In the meantime I am suggesting that everyone with a complaint against their hospital sets up a facebook site to allow others to make contact. What I am finding is that there are several from each hospital and it is a way of grouping complainents together. The more voices speaking out together the more chance you have of gettting any ...]]> Since the report was published we have been inundated with complaints from all over the UK. I will get back to you but please be patient.

In the meantime I am suggesting that everyone with a complaint against their hospital sets up a facebook site to allow others to make contact. What I am finding is that there are several from each hospital and it is a way of grouping complainents together. The more voices speaking out together the more chance you have of gettting any improvements.

If you feel you are able to set help I am suggesting that you call it Cure the NHS (and then the name of your hospital)

It was lovely to meet other campaigners at the event that I hadnt met before. I met with Will Powell who has battled for justice over the death of his dear son Robbie for many years. A brave man and all he wanted when he lost his son was the truth. Not much to ...]]> Although it was an honour to recieve the award I also reminded the audience that patient safety statistics tell us that incidents have increased and not reduced as we would have hoped.

It was lovely to meet other campaigners at the event that I hadnt met before. I met with Will Powell who has battled for justice over the death of his dear son Robbie for many years. A brave man and all he wanted when he lost his son was the truth. Not much to ask is it when you loose your child through an error. Instead he was faced with denial and a cover up. To this day his battle continues, his strength inspires me to battle on myself.

Julie Bailey’s book ‘From Ward toWhitehall’ is going to cause a sensation.  In a week when the use by hospitals of theLiverpoolCare Pathway (the so-called ‘end of life treatment’) is being passionately aired in newspapers and radio, the publication of this book could not be more apt.  Many who read Julie’s account of the death of her mother, Bella, in an NHS hospital are sure to say, with a mixture of sadness and regret but also with relief that ...]]> “From Ward to Whitehall”

Julie Bailey’s book ‘From Ward toWhitehall’ is going to cause a sensation.  In a week when the use by hospitals of theLiverpoolCare Pathway (the so-called ‘end of life treatment’) is being passionately aired in newspapers and radio, the publication of this book could not be more apt.  Many who read Julie’s account of the death of her mother, Bella, in an NHS hospital are sure to say, with a mixture of sadness and regret but also with relief that someone is telling this story, “That is my experience, too.”  It is also the story of Julie’s campaign to reveal what was happening inStaffordHospitaland her fight for a public inquiry.

I read this book with a special personal interest.  I have a mother who worked for many years in just about everyLondonhospital as a medical secretary to senior consultants.  I have a sister who is an ophthalmologist who, with a team of volunteer surgeons, has conducted, for free, tens of thousands of sight restoring operations for the poorest people in ruralIndiathrough her charity, Second Sight.  I have a husband who became part of the campaign group Cure the NHS which Julie Bailey founded.  I worked for years as a freelance trainer in nine different government departments, including the Department of Health where its formerPermanent Secretary, Sir Hugh Taylor, led one of my programmes.  So I devoured this book, reading it in a day and bringing to it a whole collection of my own preconceptions about the NHS and the Department of Health, including that, at some levels, the world of Health is full of truly impressive intellectual prowess but short of practical, emotional good sense and where many a mortal seems in awe of the NHS CEO, Sir David Nicholson, the same man who, as Professor Sir Brian Jarman points out in the Foreword to this book, chose to dismiss as “simply lobbying” the experiences and issues first raised by Cure the NHS.

It was not until I sat in on my husband’s evidence to the Robert Francis Public Inquiry into Mid Staffs that I began (only began) to appreciate what Julie and her fellowbereaved campaigners had to go through both personally and as a team.  Then I picked up this book and I found myself, in one read, feeling the kind of changing attitudes towards the NHS that these campaigners must have experienced – a deep faith in its care and professionalism tinged first by disbelief and disappointment followed by absolute horror that my pride should be shattered in the wonderful, civilised NHS system of free healthcare for all that we are lucky to have in the UK.

‘From Ward toWhitehall’ is a painful and tragic read, describing what must surely be the most shameful episode in NHS history,  but it is also uplifting and hopeful and enlightening and that’s what makes it a sensation.

My emotional journey as a reader was to try and explain away, as evidence of ward staff under inordinate pressure, the ignored call bells, the leaking catheters, the porter so rushed that he crashes his patient’s trolley into some oxygen bottles, the arrival in the wrong ward, even (Heaven help me!) the patients left distressed and smelly in faeces-soiled clothes, slippers and bed linen and given the wrong medication.  The NHS means so much to me that I was ready to find the excuses.  But what I found myself unable to excuse at any level was the behaviour. Individual behaviour, after all, is our own personal choice.  The images described by Julie Bailey are almost too much to bear – the “get back ter yer fuckin bed” behaviour, the doctor clicking two fingers in Julie’s face to illustrate how her mother “will die just like that,” the irresponsibility of the nurses eBay sessions while on duty, patients left on the floor where they have fallen desperately trying to get to the loo to avoid messing their beds, the old woman, bed ridden for three weeks, being frogmarched to the toilet and back and being left to cry, shaken and cowed, under her covers, the image of dehydrated mouths, bleeding and covered in a white film.

What is the use of all that intellectual excellence in the civil service if it does not result in a true sense of emotional responsibility to people it is supposed to serve?

Written in a conversational style and with the kind of detail of one woman’s personal journey that will resonate with the experience of others, this book is an emotional journey and it also serves to highlight how, even for a woman of grit like Julie Bailey, it is terribly hard to stand up for your rights in a bullying institutional culture, where people don’t even need to be told to conceal, deceive and deny because the institutional inclination is so strong.  And yet, despite this, the reader can admire those who went out of their way to help and to do the right thing, like the junior doctor who warned Julie “You need to get your mum out of hospital before she comes to any harm.”  The reader can feel the optimism Julie and her family felt as the day of discharge approached, and then the despair and horror when her mother was dropped and left without being seen all night while the ward manager insistently stands over the terrifiedBella stating “you slipped didn’t you!”

I find myself thinking “Is this what the 21^st Century hospital experience really is?”  And then, I question the extra £46 million (Health Service Journal article, Shaun Lintern October 2012) the NHS has just commissioned to be spent on a new “LeadershipAcademy” and I wonder about the appropriateness of this use of tax payers’ money. Is it desperation stakes?  Is it a cynical gesture? Is it self-serving plunder?  Worst of all, given my attachment to the concept of the NHS, I find myself thinking unthinkable thoughts and wondering whether, with all that intellectual brilliance I experienced in the Department of Health (the strategy arm, after all, of the NHS),  this downward spiral of care quality in the NHS is not deliberately designed to make us so fed up with what the NHS offers that we will all willingly accept its transfer to the private sector on the grounds that “anything is better than this, even a privately run NHS.”  And then I go on to wonder which big shots will most benefit from that.

I said this book is also hopeful and that is the feeling, above all, that I take away from it.  Why?  Because this is also the story of an exceptional, natural campaign leader and an exceptional team who found different roles to suit the different levels of skill and confidence in the Cure the NHS group.  They expertly organised their personal grit, resilience and determination to deal with the infuriatingly sluggish, self-satisfied, devious, dismissive bureaucratic responses they encountered when they first raised their issues.  They found common sense strategies to break through the one thing the Establishment knows how to do very well indeed – close ranks.

It’s a story of undying hope and of determined, organised, sustained application.  It’s a story of a team working at the highest level of performance, not as the result of training but because each and every one of themnever,never took their eye off the prize of truth and justice at the end of the road and, when the going was tough, even abusive and almost unbearable, they always found ways to support those whose suffering became too much.

For other campaigning groups, here is a potential model.

Yes, it’s a story of hope.

It seems that any improvements that we hear about on the wards, the next few weeks we hear that any improvements havent been sustained.

The last round of complaints involved an elderly woman left on the commode for three hours. /when the family complained they were told that the staff cannot remember it happening. And ...]]> This morning the Today programme will broadcast an interview I gave a few weeks ago, following a series of appalling complaints that came to see me regarding the care their loved one received at Mid Staffs.

It seems that any improvements that we hear about on the wards, the next few weeks we hear that any improvements havent been sustained.

The last round of complaints involved an elderly woman left on the commode for three hours. /when the family complained they were told that the staff cannot remember it happening. And no further action was taken- lessons learnt?

Another family told me that there was no water available on the ward for any of the patients- lessons learnt

We heard the same thing from another ward and another complainant, no water available through the night.

http://www.bbc.co.uk/iplayer/b006qj9z/console

This is an article we found that was printed in our local paper on May 27th 1999

The most recent case at Mid Staffs involved a 91-year-old woman who was discharged at midnight wearing only a nightgown. This was in the middle of winter and, to make ...]]> It is now more than four years since I lost my mother at Mid Staffs Foundation Trust hospital and launched the campaign group Cure the NHS. In that time we have heard of a number of cases where vulnerable patients have been discharged from the hospital during the night, sometimes in freezing conditions, without suitable clothing.

The most recent case at Mid Staffs involved a 91-year-old woman who was discharged at midnight wearing only a nightgown. This was in the middle of winter and, to make matters worse, she was sent to the wrong address.

Many people say that the HCC was the worst report in the history of the NHS, it reported that hundreds of people lost their lives unnecessary. To date no one ...]]> Good afternoon and thank you for this invitation to speak, Cure the NHS was formed four years ago following the death of my Mother. The group is made up of mostly relatives who have lost loved ones at Mid Staffs. Because of the time limitations I will take it that most people here know about Mid Staffs.

Many people say that the HCC was the worst report in the history of the NHS, it reported that hundreds of people lost their lives unnecessary. To date no one has been held to account for those deaths and failings.

An accurate figure has never been put on those deaths, when it suits the NHS they refer to the Dr Foster statistics but when the figures say what they don’t want to hear, they dismiss them.

The day the HCC report came out Alan Johnson the SOS for health at the time, stood in up in Parliament and said Stafford was an isolated case and that each family would be entitled to a case note review of their loved ones death.

It proved a wasted exercise because of the poor recording of information by the professionals, or the altering of information and missing documentation. The majority of deaths were older people or those who had other illnesses. Dr Laker who carried out the reviews claimed only a few could be certain of losing their lives through the lack of care.

My own case note review concluded that my Mother would have died anyway, although she was being discharged the next day. The evening before she was dropped by a member of staff and an ECG found her heart had been damaged, all previous ECG had found nothing. But my Mother was 86 and from experience over the last 4 years, proving an unnecessary death for the elderly within the NHS, is practically impossible.

Following the publication of the HCC, the group campaigned for a PI, the HCC had told us what had happened but not why and why so many people had been allowed to suffer for so long.

We began our legal challenge for a PI, we wanted evidence to be given in Public and witnesses compelled to give evidence. One reason for this was the refusal by the coroner to give evidence to the HCC to assist them with their investigation.  I still find that totally unacceptable.

Hundreds of people had contacted me and told me about their loved ones dreadful death. Our banners during our campaign even asked how many more unnecessary deaths? I question to this day how I could spot there was a problem and yet others couldn’t.

As you know we got our PI but it was only because it suited the political climate, at the time. Our Judicial review was unsuccessful as the Labour Gov had worded the Independent inquiry that they offered us in such a way that would make our challenge fail, if we proceeded.

During the PI we heard lots of evidence that would convince us that the law doesn’t help those within the NHS system, being harmed or who have been harmed. Each body we encountered and each body we heard from during the PI confirmed that.

There was no clear evidence that came out of the PI as to who was responsible for patient safety. We are even unsure if there is a definition of harm, error or medical negligence. Perhaps there are some formal legal definitions I can take away from this afternoon.

Through a Freedom Of Information request from a member of the public, evidence was produced over the death of Gillian Astbury. A woman who had gone into hospital insulin dependent and over 2 days had been starved of her insulin. The case exposed a catalogue of blunders and negligence throughout the whole system.

The request exposed a series of emails from the Health and Safety Executive, saying that if they took this case on the floodgates would open, as they didn’t have the resources to proceed with such cases within the NHS. They argued it was the Care Quality Commissions’s responsibility.

The HSE were also involved in the case of John Moore Robinson, a young man who had been sent home from A&E with a ruptured spleen, he died a few hours after discharge. Like Mrs Astbury, John’s case wasn’t taken up by the HSE. They did get involved with a case of a man who had fallen off a trolley but even that didn’t lead to a prosecution, this surprised us as it happened again within a matter of weeks, leading to another death.

Each case we heard about where the HSE were involved the families seemed to be led down the garden path. Long, long delays before a decision was taken, torturing the family. Eventually telling them they wouldn’t be proceeding with a case. The Crown Prosecution service did the same, they like the HSE kept these grieving families dangling for years until they decided they wouldn’t be proceeding with the case. Leaving both families further traumatised.

The police should have been there to protect us but they didn’t.

I heard of several cases where people had wandered off the ward, one man wandered off the ward during my Mums stay. Confused, he had asked and asked all afternoon to go for a cigarette, a nurse had chastised him for pestering her. He was found dead a few days later in undergrowth. This I later found out wasn’t even recorded as a Serious Untoward Incident.

The police were involved for looking for this man, in fact the night he went missing they frightened the life out of me by shining a torch under my Mums bed as I slept in a chair trying to protect her.

I have heard from several people during the campaign whose relatives tried to escape from the hospital. Sadly the police just returned them back to the suffering. The only involvement the group had with the police was when they would watch over us while a group of elderly grieving relatives would stand in silence, always in silence, never any trouble. But the police thought they needed to watch us, instead of protecting the vulnerable.

I could spend all day discussing the coronial system but I will keep this brief and urge if you haven’t to read the South Staff’s coroner’s evidence, to the inquiry.  How can one have confidence in a department which includes serving solicitors and doctors from the hospital in its own area, is this unusual? I don’t know.

We know from the PI that although there was so many unnecessary deaths, the coroner didn’t spot a trend. There was no consistency with Rule 43 letters, very few were written. We saw internal emails, though, that said that letters the coroner had sent in the past to the hospital, would they now consider them as rule 43 letters, although they weren’t marked as rule 43 letters. There didn’t seem any point to them, as there was no follow up as to what actions had been taken or what actions should be taken. Although this coincided with the beginning of the HCC.

The first thing a family have to do is to fight for the inquest even when there is concern over a death. Families then often face years, before an inquest takes place. We had never heard of a jury inquest inStafforduntil after the HCC report and then there have only been a few. Once at inquest the families feel that the coroners department isn’t impartial and they are faced with a group of professionals. Very often they are a lone voice as getting representation is too expensive and not covered by legal aid.

Getting any legal representation is difficult, solicitors are reluctant to take on negligence cases. Despite all the evidence at Mid Staffs families were advised to settle out of court and relied on round table discussions for small settlements, as they were mostly older people anyway. Some were given advice before the failings were exposed and are now unable to challenge the decision without private finance. One member of the group who gave evidence to the PI now tries to live with the harm that was caused, her name is Nicola Monte and I urge you to read her evidence. A young woman who’s life is ruined, unable to challenge because she doesn’t qualify for legal aid but doesn’t have the resources for other legal support.

This is the battle we did and still face, once there is a death, the family believe is avoidable.

The first hurdle is getting the case notes. That’s always a battle and it is whilst you are grieving. Then you have to pay £50 and take a risk that they are complete, which they are usually not. Very often they arrive without the information we need. CTNHS believe, these should be given as a right if there are concerns over a death of a loved one.

During the PI we heard evidence about the role of a medical examiner and this CTNHS believe is the way forward. Although we heard that this role is still being tested. It was something that we believe would help.

What the public want is honesty, fairness, justice, transparency, impartiality, consistency!

For this there needs to be a whole culture change, we don’t need the HSE, medical defence unions, and the police in our hospitals, we need zero harm and right first time adopted throughout the whole of the NHS.