A Nurse in Never-Ever Event Land

“The term ‘never event’ was first introduced in 2001 in reference to particularly shocking medical errors that should never occur.” … Care Quality Commission

neverlandIn 2007, I made a report to Morecambe Bay Trust management that a patient had been injured by inappropriate insertion of a naso-gastric feeding tube which had resulted in ‘Aspiration Pneumonia’ or feed being pumped into the lung(s). Misplaced naso-gastric tubes are listed as ‘never events’ because they ought never to happen. The patient died 10 days later. The Death Certificate did not blame the never-event; as though it had never happened. When the Trust failed to initiate any investigation of the incident, I resigned my post as Staff Nurse citing Trust failure to prioritise patient safety.

Four years later, I read, the Trust was responsible for the death of another patient by the same means:


NORTH-WEST EVENING MAIL Thursday, 20 February 2014

Hospital patient had feeding tube in lung A HOSPITAL patient died days after a wrongly placed feeding tube was found in their lung. The catastrophic error was one of nine “never events” – mistakes so bad they should never have taken place – recorded at the University Hospitals of Morecambe Bay NHS Foundation Trust during the three-year period spanning 2011, 2012 and 2013. UHMBT faced a clinical negligence claim for one of the events, the misplacement of a naso-gastric feeding tube at its Royal Lancaster Infirmary site in 2011. Confirming details of the incident the Trust said: “The patient had an NG tube in situ and had been fed through this tube and feeds had been running for four hours in total. The patient experienced right-sided chest pain and an urgent chest x-ray showed the NG tube in the right lung. The patient died two days later.”

“We take these events extremely seriously, investigate them thoroughly and ensure that we share learning from each to minimise any re-occurrence of a similar event.

“The safety of our patients is our priority and we actively encourage members of staff to report any events which take place where they have concerns that patient care may have been compromised.”


Plus ca change, plus c’est la meme chose…

Now please recall that, in 2007, the Trust had failed to investigate an identical event. When I took out a Formal Grievance in 2008, on that very subject, the Trust admitted the failure, but again failed to initiate any investigation. Imagine then my surprise, to read that the Trust Press Responses to inquiries from both a national and a local newspaper assured readers that “The Trust did carry out investigations into many of these concerns, in 2008…”


 

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The Sound of Silence

I first heard this song in 1970, but had never fully appreciated the significance of the lyrics until Morecambe Bay NHS Trust attempted to conceal what I had reported to them. Every effort was made to stop anyone from hearing what I had witnessed. When they had cheated and lied their way to overcoming my efforts to expose their failures to prioritise patient safety, they forced me, under financial duress, to sign a Compromise Agreement, complete with Confidentiality “Gagging” Clause. At that time, the Trust’s much-trumpeted reputation could not be challenged. Silence thus preserved, they went on to record the highest Hospital Mortality Rate in the country. Board “resignations”, Coroners’ verdicts, Police investigations, Media revelations, NHS Watchdog inspection failures, Special Measures, DoH Inquiry and utter disgrace followed in rapid succession.

“Today, the name of Morecambe Bay has been added to a roll of dishonoured NHS names…” … Dr Kirkup, Chair of Morecambe Bay Investigation, March 2015

I have taken the liberty of editing the lyrics, though the words pretty much stand up for themselves.

The lookouts reported seeing an iceberg ahead...

“Silence like a cancer grows”

Hello, darkness, my old friend
I’ve come to talk with you again
Because a vision softly creeping
Left its seeds while I was sleeping
And the vision that was planted in my brain
Still remains
Within the sound of silence

In restless dreams I walked alone
Narrow streets of cobblestone
‘Neath the halo of a streetlamp
I turned my collar to the cold and damp
When my eyes were stabbed by the flash of a neon light
That split the night
And touched the sound of silence

And in the naked light I saw
Ten thousand people, maybe more
People talking without speaking
People hearing without listening
People writing songs that voices never shared
No one dared
Disturb the sound of silence

“Fools,” said I, “You do not know
Silence like a cancer grows
Hear my words that I might teach you
Take my arms that I might reach you”
But my words like silent raindrops fell
And echoed in the wells of silence

And the people bowed and prayed
To the neon god Trust they made
And the sign flashed out its warning
In the words that it was forming

And the sign said, “The words of the prophets whistleblower
Are written on the subway Facebook walls
And tenement Twitter halls scrolls
And whispered in the sounds of silence”