Episode 1 Hospital

Just move yourselves over to the side for a minute.

This winter, one of Britain's busiest NHS trusts

opened its doors...

We have to look after the patients

whether they come from Buck Palace or the park bench.

..to show us what's really happening inside our hospitals.

We've got lots of patients now competing for

an unknown number of beds.

Every week, more than 20,000 people are treated here...

The pressure's just gone.

What?! Is it completely gone?

..and the numbers, as well as our expectations, are rising.

We just had our worst ten days on record,

there's nowhere in the hospital to move anybody.

At some point, somebody will be telling us

whether we're allowed to do any work.

This is a place with some of the best specialists in the world...

Tumour's out, job done.

..where lives are transformed...

This is saving his life.

It has to work.

..but they are operating in a time when the NHS

has never been under more pressure...

-Got any beds?

-No.

-No beds for anyone?

-No.

-OK.

It does feel to me like the elastic's a bit nearer

to breaking now than it ever was.

..its very future under scrutiny.

All right, well, I think we will go out on red because we're

under real pressure in the emergency department.

We're aware of the problems -

anybody got a solution?

Following the patients from the moment they are admitted...

Anything I've done up to this point means nothing compared to

when you can literally give a bit of yourself to save someone else.

..to the moment they leave...

It's all good news - the cancer has gone.

You don't need any more treatment.

Fantastic.

Thank you so much.

..week-by-week, we reveal the complex decisions the staff

must make about who to care for next.

That patient is coming to me to be operated on,

and if I don't do it, then there's only one inevitable outcome -

they're going to die.

Right, good morning, everybody. Shall we begin?

I've seen the gang at Charing Cross.

-Good morning, Charing Cross.

-'Morning.

-Good morning.'

OK, do you want to just talk us through your screen this morning?

Lesley Powls is the site director at St Mary's,

the biggest of the five hospitals

in London's Imperial College Healthcare NHS Trust.

Every morning, she leads a conference call

with the other hospitals to plan the day.

The focus is always the same -

how many empty beds have they got?

-CHARING CROSS:

-'There's currently no cubicles anywhere in A&E

'to see any new patients.'

OK, so not a great start to a Monday morning for you guys, then?

'The first call of the day is to kind of take the temperature of

'what's gone on overnight,'

and what our beds look like going forward

for the next couple of hours.

Let's go to St Mary's. So, as you can see,

we're in a very similar position to Charing Cross this morning -

very full and busy ED screen.

Let's just have a look at the beds.

It's probably easier for me to say what we've got,

which is absolutely nothing at the moment.

So, really, priorities for us this morning are to sort out the

rest of the unplaced patients in the emergency department

before we do anything else.

We'll pick up surgical electives in about ten minutes.

All right, well, I think we will go out on red this morning, then.

OK, thank you very much, everybody, we'll speak again at lunchtime.

St Mary's uses a colour coding system to indicate its bed status.

Amber means that the hospital is almost at full capacity,

with only a handful of its 301 adult beds available for new admissions.

Code red is even more serious.

It means that, throughout the hospital,

from the A&E department to the Intensive Care Unit,

from the High Dependency Unit to the general nursing wards,

there are not enough beds available

for the number of patients that need them.

The hospital is full.

St Mary's must now put scheduled operations on hold.

The pressure on beds can only be relieved

by existing patients leaving the hospital.

It's one in, one out.

For the last three weeks,

we've run at almost completely 100% capacity.

We are probably on code red every three or four days.

I'm hoping that, within the next couple of hours, we get

enough beds that we can at least do

a couple of our elective patients.

SIREN BLARES

That's the trauma patient.

Which means that we are very likely, shortly, to need another trauma bed.

So today, we are in trouble.

So at the moment, there are no beds in the hospital.

There's a lot of emergencies who will need operating on.

When St Mary's is on code red, surgical staff must wait

while site operations look for patients to discharge.

Today, there are no beds in the Trust at all.

Right, let's go and postpone things.

It's the job of the on-call anaesthetist to stop planned

operations getting underway.

Until the hospital gets off code red, there won't be enough

beds for all the patients to recover from their surgery.

What tends to happen is, people can be a bit naughty,

and suddenly they just start their patient.

I mean, after knife's to skin, there's absolutely nothing

you can do about it.

There is no bed, 100%.

There's loads of patients in A&E, there are no beds whatsoever...

-OK.

-..in the Trust.

Rex, you know that it's only day cases or inpatients?

Right, or day care, yeah.

-I didn't know that, but I do know now.

-Yeah.

They said not to go ahead, and they want to go ahead.

Well, no, you can't go ahead if we haven't got a bed.

Even if we don't have a bed,

if we do any patients that need beds,

they have to stay in recovery, that's not acceptable.

No, no, no, they can't go cos we haven't got the

-recovery staff to look after them.

-Exactly, but you're not listening.

Because I said they have to stay in recovery

doesn't mean the patient can go to recover -

it means that it's not acceptable.

But nobody's listening.

This is really annoying, isn't it?

Because many hours are wasted waiting for things,

which just pisses me off.

This is a bad Monday morning.

There's been no frost, there's been no flu, it's not cold, you know?

And the fact that the hospital's already overwhelmed

is really quite scary.

Anyway, so I better have my mango lassi.

George Reese is one of the surgeons waiting to start work.

He specialises in keyhole surgery.

IT support as well.

We have one operation to do today,

and that's an anterior section,

which is an operation for rectal cancer.

The gentleman's here, my team have seen him,

but the hospital's on red alert, so we are just going to wait to

find out to see if we've got permission to start operating.

George Reese can't begin his patient's surgery until a bed is

available on the High Dependency Unit for him to recover in.

Morning.

Nurses there are currently trying to discharge patients to make space.

Hello. Can we do a quick brief, please?

So we don't have permission to start because they don't know if

there's a bed or not, so we're not allowed to do anything.

The difficulty is...

that it's 3.5 hours of surgery.

-Yeah, and it's cancer.

-And it's cancer.

So if they don't tell us early, we've run out of time.

But they know that.

Professor George Hanna is also waiting to start a cancer operation.

I'll come later on.

His patient will need a minimum of six hours of surgery,

followed by a bed in the Intensive Care Unit.

-Oh, hello.

-Hello.

-How are you?

Good morning to you.

-So let's stand him up.

-SHE LAUGHS

-Hello.

-How are you?

-Good, thank you.

-Pretty good, thank you.

-Are we good to go, or not?

-We're just waiting.

-We're just still waiting? OK.

-Yes, still waiting.

Have you been doing your exercises?

I have been doing my exercises.

Very rigorously.

So once we know, get back to you.

-We'll let you know.

-Yeah.

-We'll call you to come in.

Well, I'll see you shortly.

-See you again, yes?

-OK. Take care.

The patient has a cancer of the gullet, which is the oesophagus.

To cure him, he needs to have the operation -

otherwise, really, he can't survive.

I was first diagnosed back in April,

and then I went onto a chemo

and radiotherapy treatment course,

which was designed to shrink the tumour.

Became quite difficult to eat.

-PRODUCER: Do you feel poorly?

-Not now, no. But I did then.

Oh, my God, I did then.

And the thing is, you know, he's, what, sort of

-13st or whatever normally.

-Not now.

Well, no, but you were.

I was more like 14st.

I mean, big, strong, healthy guy, you know?

Playing golf three times a week or whatever.

And suddenly, he's not.

So looking at the scan, it looks actually, he...

he has a good response to chemotherapy and radiotherapy.

Here is the oesophagus.

And this black is the food channel inside the oesophagus.

And if we go up, you will find it is wide.

If you go down, you will find it narrow.

So the tumour and the thickening makes it

so that inside is small,

and this is why the patient struggles to eat.

One of the main aims of the operation is to have a clear

margin of normal tissue to ensure

that the tumour is completely removed.

Simon's surgery has already been cancelled once before.

Just like today, the Intensive Care Unit was full.

We've only got 16 intensive care beds at St Mary's,

and those beds are always needed for our sickest patients

in the organisation.

So those coming through our emergency department,

are major trauma patients and are patients who are going to

recover from some of the biggest surgery

that we do in the organisation.

St Mary's Intensive Care Unit, or ICU,

contains the most sought-after bed spaces in the hospital.

Each one provides one-to-one nursing care,

and the most advanced life support systems.

There is no capacity to add more beds.

The team tries to keep at least one of these bed spaces

in reserve in case of an emergency admission.

But with patient numbers rising,

this is proving increasingly difficult.

Today, all 16 beds are full.

I need to move patients off intensive care

and down to the ward.

But before we move them, I need to go and have a look at them

and make sure that

'they're well enough to move and that they'll be safe on the ward.'

Hi, there. How you getting on?

How are you doing?

It's good to see you're all right.

I think you're doing really well, sir.

How you going?

OK, good. All right.

I think you're improving.

All right? I think you are.

Simon Ashworth has identified two patients who could

potentially be stepped down from the ICU to other wards,

but only if their conditions improve over the next few hours.

I have to tell you, it's nine o'clock.

PRODUCER: And what does that mean?

It means, at some point, somebody will be telling us

whether we're allowed to do any work.

-Nervous?

-No, I am not.

HE LAUGHS

I am nervous for you.

You worry too much - you'll get heart attack.

LAUGHTER

George Reese's cancer patient Eladio's operation is already

two hours behind schedule.

I've decided not to get frustrated.

There's nothing I can do to fix this problem.

So...I will trust that the people who are doing it

are doing their very best.

-Morning.

-Hello.

How are you?

-Hello, we didn't get to meet last time.

-No, no, we didn't.

I just want to set the scene of today a bit.

At the moment, they haven't given us permission

to start the operation because there isn't a bed in the hospital.

-Yeah.

-But they're working on it.

-OK.

-And when I know, you will know.

-OK.

-Lovely.

Is there anything you wanted to ask me?

-Well...

-No, I think...

-..I just would like to ask about the parking outside.

-The parking?

The cost to me now is £10.80.

Please...

please, because if we're going to be here all day,

that's going to cost me an arm and a leg.

I kind of meant, is there anything you wanted

to ask me about the operation or about the...the surgery today?

-No, I'm OK.

-OK.

Site director Lesley has received an update on the bed situation

from the High Dependency Unit.

So we've managed to get some discharges,

which means we can start to operate on patients

who can go into High Dependency,

but not patients yet who need intensive care.

Yeah. So, marvellous, and then,

start the Reese patient needing HDU.

Miriam?

-Don't feel any pressure(!)

-LAUGHTER

I'm coming to find out if I'm allowed to start,

cos if I can't start now, we have to send him home.

So the cancer patient who needs level two, that can go ahead.

OK, great - so we can go ahead?

Thank you.

So we need to go and tell them.

Can you hear me? We're coming down to theatre.

We're allowed to do the case, OK?

They found a bed.

PHONE RINGS

Hello, site office, Lesley speaking.

Lesley must now deal with a new emergency.

A patient is on her way from Norfolk with a ruptured aorta.

SIREN BLARES

The aorta is the main artery in the body.

If it bursts en route, the patient will die in the ambulance.

St Mary's lead vascular surgeon, Richard Gibbs,

will perform the life-saving operation.

I've been sent here because we're a specialist centre

for aortic surgery.

We feel a real moral responsibility

for accepting patients like this.

Without any shadow of a doubt, they

will need an intensive care bed.

But, to a certain extent,

we just have to get on and do the operation.

So we'll have to worry about the ITU bed at a later stage in the day.

That patient is coming to me to be operated on.

If I don't do it, then there's only one inevitable outcome,

which is they're going to die.

ITU are uncertain now as to...

This morning, they were declaring two patients to step down.

They're now not sure that they have two to step down.

They think they might just have one bed.

If they have one bed, that bed will have to be held for

the ruptured patient coming from Norwich.

Richard Gibbs goes to discuss the impact of his incoming

emergency on George Hanna's patient.

George.

As things stand, you need an ITU bed,

we need an ITU bed,

cos we've got this woman who's in an ambulance

on the way from Norfolk

with a ruptured aneurysm, so she needs an open operation.

So if she arrives alive, which we think and hope she will,

she's going...we are going to do her in theatre nine

and not worry about ITU for now.

We've got to get on with that and sort it out.

Fine.

So what are we waiting for now?

There's...one or maybe two patients in ITU who can step down.

So we're just waiting for confirmation from them

that one or both will go. We only need one bed,

which will free up the ITU bed for you.

Simon and Patricia, his wife of 36 years, have been waiting for

three hours to find out if his operation can go ahead.

You don't quite know whether not hearing something is

a good sign or a bad sign, do you?

You're geared up to do nothing, really - just wait.

When we first embarked on this process,

we were told that there is...

a window of,

I don't know how many weeks - five-to-eight weeks -

after the chemo and radio stops

when it is the best time to do the operation.

I haven't asked the question, "So if you can't do it today...

"..do I then have to start doing chemo and radio again,

"or something? Or what actually happens?"

Cos you don't like to ask those questions. You don't...

you don't really want to have the answer.

You just rely on them to do the operation.

But you reach a point where you just say, "I want it done."

You know? You just can't keep putting it off forever.

And I guess it's not just for you,

it's the impact on family,

-loved ones, and...

-Oh, yes.

Yeah.

-..me...

-SHE LAUGHS

-..particularly.

-Yeah.

Can you tell me your name?

-Eladio Pracoyo.

-Great.

And your date of birth?

January 22, 1941.

That's a great birthday.

-It's my birthday as well.

-Yeah?

All right, just open and close that hand a couple of times.

So it's exactly four weeks after Christmas, isn't it?

-Mm.

-Your birthday?

-Yes.

-From the Philippines?

-Yes.

-Yeah?

Surgeon George Reese begins his patient Eladio's operation.

We're going to do a keyhole operation for him where we

remove the part of the bowl with the cancer in it,

and its adjacent blood supply

so that we can take any lymph glands

that may or may not be affected by the cancer.

And then we're going to join it all back together again.

Four hours later, the tumour is out,

and the operation is over.

Why should I feel victorious that I'm actually just allowed to

do what I should have started doing

at eight o'clock this morning?

It's because the beds are so bad at the moment that

it seems rare to be allowed

to actually go ahead and do an operation.

-Very bizarre.

-SIREN BLARES

The emergency patient from Norfolk is an hour away.

The team doesn't know if she will survive the journey.

The risk we run here is we're holding a bed for

a patient who hasn't even made it into the organisation yet,

and not going ahead with patients who are already here.

Do you have to do this for people every day?

-Struggling with socks?

-Yeah, yeah.

-THEY LAUGH

-Ah.

-Hi, George.

Hi, thank you.

The two people I'm kicking out from ICU,

I-I...one of them I'm not really that comfortable with,

so I don't have a guaranteed bed for anybody at the moment.

Right.

So I might get one or both of them out, but, you know.

And if your patient leaves,

do you think you will have a space?

If this patient doesn't survive from...

from Norfolk, then, you know.

But we can't predicate.

-So shall we wait a bit more time?

-The only thing you can do is wait.

But I don't think the odds are very good.

We don't have enough slack in our capacity to be able to let

Prof Hanna go ahead and do the oesophagectomy.

Um...I mean, what's hard about this is that, you know,

we're also talking about

whether we can go ahead and do it...

..if the patient from Norwich doesn't survive the journey,

and that's a very hard and callous-sounding thing

to be talking about, but that's the practical reality.

They have this patient coming in who might require the I...

intensive care bed.

-They might die.

-If they die, then the bed is available for me.

And we can do the operation.

But if not, they've got the bed.

-That's the seriousness of...

-They've got the bed if they need it.

How does that make you feel?

Guilty, actually.

-Yeah.

-In a way, yeah.

I'm the person that, when someone is really irate and they say,

"Who made the decision that we're not going to do blah?"

my team or various other general managers

will say, "Lesley did that - and here's her number," usually.

So that's who I am.

So you're the one that stops things happening sometimes?

Sometimes I stop things happening, yeah.

-What's that like?

-Horrible.

It's a horrible feeling because when you stop something...

You know, I'm a nurse. I've spent my whole working career...

doing the bit that is about making things right.

Not always making things better

but doing the right thing by people all the time.

And I do the right thing all the time in this job

but it's not always the right thing for one person.

I do the right thing for the hospital.

And that's really difficult because that does mean

that there will be people who today we haven't done the right thing for.

-Hello.

-Hi.

Hi, Simon.

I thought I'd pop up and see what we can do to help.

I have very few options.

What worries me is, we've got no slack

for the...for the unexpected that is the norm here.

What I don't want to do is put you guys under loads of pressure.

I think we are asking for trouble if we try and do...

Yeah, but we are trying to work out...

George, if you can operate, if you could do it tomorrow,

I think the chances are better.

Yeah, but I think...

We can certainly... Whatever you step down from ITU,

we will create beds to allow that to happen.

But Simon is now trying to keep an empty bed

just as a slack for something to happen.

-How long do you think you're going to be...?

-I will be very late.

I will take six hours' operating.

If we go ahead now, we'll finish by midnight.

I think the safest thing to do is to defer it,

but, you know, I understand the logistics of that are a disaster.

It's not just the logistics, there are clinical issues here

because it's the second cancellation

with a dedicated time in radiotherapy

and we're not doing him to keep a slack in the system

which doesn't have a slack.

But I've got no ability to manage any other problems.

If he didn't have a bed, I would have no problems.

I can understand it.

But if we are not doing him to keep a slack while we can

use recovery as an alternative, this is the difficulty I have.

-We're very close to the limit.

-We are close to the limit.

We're very close to the limit

and operating absolutely on the limit is unwise.

The question really, if we wait another week or another time,

this will not be... I'm not sure how this will get better.

Cancelling a cancer patient three times is a serious incident, so...

This is something you need to... to work on it.

It's your call, Simon. What do you want us to do?

You know, we don't have the slack at the moment to do this safely.

We are stuck at that point.

OK. That's fine.

So, from my point of view...

I think you need to get on with her, whatever you do,

and I'll work on the basis that they will be able to give me a bed.

SIREN

The scans from the hospital in Norfolk

have been received by Richard Gibbs.

They reveal a huge aneurysm in the main artery

from the patient's heart.

OK, shall we just... so, the team brief here...

this lady has a ruptured aneurysm.

Her aorta is four times the normal diameter

so it's very dilated and that's like a balloon.

It's just stretched and stretched and stretched

and now it's finally given, so blood's starting to come out of it

where it's got a small tear in it.

The surgical plan is to do a left thoracolaparotomy

and not disturb the abdomen until we've got control

of the lower thoracic aorta and then we'll obviously open up.

All right? See you in a few minutes.

'There are frustrations so the whole team gets assembled

'and we make a plan and it takes quite a lot of effort

'and concentration to get everyone pulling together to do it.'

And so if that plan is preceded by three hours of negotiations about,

can we slot someone into HDU if they go to Hammersmith

so the ITU patient can drop down?

You know, I...I...

I sometimes feel that I spend as much energy on trying to organise

and manage beds and the movement and the flow of patients

within the hospital in order to allow us to do what we

actually want to just do and get on with, which is to operate.

SIREN

Professor Hanna has now been waiting to be given the go-ahead

for HIS operation for five hours.

Hi, Lesley. It's George Hanna.

Hi, Lesley. The aneurysm will come in one hour's time.

I spoke to Rick.

So, yeah...

So now we need to make a decision, really.

'We had a patient come in who was a self-hanging.'

OK, just one second, Lesley.

There is a trauma came in just now. Just now.

Somebody's hanging,

so there's an extra case into the equation.

If this patient goes to ITU,

then potentially there will be no beds?

Definitely no?

Head of intensive care Simon Ashworth must now go to A&E

to decide if the hanging patient will need an intensive care bed.

-He didn't have a cardiac arrest?

-Correct.

Have you got him sedated or anything?

He is on a propofol infusion.

The patient will need life-support, which only ICU can provide.

We'll need to find a bed for him.

I think it'll be possible,

providing that nobody else here needs to come up.

But it certainly means that the chances that we would be able to

do the oesophagectomy is zero now.

It's just a trauma came in now. Just literally now.

-Do we all have to go home?

-Yes.

-OK.

OK.

Waste of resources.

There is anaesthetist, there is a surgeon,

there is theatre, there is three or four nurses,

and this is empty - it is not used, not utilised,

so it is a waste.

SIREN

After a four-hour journey from Norfolk,

the patient with the ruptured aorta, retired school teacher Janice,

arrives at St Mary's A&E.

OK, Mrs Metcalf...Medcalf.

Sorry, is it Mrs or Miss?

M-E-D.

What's happened is, the aneurysm has ruptured

but, luckily, the blood is just sitting in the back of the abdomen

by the big back muscles, so it hasn't just blown,

and that means we've got a chance to fix this.

We've had a look at it on the scans.

The safest way to do it is, we're going to make a cut

which is going to go run near your chest and down into your tummy

and then we can clamp the aorta and hopefully sew a big graft on

and that will be the end of the problem.

-It's obviously a bit risky.

-SHE LAUGHS

I'm going to be honest with you.

And there's a few complications that can happen.

I mean, you're definitely going to lose quite a bit of blood.

And there's always the risk of things like a heart attack

or a stroke or kidney failure, erm, afterwards.

But the thing is, we haven't got a lot of choice,

because if we don't do it, then that's the end anyway.

-OK?

-Thank you.

This case has trumped the patient with cancer

that was going to get done in the other theatre

because she's...

..got a condition which will kill her, erm...

sometime in the next three, four, five, six hours,

so if we don't do it now,

then there is going to be no "five hours' time" for her.

'Multiple cancellations are something we really try

'very hard to avoid but, actually, without slack in the system

'it is impossible.

'And if you try too hard to avoid them, what you end up doing

'is prioritising somebody because they've been cancelled'

'over somebody who is at immediate risk of dying.

'They are the issues you are juggling.'

Janice's sons arrived minutes later,

by which point their mother's operation has already begun.

'We spoke to her last night, literally.

'She'd said that she was in some discomfort, got stomach pains,

'but she decided to go to the out-of-hours surgery

'and took herself off... drove herself there,

'but didn't reach -

'she passed out behind the wheel and crashed the car.

'I heard about it from the ambulance driver about 4:30am this morning,

'saying that she had this aneurysm.'

'Will she survive? Will she pull through or not?

'There's always significant risks.'

Mortality is probably about 50-60%.

We'd like to try and get the aorta dissected out in a nice, clean way

before it blows.

I mean, it's already ruptured, but if it starts bleeding freely

because we're dissecting around it,

then we're going to have to clamp in a real hurry.

OK, guys? Thank you.

Have you got a periosteal elevator?

Can I have a Wylie?

So the fish slice just needs to go there.

We can put the lung down if we want but let's try to avoid it

because she wouldn't like it.

So that's the heart...

and this is the thoracic aorta.

The problem is actually a bit lower down in the belly.

So she's got a huge haematoma.

Don't touch the haematoma, whatever you do.

I mean, it might blow any minute. It really might, literally.

That's the blood from the rupture which is tracking round the back

and coming towards the front.

That's the aneurysm. Don't press it too hard.

This is going to go, so we need to get a wiggle on.

'She...

'likes to keep herself occupied.

'Reception-aged children, she used to teach,

'she does various crafty things, she goes bowling,

'she plays darts.'

We would joke that we have to make an appointment to go and see her.

Keeping our fingers crossed.

Very nervous.

OK.

The difficult bit is just about to start.

Everyone do it slowly. Take the diaphragm away from us.

So this...gently. Let me just get this down here.

It's the last bit and then we're there.

Relax, let go. Let me just do this.

Move that up to there.

Get that.

Suck, suck, suck, suck, suck.

OK.

-The pressure's just gone.

-What?! Has it completely gone?

OK, is the patient all right?

Guys, give it a minute.

I can clamp the thoracic aorta any time.

-She didn't tolerate it.

-All right.

-It's coming up anyway, isn't it?

-It's coming up.

-Hi. I'm Richard Gibbs.

-Hello.

-Hi.

I'm just going to tell you this straight,

the operation was, erm, a success,

but it was quite challenging at times

and although she's stable at the moment,

I won't say anything yet about the prognosis.

She needs to go to ITU for the next 24 hours

and they will stabilise her

and support her in any way that is necessary.

But at her age, and having a really big operation like this,

I don't think we can say she's in the clear yet.

I think we need to give that 72 hours

and if she starts to get better and better,

then I'll be really hopeful.

'We've been full all day.

'Sadly this has meant we had to cancel George Hanna's patient,

'but, you know, I'm hopeful that we might be able to do that tomorrow.

'I think we do need more capacity because we're always under pressure

'and it does feel to me like the elastic

'is a bit nearer to breaking now than it ever was.'

It's wearing, constantly going around, taking bad news to people,

and, you know, everybody gets a bit irate and it...

you know, it takes it out of you.

St Mary's' capacity problems are directly linked

to its status as a major trauma centre.

Its A&E department must provide round-the-clock emergency care.

A 10% increase in patients in the last 12 months

means that it now handles more than 150 new cases every day.

A&E has four resuscitation bays

for patients with life-threatening conditions

and a further 16 beds for the seriously ill.

Government regulations stipulate that patients either have to be

discharged or moved on to another ward within four hours.

But when the hospital is at full capacity,

the department quickly fills up with patients waiting for beds

and the four-hour time limit is regularly breached.

Hello, I'm Ali, I'm one of the doctors.

Can you squeeze my hand?

Alison Sanders, Clinical Director of Emergency Medicine,

is the consultant on call in A&E.

'What's happened in the last two years is the whole system,

'country-wide, seems to have ground to a halt.'

It just makes us feel as though we are firefighting every single day

and we're not unique, we're not unique at Imperial,

we are the same as any other emergency department

in the country and any other major trauma centre.

Every day we just feel like we are struggling to just keep afloat.

That was just another trauma coming in now.

A fall from six foot. LOC.

Is the shooting coming to us?

He's had two lines of cocaine,

unknown quantities of vodka and beer.

28-year-old male stabbed three times.

It's been given as seven men with guns have gone into a building,

someone's not moving.

And what about trauma beds?

Two.

Hello. What beds have you got for me, please?

The minute that we have bed problems,

usually due to patients not being able to leave the hospital

at the other end, then we end up in this state.

Erm...we're going to need this man in resus to go to ITU,

so what have we got that can come out and where can we put it?

Everyone is already working as hard as they can and I think

they're fed up of being told to be more efficient all the time.

There's only so efficient you can be

and also, when everybody is working so hard, day in, day out,

then eventually, you know, they get tired.

You hope they don't get tired and make mistakes,

you hope you've got enough resilience in the system for that,

but it certainly doesn't make everyone more efficient.

With winter approaching,

the pressure is set to intensify within A&E and across the hospital.

Good morning, everyone. Who have we got at Hammersmith this morning?

And Charing Cross, have we got you guys?

OK, let's look at capacity at St Mary's.

We've got a completely full resus, very full majors,

minors is creeping up

so a big push on anything we've got dischargeable, please.

St Mary's remains close to capacity.

However, it is no longer on Code Red.

From a critical care perspective,

it's not been the best start to the week.

Unfortunately, sometimes, being a major trauma centre,

our demand for very sick patients

outstrips what we have in capacity and we can't predict that.

On the high dependency unit, George Reese's patient Eladio

is awake and stable following surgery yesterday.

More.

So you had a nice sleep?

-About one hour, two hours.

-Yeah?

-Enough.

Yeah, I'm waking up.

He should be well enough to go home by the end of the week.

In intensive care, Janice is yet to wake up

following the operation to repair her aorta.

Squeeze my hand, Janice.

Janice?

Janice, squeeze my hand if you can.

As the nurses reduce her sedation,

she should begin to regain consciousness.

Can you open your eyes for me?

After being forced to postpone Simon's operation yesterday,

Professor George Hanna is waiting to find out

if there is a bed available in intensive care this morning.

There's Dr Ashworth.

Good morning.

-Morning.

-You all right this morning?

-Ish.

We're still trying to get George's case done.

It's probably contingent on... Hi.

on moving one of our patients to Charing Cross.

-They've still got the bed.

-They've still got the bed, OK?

If the patient is stable enough to go.

-Are you going to let George know?

-I'll let George know.

-I told him that was the contingency.

-He'll be delighted.

Hi, George.

Yes, you can start. I've just spoken to Lesley.

Wonderful.

Fine.

Good morning. I've got good news. We have a bed.

Finally, after weeks of preparation and two cancellations,

the operation to remove Simon's tumour can go ahead.

How was he last night?

Erm, he was OK.

We had jumbo prawns and noodles.

Yes, I gave him a great big bowl, as I have been doing,

with cream lashed onto it for him!

So we ate and, erm...

watched a bit of TV and chatted and...

..he was fine.

And I knew he probably wouldn't sleep very much but that was OK.

The operation will take more than six hours.

An oesophageal tumour, you know, you, you...

you bombard it with the radiotherapy,

you bombard it with the chemo, which he had,

and it has shrunk.

But if we just carried on with our life,

it could just grow again

and so that's...

You know, there is no...

there is no choice, you just have to have the surgery.

So, yes, I do feel relieved...

..because it's now happening and there's nothing else anyone can do

except the team, so...

And waiting is... Sorry.

Waiting is going to be tricky.

But it'll be fine.

It's a privilege to operate on a fellow human.

The patient will put his life in my hands

and I have a duty to do the best of my ability

to give them the best outcome.

The first stage of the operation is to remove Simon's oesophagus

and the tumour it contains.

'You open the chest, you open the abdomen,

'you dissect along a lot of blood vessels,

'and that's why, actually, in terms of the impact of the operation,

'it's one of the biggest operations of the body can take.'

How is the patient? Is he OK?

So this is the oesophagus and the tumour which we removed now.

The oesophagus is taken to the pathology lab

to see how far his cancer has spread.

This is the oesophagus at the top, between my fingers,

this is the stomach here, so we expect to find the tumour

somewhere at the bottom of the oesophagus,

just where it goes into the stomach.

I'm trying to put my finger into the oesophagus

and I can feel it's thickened and narrowed.

One thing we want to know is whether all the tumour has been removed.

The further the tumour has invaded into the wall,

the worse the prognosis for the patient,

and if the tumour has spread to the lymph nodes,

the worse the prognosis for the patient,

and the more lymph nodes that are involved,

the worse the prognosis for the patient.

The most challenging part of the operation can now begin.

Professor Hanna must create a new food pipe

in order for Simon to be able to eat.

We convert the stomach...

..and we need to reconnect the gastrointestinal tract

in a way that the patient will be able to eat after that.

Going well. Really well.

Operation looks...

..looks nice, really, and if things look nice

usually it's worked very well.

Simon will spend the night in intensive care,

the same unit as Janice.

Having finished in theatre in the early hours,

Professor Hanna heads to the intensive care unit

to check on Simon's progress.

All went well. I spoke to your wife yesterday.

-That's very kind of you. Thank you.

-So she's happy.

They may send you to go to the high dependency unit.

Tomorrow?

-No, today.

-Today?

-Yeah.

-Wow.

-Most likely, yeah.

-OK.

-So it's a promotion to go there.

-Absolutely, yes.

-Heavens, I wasn't expecting that.

-Yeah.

-You obviously need the bed.

-No, you look well.

You look well. You don't need to be here if you don't need to.

Two days after her emergency operation,

Janice is stable enough to be taken off life-support.

A big bold hello.

-FAINT:

-Hello.

-FAINT:

-Hello.

You'll get there.

She's not out of the woods by any means,

so there's still a long road to recovery here,

but she's been making steady progress all the way through.

Every week, Lesley and her team meet with senior managers

to review how they're dealing with the hospital's capacity issues.

I think things have been getting more and more challenged.

Certainly the pressure feels much more intense

and it feels like we are making difficult,

really difficult decisions much more regularly

than we had been doing and than we should be doing.

Chairing today's meeting is Professor Tim Orchard,

Imperial Trust's Director of Medicine.

Top of the agenda, the chronic bed shortage.

If we have a significant flu epidemic,

we are going to be completely stuffed.

We have never started winter with so little spare capacity.

And so I think one of the things that we need to do,

and we've never had to do it in this Trust before,

but I think we need to think about

what we do when we actually run out of beds.

What do you do in terms of, if we get noro and we lose a ward,

-organisationally, we are not going to manage.

-Exactly.

We've got nowhere to go to.

It's felt on many days as though we had the tipping over the edge

of the cliff phenomenon, where you get to a critical point

and you can't function for the admitted or non-admitted patients

because everything is full.

There is no more capacity on the St Mary's side.

We know that.

It looks impractical to move any surgical specialties off this site

so one possibility is moving the paediatric outpatient department,

which would potentially allow the creation

of probably around 15 to 20 beds on the sixth floor.

But that's obviously going to be quite expensive.

It might be a really good plan for next year,

but the reality of getting all of that sorted out by winter, it feels

like we need to do something sensible and practical now.

One of the big debates people are having nationally at the moment is,

in extremis, can adults be nursed alongside children?

What do you do in terms of, like we've had on this site,

when you've had ten paediatric beds and you've got ten unplaced adults

in ED, what decision would you want to make there?

So the question is, where can we board extra patients on wards?

How would we nurse that to make sure the patients are safe

and that the patients have an appropriate level

of privacy and dignity?

Other trusts have used places like gyms,

endoscopy,

cath lab recovery,

Erm, so, I think we just need to be clear what...

what the levels of escalation are.

What we need to do is to roll out to every single ward and department

in the Trust a plan that says, we've got to aim to do X, Y or Z.

Very good. Thank you.

It is tough and I think people are working incredibly hard,

which we do appreciate.

The senior managers have agreed a set of new measures

called the Full Capacity Protocol.

I'm still a practising doctor, I still go on the wards regularly,

so I'm very, very well aware, very in touch with what's going on.

I think we know that we need to create more capacity.

I think we have put in place a number of plans

of what to do with our estate to make things better.

Every consultant will go around and make sure every patient

who's in the hospital really needs to be in hospital

and, obviously, we will then make sure that every single bed

that can be opened safely is opened.

There are some wards where there is space that is relatively unused

and we would be able to fit a bed into that space

so it's about using every single square inch of space,

even if it doesn't normally have a bed in it.

It will be down to Lesley to implement the hospital's new policy.

Problems definitely aren't easy to solve

but we've got something that will see us over the next few months.

It's much better that we have an ability for the whole hospital

to know that we're in trouble, rather than it just being me

and my office sitting here with our head in our hands.

It's better to put out an alert that says to the whole organisation,

"We need some help today."

-LESLEY:

-Right, good morning, everybody.

-Morning.

-Morning?

-ALL:

-Morning.

-That's better! Right.

Bed-wise, we've got one bed in CDU and two beds on Albert,

no confirmed discharges and a smattering of queries,

so we have a really challenging day at St Mary's.

I think we'll go out on Red this morning.

We'll keep this line open because it will require people to dial in

to let us know they are undertaking a new set of actions

in the Full Capacity Protocol.

Great. We'll speak later. Thank you.

'There's a lot of both nervousness and excitement

'about the Full Capacity Protocol.

What we want to try and do is get to the point where if we're struggling,

we take an early set of decisions

that give departments a bit of breathing space.

Having been stepped down from intensive care,

Simon is making steady progress.

He's doing well.

There's a lot of work that went into him to be at this stage.

He's very positive.

If you ask him to walk a mile, he walks three miles.

I'm looking forward to going home.

Erm...

I've been told to expect to feel very tired

but to keep exercising...

by walking once we get home.

Erm...

there will be some ups and downs, inevitably.

So you cope with them and come out the other end of that.

There will be dips and they are quite severe.

Anyone who thinks there won't be is kidding themselves, basically.

Simon must now wait to find out if his cancer has spread.

The pathology lab results are expected in a week.

In intensive care, Janice is doing well.

-We're going to hang on to her tonight.

-That's fine. OK.

I'm not going to send her out today.

I want you to lean forward

and we're just going to help you over here.

Really push with your good leg.

If her progress continues, she will soon be able to leave intensive care

and recover on a general ward.

Tuck your bottom in. Tuck your bottom in.

Well done.

So push through your arms.

Look up. That's it.

Take a big breath in for me.

-Well done.

-Big breath.

Hello, world.

Janice is out to get you.

Oh, dear.

Hello, Mrs Medcalf. It's great to see you out of bed.

You get your chest going again and I think that makes the potential

for you to be home in a week or two real,

as opposed to what might be a month or two otherwise.

-So, really important, OK?

-Yes.

-All right.

-Thank you very much.

Sorry?

-Thank you so much.

-No, it's a pleasure.

-We'll try and get you right as soon as we can, all right?

-Thank you.

Five days after his operation, George Reese's patient Eladio

is well enough to go home.

He doesn't need any further treatment.

The cancer he has was completely removed

and there was no sign that it had spread

anywhere else around his body,

which is the best result we could have hoped for.

Some weeks are more emotionally challenging than others

and I think this week has been one of those weeks,

that emotionally we've, kind of, put ourselves through the wringer.

The organisation chose me to do this role because I'm resilient.

Don't get me wrong, it's not like I don't go home some days,

walk through the front door, and start crying, because I do.

I've never done it in the office, I'll always wait until I get home,

but I do because I've had a day that, sometimes you think,

that was the day from hell,

I don't know what went so horribly wrong there,

but it's gone because I've got to make it right the next day.

The pathology team has concluded its analysis of Simon's tumour.

They must now disclose the results to Professor Hanna.

OK, let's start. The first patient.

Simon A.

So here is the lumen, here you can see some normal mucosa,

but in all the blocks we examined,

there's just a single focus of cancer, which is here...

..in the oesophagus.

-All margins are negative, so...?

-I should have said it was.

It's a very good response.

I think sometimes it would feel like all we do all day is manage beds.

Actually, what we manage here are people who need us

to help them.

That's what we really do.

The tumour is only in the inner surface of the oesophagus,

in the very first layer.

All the margins are clear so...

you continue to be a lucky man.

Thank you.

So we'll keep an eye on you and see you for the next year

-every three months.

-I can start feeding him again now.

Shove lots of food into him.

-Thanks very much for all your help.

-Well done.

-LESLEY:

-'We can never predict what's going to happen to a patient

'when they've left us on the next part of their journey.

'We can't see into the future,

'all we can do is the here and now for people.'

It really is as if we've been in a thick fog

and now we can see the sunshine, which is great.

-LESLEY:

-'We go home knowing that that day

'we cared and we did everything we could have done for our patients.

'The heart of what hospitals do is have people in them

'who have a tremendous respect for life but also an understanding

'that sometimes we can't always save that life.'

SIREN

Next time, a busy A&E must contend with a suspected brain injury.

You know, he's 21 years of age, he's got a little baby.

One of the hospital's oldest patients is ready to leave,

but the problems begin when they try to discharge her.

It's a farce, really.

It could be made into a comedy.

And a specialist team is assembled

for a complex and challenging operation.

It's been amazing, the bringing together of all this expertise

just for Peter.

What choices would you make

when faced with complex health care decisions?

Visit our interactive pages to find out how you would respond.

Go to...

and follow the links to the Open University.