Wednesday, March 18, 2009

Mid-Staffs Scandal - Being There...

...How far is it one wonders, pondering today the shame and scandal of Mid-Staffs Foundation NHS Trust, from the Boardroom at Stafford Hospital to the A&E Department? Fifty feet, fifty yards? A hundred perhaps at the outside.

How long then would it have taken a Board member (a non-exec doing his or her duty) to walk from the one to the other? Two minutes, maybe five. Hardly more.

Did any Board member choose to take that small walk to save, perhaps, a thousand lives by seeing the chaos for themselves? Doesn't appear so.

Why were phone calls not made to the Chief Constable of Staffordshire demanding that a criminal investigation begin under s.44 of the Mental Capacity Act 2005 on the grounds of 'wilful neglect or ill-treatment' of people who lacked capacity to take decisions for themselves, as clearly was the case on some medical wards? (Perhaps they were, and if not then not too late to make that call now.)

How can Monitor now claim it didn't even know about the Healthcare Commission investigation when it approved Foundation status, or the Healthcare Commission not inform Monitor of their concerns?

How in any sense can the local PCT claim to have 'commissioned' this disaster if they knew nothing of what was happening?

Where was the relevant Local Authority charged with 'safeguarding' throughout its patch?

Can it really be true that the former Chief Executive of the local Strategic Health Authority is now to be the head of the new Care Quality Commission? (When did she last visit Stafford A&E or indeed any hospital ward?)

Why would the local coroner not co-operate with the Healthcare Commission investigation when asked to do so? ("We thought that information from the coroner would be useful for the investigation. We were disappointed that he declined to provide us with any information about the number or nature of inquests involving the trust." p.11 of the report.)

Why haven't Board members fled the country in shame taking with them the architects of this whole sorry mess - those in the Department of Health and their Ministers who designed the whole 'information managed' and 'target driven' monster they have created.

And where else is this happening right now in other hospitals? I would urge today all Trust (the very word makes one wince) Board members to take a few short walks about their respective hospitals. They might learn a thing or two, not to mention save some lives in the process.

Being there is what matters, not reliance on status reports, spreadsheets and data forecasts. Worked for Taiichi Ohno, and he was only making motor cars not preventing the slaughter of patients.

(It is mercifully infrequent that one's real day job intrudes into this pleasant, if imagined, place of respite from the rough and tumble of management consultancy. This time though one is so cross one must speak. There is another world - to be kept at thorough arm's length from the happy doings of my endearing if Pooterish alter ego - and if you must go in search of further unreality you may find it at http://www.hemina.co.uk/ I am hardly ever in. This place is so much nicer!)


Sunday, March 01, 2009

18 up....

...Cometh the hour, cometh not the baby. Appreciating the science to be imprecise, E's due delivery date - and hence this most especial birthday of hers - should have been a fortnight before it eventually came to pass.

'Twas indeed eighteen years ago this very day - that the speciality we celebrate tonight - at thirty-two minutes past midnight E was born. Expected a while earlier, she had kept us all waiting an age it seemed at the time.

The delay, though stressing, did prevent her from being a 'War Baby' for which I am glad. The first Iraq war may well have been a 'just war' in theological terms - I do believe it to have been so indeed - but it was a war in all regards and not the contextual stamp I had been desiring for my first born.

So she escaped that, but not so many other civil alarums and excursions. She nearly died on us, she could have been desperately disabled at birth. The umbilicus was - we discovered - wrapped round her neck, foetal distress was clear to see and but for an emergency Caesarean we would not have her now.

All laud and praise then to the fine surgeon who rescued her. All glory to the nursing staff who cuddled a desperate Ma and Pa through those horrid hours of fear.

But balance that paean I must with total astonishment that, when it was known there were problems within we yet still had to share a foetal monitor with another anxious mother because there were not enough such devices in the hospital for all who needed them. Turn and turn about it was for half-hour on and half-hour off.

That even when we had it, the machine was defective and like a pump sprung a leak needed me to crank some handle or other to make it work! That when the relief night midwife came on duty she knew nothing of our plight, had trouble configuring the monitor - could not even plug it in without assistance - and was clueless when it came to the twenty-four hour clock that was integral to how the machine delivered its news.

Cometh the hour, cometh the Pa. Bursting into the doctor's rest room I veritably screamed at them to sack the useless midwife and get their fucking arses over to my wife at once. To their credit they did all of that and more. The doctor just due off duty after a long, long day stayed with us all night long. He indeed who performed the Caesarean. (Had indeed E been a boy she would now be holding some complex Greek name, not the intended Samuel, that being the nationality of our saviour.)

Was that the note of the first of, doubtless, several posts concerning this magnificent anniversary I had intended? I doubt it was, though mostly one just sets off with a theme without clear sight of how it may develop. But say it I must, having now done so.

Before that night I would have counted myself among those who take what they are given and do what they are told by the NHS. But not from that time onward. That night I, in all probability, saved E's life. Some years later that same challenging attitude and approach to health personnel was to save mine as well.

A fig on the latter, but I will stripe down the first of many proud parent moments - what she has achieved not me - in this: that I acted out of character that night in order to do what was necessary for the life and well-being of my only and beloved child, now turned tonight into a fine young woman these eighteen years later.

It is, when all is said and done, a parent thing.