every bedside. Disposable plastic aprons and surgical gloves were clearly available and colour-coded. There were also instructions to visitors about not sitting on beds or patients’ chairs. The dedicated single rooms had clear instructions displayed at the doors.

However, everything has an opportunity cost. To do something you miss out something else. It seems to me that the pressure of work made lapses from the policy inevitable. Even senior nurses did not always put on gloves and aprons to handle containers of body fluids. Sometimes there just did not seem to be time and choices have to be made.

Visitors sat on beds because there were not sufficient chairs available.

Cleaning

Cleaners worked systematically and well to clean the floor of the ward. I only once saw other surfaces being cleaned by the cleaning staff. Locker tops and other similar units seemed only to be cleaned by care staff when one patient vacated a bed and before another patient was admitted.

The shower room was badly designed and water from the shower failed to drain properly.

Cleaning of this and the lavatory could have been improved. Ambulant patients know they are in hospital and make allowances but it is still disconcerting to discover someone else’s blood and body fluids on the toilet seat that you are about to use.

Information about Patients

This seems to have improved since last time I was in hospital. All the same admission through A & E still caused problems. It seemed that my notes were unavailable for a time because, during the previous week, I had attended a routine Outpatients appointment with Cardiology.

Information for patients

Surgeons were generally very careful to keep patients informed and to answer questions. Nurses too were generally good at telling patients about their conditions and what to expect from the treatment.

There were leaflets. Most were out of reach of patients confined to bed so it did not seem to matter that much of the information in them was out of date.

Who can keep pace with the constant changes taking place in the NHS and social care?

Communications with Patient’s Next of Kin

This could have been handled in a more sensitive manner. I have been told that, after the operation there was a lengthy period of uncertainty during which my wife did not know where or how I was. About 19.30 hrs, in response to her telephone call my wife was informed that I was back on the ward. Her request to see me was met by a blunt statement that visiting time was almost over. My son and daughter brought my wife to see me anyway and, with the promise that they would remain only for a minute or two, were admitted.

Surgical operations are part of a nurse’s routine but that is not the case for close relatives. They tend to be concerned and they may have reason. A reasonable attempt at reassurance does not seem too much to ask.

Patient Advice and Liaison Service (PALS)

I did not see any sign of this or hear anyone mention it on my ward but I visited a friend who was in another ward and there was a poster on the wall.

Hospital Discharge

Once again there seemed to have been considerable improvements made since I was last in hospital. Soon after surgery I was asked if there were any social care issues. I replied that the situation had not changed since my last hospital discharge but I would like to talk to Occupational Therapy about possible problems I might have getting into and out of bed at home.

The OT got in touch with me and we settled the problem to my satisfaction.

The Physiotherapy Service made sure that I could walk with a stick provided by them and checked that I was able to get up a few steps safely before the discharge date.

The only criticism concerning discharge is that, as far as I am aware, my wife, who is my registered carer, was never consulted; only informed, about my discharge.

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Responses

Response from Royal Lancaster Infirmary

Thank you for the comments which we have passed onto the team concerned.

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