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One of London’s busiest A&Es slammed for poor patient safety standards

CQC inspectors found too few doctors and overbearing, unsupportive management

Caroline White

Wednesday, 06 July 2016

Urgent and emergency care services at North Middlesex University Hospital, which runs one of the capital’s busiest A&Es, have been rated ‘inadequate’ following an unannounced inspection by the health and care services regulator, the Care Quality Commission (CQC), in April.

The inspection of the emergency department, which deals with around 500 patients a day, and serves more than 350,000 people living in Enfield, Haringey and the surrounding areas, including Barnet and Waltham Forest, was prompted by more than 20 serious incidents over the past year, raising concerns about standards of care.

Inspectors found there were ‘excessive’ delays in the initial assessment of patients on arrival, in their subsequent assessment by a doctor, and in moving them to specialist wards.

They also found there were too few middle grade doctors and consultants on duty, and multidisciplinary team work was poor, with doctors from other parts of the trust slow to come and review patients and unsupportive of staff in the emergency department.

The rapid assessment and treatment of all patients arriving by ambulance was led and undertaken by nurses without any input from a doctor.

Patient flow was poorly managed and the trust’s performance waiting times had deteriorated. In February 2016, only 67.2% of patients were seen and treated within the national four hour target, compared to an England average of 88%.

At the time of the inspection, which revealed that a patient had lain dead and undiscovered for at least four hours, the emergency department had been without an established clinical director to provide leadership for more than six months.

Nor had the trust's senior clinical team been visible in providing leadership and support to the department.

Trust management was seen by staff as overbearing and unsupportive. The culture left staff feeling uncomfortable about raising concerns. Inspectors found that the trust had not learnt from previous ‘never events’ and serious incidents. The trust is not seen to be open and transparent. Relevant information is not shared with staff.

CQC inspectors raised their immediate concerns, and subsequently issued a warning notice requiring the trust to significantly improve the treatment of patients attending the emergency department.

Last week, inspectors returned to A&E to check on steps taken by the trust to deal with CQC’s main concerns.

Chief Inspector of Hospitals, Sir Mike Richards 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.”

Professor Richards said that there was already evidence of progress since the original visit in April. “The evidence from our latest inspection last week is that North Middlesex’s emergency department has turned a corner, but there is still much more that needs to be done. We will be watching their progress very closely,” he said.

CQC was also aware of several safeguarding incidents for patients on the hospital’s medical wards.

On the medical wards, inspectors found there was good consultant support and availability and the number and skill mix of doctors was satisfactory. Inspectors observed daily multidisciplinary team meetings and good team working in patient care and on ward rounds. However, there were, on occasions, insufficient numbers of nurses per shift.

There was a lack of respect and dignity in the way patients were treated on the medical wards and inspectors found that patients’ needs were not always met appropriately. Patients’ safety was being compromised through omissions in risk assessments, and through inconsistencies and inaccuracy in completing care records and observation charts.

Patients were not getting the food and drink they needed. Trained staff were not following the medication policy in the safe storage, recording and administration of medicines.

The trust has supplied an action plan setting out the steps it will take to address the concerns identified in the warning notice and report.

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