HC Deb 24 May 1999 vol 332 cc134-42

Motion made, and Question proposed, That this House do now adjourn.— [Mr. Clelland.]

10.51 pm
Mr. Nigel Waterson (Eastbourne)

I am delighted to have this opportunity to highlight the concerns of many of my constituents. Let me begin by paying a warm tribute to the nurses, doctors and other staff who work at Eastbourne district general hospital. Their commitment to patient care, their expertise and their sheer hard work are commented upon by almost everyone who visits the hospital, whether as a patient or in any other capacity.

Although I am raising some genuine concerns this evening, they should in no way be allowed to overshadow the excellent work of the DGH, to undermine staff morale or to cause apprehension among those who may be undergoing or awaiting treatment there.

I want to touch on two specific cases, both tragic. Mrs. Marjorie Dyer was admitted to the DGH in October 1998 after collapsing at home. On 18 October, another patient alerted nursing staff to the fact that Mrs. Dyer was in difficulties—she was choking on a sandwich. First aid was given. A nurse obtained medical records—but, tragically, those relating to another patient. The records said that she was not for resuscitation. The cardiac arrest procedure was not implemented. Other attempts to revive her proved unsuccessful, and she sadly died.

Another incident, which occurred in March 1998, attracted even more local publicity following the recent inquest. It concerned Mrs. Pauline Freeman, who went into the DGH for a hysterectomy. This is a major, but routine, operation. In the normal way, it should certainly not be life threatening—especially for a healthy woman like Mrs. Freeman.

While she was recovering from her operation, a ligature used to tie a main artery slipped. As a result, she haemorrhaged badly, and later suffered a fatal heart attack. It emerged at the post mortem that there were 4,000 ml of blood in her peritoneal cavity. Expert evidence stated that that could have taken up to four hours to accumulate.

At the time of her death, Mrs. Freeman was in a ward of 35 patients who were being looked after by just one registered nurse, with two nursing auxiliaries and a health care assistant. Her consultant gynaecologist—acting as an expert witness at the inquest—stated that, in his opinion, the ward was understaffed, and that more frequent observations of Mrs. Freeman could have identified the problem earlier.

There seems to have been no proper care plan in place for Mrs. Freeman, post her operation. Instead of being observed every half-hour—as was thought appropriate by the expert evidence—she was observed only, at most, every two hours, and the decision was made to reduce the frequency to every four hours. An expert nursing consultant told the inquest that, in her view, staffing levels were too low. The obvious conclusion is that more nurses would have meant more frequent observations, but that is not accepted by the hospital.

Mr. Charles Wardle (Bexhill and Battle)

I am grateful to my hon. Friend, and I know how hard he works in the interest of his constituents. He referred to the terrible tragedy of Mrs. Pauline Freeman, a constituent of mine who died last year in the DGH after a hysterectomy. The House will appreciate how devastated her husband, Roy Freeman, and her family have been by the suddenness and the appalling circumstances of her death.

After meeting Mr. Freeman and listening to his account of his painful experience and of his family's sense of total shock and loss, I was able to speak to the chairman of the NHS executive south-east and to the Secretary of State for Health and to communicate with the chairman of the local health authority, all of whom, I am sure, appreciate Mr. Freeman's feelings. I believe that they are trying to help.

I know that my hon. Friend is working closely with the hospital trust. It may be helpful if I tell the House briefly what Mr. Freeman wants as an enduring tribute to his wife. He—

Mr. Deputy Speaker (Mr. Michael J. Martin)

Order. I feel for the hon. Gentleman—it is a very tragic situation—but the rules of the House do not allow an intervention to go on for so long, and I will have to stop him.

Mr. Waterson

I know that my hon. Friend has been in contact with Mr. Freeman and has passed on his views to the authorities, and in particular to the Secretary of State for Health, and I am sure that he will continue to do what he can to look after his constituent in this time of great need.

The trust has maintained that the decision to reduce the frequency of observation was a proper one in the circumstances. It also contends that, had there been more staff on duty at the time, it would have made no difference to the management of Mrs. Freeman's care.

In a letter to me, the health authority's chief executive said:

"It is the Trust's view that the staffing level on the night of Mrs. Freeman's death was deemed to be acceptable by the sister in charge of the evening shift, and the trained nurse in charge of the night shift considered the staffing levels adequate for the patients under her care at the time. That view is shared by the Trust's Chief Nurse."

He also said:

"at no time has the Trust advised the Health Authority of an inability to provide a safe service, although it would be fair to say that the Trust had requested funding to improve the quality of nursing cover above the current level."

I view those claims with considerable scepticism. Can it really be the case that extra staff would have made no difference at all? Why was the decision taken to reduce observations of Mrs. Freeman to only once every four hours? If the trust is confident that it is providing a safe service, why is it requesting funding to improve the quality of nursing cover?

I do not want to dwell too much on individual cases, but the cases have revived concerns that have been around for some time, about the total number of nursing staff on duty at any one time and the heavy use of agency and bank staff. The local community health council, to which I pay tribute for its concerned but balanced role, has raised concerns over a two-year period; I have expressed concern about the level of nursing staff in the past; and many local people have spoken out, often through the columns of my local newspapers, the Herald and the Argus.

Perhaps most worrying was the district audit report produced by the Audit Commission last September. I have retained a copy. The main conclusions are summarised as follows:

"the Trust has on average significantly fewer nurses than other Trusts calculated on a like-for-like ward basis. While quality is being given an increasing emphasis, the lean staffing levels doubtless limit the quality of care that can be delivered to patients."

The report goes on to talk of

"staffing more than 10 per cent. lower than is the norm elsewhere … Eastbourne has 65 fewer nurses in post on these wards than the average elsewhere."

In fairness, I should say that, at each of the inquests, the coroner recorded a verdict of accidental death, but we know that there are limits on the extent to which a coroner can apportion blame or indeed engage in detailed investigations. It may be that those were in truth tragic accidents that would have occurred in any case, whatever amount of nursing care was available, but I continue to be troubled by the expert evidence that has been adduced as well as by the fact that the concerns are not new.

What action is being taken in the light of those findings and events? The trust and the health authority have challenged the findings of the audit report. Investigations were carried out after the two fatalities. The hospital's patient services director is reviewing her original investigation into the death of Mrs. Freeman in the light of the independent expert evidence at the inquest. The health authority has engaged the services of a former regional director of nursing to advise it.

I welcome the fact that the south-east region of the NHS executive is carrying out an investigation. There is to be a report to the primary care group meeting on 21 June and to the health authority on 24 June.

Mr. Norman Baker (Lewes)

My constituents, half of whom are also served by the DGH, view the situation seriously. While they endorse the good work done by the nurses, they are very concerned by the incidents that the hon. Gentleman has mentioned. They are concerned about why those incidents happened and why they were not picked up earlier. Does he agree that serious questions need to be asked about the shortage of nurses at Eastbourne DGH and about the competence of the management? I assure the hon. Gentleman that, although we belong to different parties, I am willing to stand shoulder to shoulder with him on this issue of great importance to my constituents.

Mr. Waterson

I am grateful to the hon. Gentleman for that and I agree that there are serious questions to be asked. I intend to ask some of them shortly. I have received an update on nurse recruiting from Mr. Clive Uren, chief executive of the trust. He tells me that, of the 47 vacancies that exist, 18 have been offered to newly qualified students and a further 17 have been offered to, and accepted by, external candidates. They have offered 22 posts to overseas nurses and, in addition, a group of 19 Eastbourne student nurses will qualify in September. That is fine as far as it goes, and those figures relate to the current establishment for nursing staff.

We all know that there is a national shortage of nurses, and that problem is not limited to Eastbourne. I received a briefing for this debate from the Royal College of Nursing that states:

"The RCN believes that this tragic case illustrates the potential dangers of inadequate staffing levels in hospitals, and thinks that there are some important lessons to be learnt."

It also refers to its snapshot survey of 55 medical wards in September 1998.

1 hope that we shall hear from the Minister what the Government are doing about the general problem. Is enough being done about nurses' pay? Why is only one nurse in 15 receiving the higher level of pay settlement? Why have some still not received it? Why will most nurses still be £53 worse off under this Government than at the time of the last election?

In a parliamentary answer in April, the Minister of State, Department of Health mentioned a figure of £16.5 million that would be made available for the Sussex education consortium, but how many new nurses will that mean? It seems curious that Eastbourne DGH is going as far afield as Canada to recruit nurses, but only recently I had in my advice surgery two local young ladies who are unable to obtain the funding to qualify as nurses.

In their attempts to return waiting lists to where they were when they took office, the Government have put enormous pressure on dedicated NHS staff and risk skewing clinical priorities. Such measures must be matched by appropriate resources, and that is the key issue. I ask the Minister for that commitment tonight.

We are faced with two particular tragedies, and I make no apology for dealing with them in detail. There is a concern in my constituency and those of my neighbouring colleagues about what is happening at the DGH. The plain fact is that the staff who work there are committed to providing a caring, effective service to their local communities, and they should be praised and respected for that. However, as I have said, they are under intense pressure and there is a danger, given that pressure and the level of staffing—especially at night—that mistakes will happen and things will be overlooked.

I ask the Minister to address the question of nurse recruitment and to say how he views the future of the DGH. How will he address and solve the obvious problems? I also extend to him a personal invitation to come and visit my local hospital to see for himself the pressures on the staff and the excellent care that they deliver under difficult circumstances.

11.4 pm

The Parliamentary Under–Secretary of State for Health (Mr. John Hutton)

First, I congratulate the hon. Member for Eastbourne (Mr. Waterson) on raising this subject tonight and on the constructive tone of his remarks. I am especially grateful for the praise that he extended to the staff at Eastbourne district general hospital, to which the hon. Member for Lewes (Mr. Baker) also referred. There is no doubt of the staffs commitment to the well-being of the patients in their care.

In addition, I should also like to offer my sincere condolences to the families of Mrs. Freeman and Mrs. Dyer on their sad and tragic loss.

Mr. Wardle

Does the Minister appreciate that what Mr. Freeman wants as an enduring tribute to his wife is to ensure that the lessons to be learned from her tragic death will be used to make a real difference for other women who go into hospital for the same operation? As Mr. Freeman said:

"If you can't provide the package, you shouldn't start the project."

He asks that much more be done to guarantee, as far as possible, that the mistakes that took away his wife's life are not repeated.

Mr. Hutton

I certainly endorse those comments, and I shall say more about both cases in a moment. The hon. Members for Eastbourne and for Bexhill and Battle (Mr. Wardle) spoke movingly about the grief experienced by both families, and I want to associate myself with those remarks.

I am sure that the hon. Member for Eastbourne will agree that, overwhelmingly, most patients who use the NHS receive safe and effective treatment and care. However, I accept that we need a culture of openness in the national health service that acknowledges, highlights and responds to problems effectively and quickly.

That is why quality is at the heart of the Government's strategy for modernising the national health service. In July last year, our consultation document entitled "A First Class Service: Quality in the New NHS" was published, and we were very encouraged by the response that it received. Good progress is being made in putting the proposals into practice and we are already seeing attitudes and priorities begin to shift.

For example, guidance was published in March on the new framework for clinical governance, and arrangements are being put in place across the NHS. That will bring a fundamental shift in the culture of the NHS to one that has quality of care at its heart. For the first time, quality will be enshrined in statute and the responsibility of NHS trusts and primary care groups will be reinforced with a new statutory duty of quality, framed in such a way to provide meaningful support to the continuing improvement of quality. A senior clinician will be responsible for quality for each health authority, trust and primary care group. Those clinicians will produce reports on quality in their respective organisations, and the first clinical governance reports will be published in April next year.

In addition, the Health Bill currently being scrutinised in Standing Committee contains provisions to establish the Commission for Health Improvement. The commission's job will be to monitor quality standards and to intervene promptly, if necessary, when things are going wrong. The commission will be established later this year, and begin its first full-year work programme in April next year.

An NHS performance assessment framework has been published for use by the NHS over the coming year, and will be followed soon by the first set of high-level performance indicators. The National Institute for Clinical Excellence came into being on 1 April, and the first two national service frameworks will be published later this year.

Those points summarise the action that the Government are taking. Once the Health Bill becomes law, NHS trusts will be obliged to have in place systems to monitor and improve both the quality of treatment that patients receive and the outcome of that treatment. The measures should go a long way to ensuring that the constituents of the hon. Member for Eastbourne can continue to have confidence that the services provided in Eastbourne are safe and of high quality.

The hon. Member for Eastbourne raised the subject of the recruitment and retention campaign for nurses, and I shall address my remarks to his concerns. The Government's target is to have enough nurses to provide the treatment that patients need. Our campaign to recruit up to 15,000 more nurses over the next three years has got off to a very good start. Since we set up our telephone hotline on 1 February, we have had over 53,000 calls from people interested in a career in nursing, and about 5,000 have been from qualified nurses who are showing an interest about returning to nursing. By the end of April, 650 had actually done so.

On 5 March, my right hon. Friend the Secretary of State announced additional funding of £5 million specifically to support return to practice initiatives in 1999/2000, focusing on getting former nurses back to the NHS. This builds on the similar initiatives already in place following funding of £4 million last year. In Eastbourne, 125 inquiries have been received as part of the return to practice initiatives since May 1998. That has resulted in 35 applications, of which to date 20 have been appointed to posts within the trust.

We have taken the first steps to persuade former staff to return to the NHS, and we must keep staff. We will do that by valuing their contribution and recognising that quality of care for patients goes hand in hand with quality of care for staff. On 1 April 1997, the total nursing establishment for Eastbourne Hospitals NHS trust stood at 790. Through additional funding provided under the winter pressure initiatives, the number increased to 811 on 1 April 1998 and to 833 on 1 April 1999, an additional 43 nurses in total.

On top of that, other initiatives are being taken by the trust. Eastbourne district hospital has made significant progress in increasing the number of full-time nursing staff. At the end of March 1999, the trust reported 47 whole-time equivalent vacancies, as the hon. Member for Eastbourne said. Since then, a number of appointments have been made. Eighteen have been offered to newly qualified students and another 10 to overseas staff nurses. With other external appointments, the trust predicts that vacancies will be reduced to approximately 12 whole-time equivalent vacancies at the end of June.

Further efforts are being made by the trust to fill vacancies with a major recruitment initiative abroad, and a further group of student nurses is due to qualify in September. The trust is making significant progress to ensure that use of bank and agency nurses is kept to the minimum. However, as the hon. Gentleman will be aware, that does not address the findings of the district auditors, that Eastbourne was below the average on its complement of nursing staff.

Following receipt of the report, a detailed action plan was agreed between the trust and the auditors to address the issues raised in the report. East Sussex, Brighton and Hove health authority, as purchaser of the services provided in Eastbourne, conducted its own review of the report, and the trust and the health authority agreed to conduct a joint analysis of current nurse staffing levels. The discussions continue, and any recommendations will be considered by Eastbourne Downs primary care group, which is responsible for advising the health authority on the commissioning of hospital services for its patients, at its public meeting on 21 June. The health authority will consider the matter on 24 June. In the mean time, it is the responsibility of the local trust management and doctors to ensure that services are provided in a safe environment.

Over the past 18 months, we have provided Eastbourne Hospitals NHS trust with an extra £5 million of additional resources over inflation. The additional money includes £1.7 million on the waiting list initiative, £1 million for emergency activity and more than £500,000 for winter pressures. The money has enabled the trust to open more than 20 additional surgical beds and has enabled two five-day wards to be extended to seven-day wards. The money has also allowed the trust to recruit additional nurses to manage these wards together with the full range of supporting staff.

I would like to turn to the tragic incidents raised by the hon. Members for Eastbourne and for Bexhill and Battle that occurred over the past year at Eastbourne district general hospital, and I should briefly explain the action taken by the trust.

Mrs. Freeman died in early 1998 following complications resulting from a hysterectomy operation. Following this tragic incident, the trust investigated the circumstances leading up to Mrs. Freeman's death. Following publication of the coroner's report, in which the verdict of accidental death was recorded, the trust agreed to reinvestigate the matter in the light of the comments made at the inquest and in the professional reports of independent witnesses. The review is in progress and the results are expected to be presented at the public part of the trust's board meeting on 18 June.

In the case of Mrs. Dyer, who sadly died earlier this year, the trust again conducted an internal inquiry into the death and is currently reviewing its resuscitation policy to ensure that the tragedy should never be repeated.

However, even with the work that the trust has done to ensure that these events are never repeated, and despite the reported views held by the Eastbourne, Seaford and Wealdon community health council

"that the very great majority of people treated at Eastbourne achieve a perfectly acceptable clinical outcome and have a satisfactory hospital experience"

there is obviously continued local concern about service provision. With that in mind, senior officials from the south-east regional office of the NHS Executive visited the trust last Thursday to discuss these events. Following the meeting, and after careful consideration, the regional director has asked the regional nursing director to carry out a review of nursing care at the trust.

The review will provide the regional director with an objective assessment of the current position and provide recommendations that will form the basis of an agreed action plan for the trust. It will also take account of current work being undertaken by the trust and the health authority. However, I can assure the hon. Gentleman that its members will be completely independent from both the trust and the health authority.

The purpose of the review will be to assess whether the trust has in place appropriate policies and procedures to enable effective nursing care to be delivered. The review will also determine what quality standards are in place, including robust nursing policies and procedures supported by staff training, and assess whether these are monitored effectively. It will also assess the adequacy of investigation, documentation, reporting and follow-up of untoward incidents and it will consider, in the light of all of the above, the trust's progress in implementing the clinical governance agenda.

Further details, announcing the terms of reference and membership of the review team, will be issued by the south-east regional office in the near future. I can assure the hon. Gentleman, his hon. Friend the Member for Bexhill and Battle and the hon. Member for Lewes that the review will be open and fully accessible. Its full report will be published by the end of September.

I hope that what I have said in the House today shows that we take quality issues seriously and that that is at the heart of the Government's strategy for modernising the NHS. Let me reassure the hon. Gentleman and his constituents that the Government are taking, and will continue to take, action to ensure that the highest standard of care is delivered throughout the national health service. Nurses have a crucial role to play in that. For that reason, more nurses are being recruited, both in Eastbourne and in other hospitals throughout the country.

We want the public to have full confidence in the local NHS. By taking action to raise the quality of care and by responding to local concerns in the way that we have, I hope that the hon. Gentleman can be confident about our commitment to the NHS in his constituency.

Question put and agreed to.

Adjourned accordingly at seventeen minutes past Eleven o'clock.