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NHS failing to learn from mistakes, says ombudsman Dame Julie Mellor

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David Joseph as a young man. He died aged 81 in 2009.Hospitals told to be 'more like John Lewis and M&S' days after damning report into death of man with diabetes

James Meikle

A health watchdog has criticised the NHS for failing to learn from its mistakes, days after a damning report into the death of a man with diabetes who suffered poor care at a hospital where staff appeared to have deliberately tried to cover up failings.

Dame Julie Mellor, the parliamentary and health service ombudsman for England, told the Financial Times the NHS and other public service providers should act "more like John Lewis and Marks & Spencer" in learning from complaints.

Earlier this week, Peter Tyndall, the public services ombudsman for Wales, said he found a lack of detail in medical records and "dubious" completion of a blood-sugar monitoring chart for David Joseph, who died more than three years ago.

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Tyndall was speaking after his investigation of the Joseph family's complaint against Bronglais hospital, Aberystwyth. His verdict has implications for the NHS – as an ageing population means more people have long-term conditions that need monitoring while they are treated for apparently more urgent problems.

Joseph's daughter, Rowena Jones, a nurse at another hospital governed by the Hywel Dda health board, said: "I've worked in the NHS all my life. I love the NHS but I'm not prepared to defend poor record-keeping, poor nursing, poor management and lying." Her 86-year-old mother, a former nurse, had been devastated.

It was the second time in three years that Bronglais staff had been criticised by the ombudsman for poor record-keeping and alleged falsification – the other, when it was under different management, involved the transfer of a patient to another hospital.

Tyndall said: "I am concerned at the number of cases I see where proper monitoring of a patient's condition has not been undertaken. Then there are cases where even when monitoring has been undertaken, it has not been properly recorded. In other cases, monitoring has been undertaken and properly recorded, but then the results of the recordings are not acted upon."

Mellor recently succeeded Ann Abraham as ombusdman for England. Her office said: "Since 2010 to date, we have seen several recurrent issues in complaints that have been brought to us to look into. The top 10 complaint causes include poor records management, clinical care and treatment and failure to diagnose." But the key theme from her report, Listening and Learning 2010-11, was poor communication, including when authorities handled complaints.

The Department of Health in England is considering introducing a "duty of candour" which would demand NHS providers be open with patients when things go wrong with their healthcare. There are no such plans in Wales.

Tyndall's report said Joseph had a hypoglycaemic attack, caused by low blood sugar levels, to which the hospital's failings contributed. The attack had an "unspecified causal effect" on his subsequent cardiac arrest and deterioration, that left him needing 24-hour nursing care. He died, aged 81, in April 2009, days after being discharged to a nursing home.

Staff were not vigilant in recording information about his diabetic regime or blood sugar levels and there appeared, Tyndall reported, "to be a false blood sugar reading added retrospectively to the record". The hospital's response to the family was "thin and protracted".

The report added: "Diabetes is a fast growing disease. Increasing numbers of people will be admitted to hospital with acute conditions, whilst suffering from diabetes.

"It is crucial that nursing staff operated a patient centred approach, follow medical direction, monitor patients carefully and have the knowledge to underpin the care they provide."

Joseph, a former regional director of the Open University, had five children and 14 grandchildren.

Tyndall said the health board should pay the family £1,700 for the uncertainty and distress over how the failings might have led to Joseph's death and the timetaken to pursue their complaint.

Jones, a paediatric oncology nurse, said she had "a pretty shrewd idea of what happened to my father", despite the family being "fobbed off" by the health board. She broke the family's anonymity because of the wider implications of the case.

"My father had mild Alzheimer's and I know there would have come a time when we had to make decisions about where he lived and where we cared for him."

But the day before he was admitted to hospital, he had showered and dressed himself, had breakfast, walked the dog and had a long phone conversation. "He was left bewildered, incontinent and immobile."

She wants meetings with ministers in Cardiff and London to stress the importance of stronger clinical leadership in treating diabetes and ensuring NHS managements are more forthcoming when things go wrong.

Caroline Oakley, director of nursing and midwifery at the health board, apologised to Joseph's family.

"Since 2008, when this incident occurred, we have put in place numerous measures, including extra training for nurses in diabetes care and a review of the blood monitoring equipment," she said.

"We are committed to ongoing improvements, specifically for the growing number of patients living with chronic conditions, to ensure that we provide a patient-centred approach for every individual in our care."

She added: "The health board takes seriously any allegation of breaches of professional standards and will always investigate these as it did with the previous case. All nursing staff have been reminded of the professional standards expected of them by the health board and their professional body, the Nursing and Midwifery Council."

Source: Guardian UK, 20 April 2012



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