Catalogue of hospital errors destroyed dad’s life
Family of brain-damaged man tell of their outrage as investigation reveals the hospital blunders that could have been easily prevented
A catalogue of devastating errors at Northern Ireland's biggest hospital were to blame when a Belfast man suffered a severe brain injury during botched attempts to resuscitate him, a high-ranking investigation has found.
The Belfast Telegraph can today reveal the details of a damning official investigation into what went wrong when Jimmy Stewart suffered irreparable brain damage, leaving him in need of 24-hour care.
His family spoke of their anger after the report found that the cataclysmic series of events which led to Mr Stewart's injury at Belfast's Royal Victoria Hospital could have easily been prevented.
His wife Linda said she found it hard to believe that “one patient could be failed by so many mistakes in his care”.
And she said she was horrified when the report uncovered failings in the grandfather’s care of which the family had been previously unaware.
The investigation was ordered by the Belfast Health and Social Care Trust, which incorporates the Royal.
The tragic series of events began when Mr Stewart was initially |admitted to the Mater hospital in north Belfast on March 7 last year with a chest infection.
His condition worsened when he developed pneumonia and he was transferred to the Royal's |intensive care unit on April 2, 2008.
Twelve days later he was moved to a general ward in the Royal.
The 50-year-old was placed in a side room because he had picked up four superbugs in hospital and was considered to be an infection risk.
The report, investigated by six senior Belfast Trust staff and two independent experts, highlighted the “inappropriate decision” to nurse the patient without one-to-one care.
He was therefore on his own in the sideroom on April 16 last year when he suffered a cardiac arrest after his oxygen supply became disconnected.
The investigation found that staff were delayed in reaching Mr Stewart because an alarm signalling that he was distress was not audible from the nurses' station.
Resuscitation was further delayed because none of those who responded when the alarm was heard knew that Mr Stewart was a tracheostomy patient who breathed through a tube fitted to his throat.
Staff attempted to ‘bag' the north Belfast man through his mouth and nose, leaving air going into his stomach instead of his lungs, until a nurse who was aware of the trachoestomy arrived in the room.
All this time Mr Stewart’s brain was being starved of vital oxygen.
According to the report, it took eight minutes for staff to re-establish circulation in Mr Stewart after the alarm was raised.
But the report doesn’t shed any light on how long Mr Stewart was starving of oxygen before the alarms were heard.
The investigation highlighted four broad failings which the team said “collectively led” to Mr Stewart’s brain injury:
- An inadequate level of monitoring and care of Mr Stewart before his cardiac arrest.
- Failure to recognise and respond to a deterioration in his condition.
- Failure to notice that a tube vital to his oxygen supply had become disconnected and caused his cardiac arrest.
- Delay in resuscitating the patient through a failure to re-connect his oxygen supply and resuscitating him incorrectly.
Each of these areas were looked at in detail by the team, which highlighted dozens of errors.
The report came to eight conclusions and made seven recommendations to be implemented in the Belfast Trust and three to be rolled out across all Northern Ireland hospitals.
Linda Stewart said she agreed with the report’s conclusion that a “system’s failure” was to blame.
But she said that didn’t lessen the heartbreak she suffered when reading the hospital failures.
“I can’t bear the thought of him fighting for oxygen and desperately trying to get someone’s attention,” she said.
Mrs Stewart said she asked to stay with her husband that night but was told to leave when visiting time was over.
“This would never have happened had I been allowed to stay with him,” she added.
The Stewart family solicitor Peter Bowles, who has practised extensively in medical negligence cases, said the treatment “undoubtedly ranks as one of the most devastating cases I have come across”.
“It is of some comfort that the Belfast Trust has now held its hands up and accepted that the quality of care provided to Jimmy was not what should be expected and have admitted extensive failings which have caused such dreadful consequences,” said Mr Bowles.
A spokeswoman for the Belfast Trust said: “We deeply regret what has happened to Mr Stewart at a critical stage in his treatment. Our care for him fell short of the standard all our patients have the right to expect.
“We will continue to support and work with the family to |ensure that Mr Stewart's on-going care is the best it can be,” added the spokeswoman.
Investigation identifies litany of mistakes
Some of the main findings of the probe were:
- An alarm to signal Mr Stewart was in distress could be heard only at his bedside in a sideroom
- His tracheostomy tube was not downsized, as recommended by physiotherapists.
- Eight doses of a prescribed drug were not administered at any time during his three days on a general ward.
- A chart indicated that observations were not recorded as frequently as specified.
- A nursing care plan handed to staff was printed out incomplete with four sections missing.
- There were supposed to be four trained nurses on the ward the night of April 16 but one was replaced by an untrained nurse after an agency nurse who worked the previous night was asked not to return because of “concerns about her performance”. One of the three trained nurses on duty had a medical certificate saying she was “unfit to work” but she did not tell anyone this, rather than “go off sick at short notice and potentially leave the ward shortstaffed”.
- Mr Stewart should have had hourly observations carried out. There were no recorded observations between 7.30pm and 11.15pm on the night of his arrest, although there is evidence that staff had been in contact with him.
- A specialist registrar said that Mr Stewart’s lung condition was “very bad and progress was uncertain, to say the least”. Yet there was no decision to return him to intensive care.
- Many people were involved in giving ‘orders’ when Mr Stewart was found unconscious, some of which were conflicting, and there was no-one in charge of the arrest in the initial stages.
- Multiple teams were called to the arrest resulting in 15 people being in the side room for a short period of time.
- Eight or nine staff were bleeped by the hospital switchboard as a result of the cardiac arrest call. The number of staff attending the incident caused confusion.
THE TRUST’S EIGHT DAMNING CONCLUSIONS
The Belfast Trust investigation came to eight damning conclusions on what went wrong with Jimmy Stewart’s care the night he suffered a brain injury:
1 For three days on the general ward, Mr Stewart’s condition fluctuated, triggering numerous interventions by several staff. The alerts did not instigate communication with his consultant or trigger a case review to consider his condition and need for specialist input.
2 There was lack of ownership and leadership shown by both medical and nursing medical and nursing teams.
3 Key opportunities to identify the developing problems and to intervene were missed and no-one recognised the need to escalate the level of care.
4 Practical aspects of Mr Stewart's care were not properly delivered; for example the failure to give him one of his prescribed drugs for three days.
5 The decision to nurse Mr Stewart in a side ward without one-to-one nursing was inappropriate. The disconnection of his oxygen supply would have been immediately identified and reconnected with constant supervision.
6 An advanced warning chart alerted staff to Mr Stewart’s changing condition, however its use was not sufficiently effective to prevent this incident (the arrest) from occurring.
7 Medical and nursing staff who had CPR training would not have been taught how to provide resuscitation to a patient with a tracheostomy.
8 Management of tracheostomies in patients with other existing co-morbidity (the effect of a number of diseases on one patient) and care needs is an ongoing challenge for the hospitals in the Belfast Trust area.
‘Dad deserves a chance to recover’
Jimmy Stewart’s family has been battling to bring him home permanently since he was left severely brain-damaged in hospital just over a year ago. Claire Harrison met the father-of-three during a precious visit home
Family has always meant everything to Jimmy Stewart but he has needed his wife and children more than ever in the past year. He was a doting grandfather to five-year-old Kirstie and was delighted to have another on the way when he found himself in hospital with a chest infection last March.
But the north Belfast man never got the chance to know little Lucy, now a bubbly one-year-old who was born on the day he was admitted to intensive care in the Royal Victoria Hospital. Jimmy’s eldest son Thomas put off bringing the newborn to visit until he was better. But a fortnight after her birth Mr Stewart had suffered a severe brain injury and was robbed of the chance to get to know his grandchild.
Last year was one the Stewarts had been looking forward to with a number of special occasions marked in the calendar. January 2008 saw Jimmy and his childhood sweetheart Linda celebrate their 30th wedding anniversary with a holiday to Gran Canaria. Jimmy's own 50th birthday was coming up in July while his two sons Mark and Thomas were preparing celebrations to turn 21 and 30 respectively. Little did the father-of-three know that he would be spending his birthday in hospital, suffering from a devastating brain injury and permanently unable to do anything for himself.
A year after the botched resuscitation he’s still in hospital despite the Stewarts’ fiercest efforts to bring him home permanently.
Linda and the wider family circle have visited him at Musgrave Park's regional brain injury unit every day and the strain has taken its toll. Linda's mother Daphne Seaton also died of cancer in December, capping off a harrowing year.
Permanently in a wheelchair and unable to do anything for himself, Jimmy will need round-the-clock care but the Stewarts are determined he will not be going to live in a care home. His Woodvale home is unsuitable for his extreme care needs so Linda is having to move.
The Stewarts found a suitable house in the Woodvale area but couldn’t buy it while waiting to hear the outcome of the trust’s investigations. Linda said it was only down to help from the Filor Housing Association and McMillan Estate Agents in Glengormley that the house was held back and they are now able to move in within six weeks.
In the meantime Jimmy has been allowed home to his daughter Paula’s house in Woodvale three evenings per week. They said they first had to pay for Jimmy’s wheelchair transport until Health Minister Michael McGimpsey stepped in and asked the trust to pay out. The DUP’s Diane Dodds has also helped the family.
Jimmy is conscious but not able to communicate in any way. His family don't know if he's aware of what's happening around him but they assume he is.
Daughter Paula Picking (28) says the family are angry about the mistakes made in Jimmy’s care but are determined to face the future and give him the best life they can.
Officially in a “vegetative state”, they refuse to give up hope there may be some form of recovery.
Paula said: “We come from the point of view that dad understands everything going on around him because no-one can prove otherwise to us. We’re told there’s no point in giving him physio but we fought for that and it has made a difference to his legs. We’ve heard him trying to speak, but it was just completely dismissed.
“We know him best and we know he’s trying. We're not willing to let him vegetate, we just want to get him home to look after him.
“He's still my father, he's a human being and he deserves to be given a chance to recover.”
Sitting in a wheelchair in Paula’s home it's clear Jimmy’s still the centre of this close-knit family and is included in all the conversations buzzing on around him.
Linda, too, is angry about the “defeatist” attitude to his recovery.
“We have to pay tribute to the nurses who have cared for Jimmy. Musgrave Park is a great place and we’ve no complaints about the care there. We have so many people to thank for helping us piece life back together. If it wasn’t for a charity called Headway, which helps patients with brain injuries, I don’t know what I would have done.
“There’s no doubt we’ve lived our worst nightmare in the past year, we have come to accept that — we just live in hope.”