0:00:02 > 0:00:05Last month, a major incident was declared
0:00:05 > 0:00:08at the Royal Victory Hospital's Emergency Department in Belfast,
0:00:08 > 0:00:13as staff became overwhelmed by an influx of sick patients.
0:00:13 > 0:00:15From the outside, it looked like chaos.
0:00:18 > 0:00:22It reminded me of a war picture. You know, like a disaster film.
0:00:22 > 0:00:24There was no organisation.
0:00:24 > 0:00:27It's a volcano and last night it erupted.
0:00:27 > 0:00:30It's got to the point where it's embarrassing to actually stand
0:00:30 > 0:00:32and watch doctors and nurses in tears,
0:00:32 > 0:00:35in tears simply because they're struggling.
0:00:36 > 0:00:40But the next day, those responsible for running the system set out
0:00:40 > 0:00:43to reassure the public that this was a unique event.
0:00:43 > 0:00:47This particular case was a one-off.
0:00:47 > 0:00:50They said it showed that the system worked under pressure.
0:00:50 > 0:00:54We got staff in and within a relatively short space of time,
0:00:54 > 0:00:55the system reacted well.
0:00:57 > 0:01:01Since then, health service managers have been quick to point out
0:01:01 > 0:01:04that the emergency medicine system is not in crisis,
0:01:04 > 0:01:06but is that really the case?
0:01:07 > 0:01:08For the last several weeks,
0:01:08 > 0:01:10Spotlight has been investigating the state
0:01:10 > 0:01:12of our emergency departments here in Northern Ireland.
0:01:12 > 0:01:15We've been speaking to doctors and nurses
0:01:15 > 0:01:16who work in emergency medicine,
0:01:16 > 0:01:19doctors and nurses who say that time and again,
0:01:19 > 0:01:21they've been warning their managers
0:01:21 > 0:01:23that the system is putting patients at risk.
0:01:23 > 0:01:27We've also uncovered evidence that unacceptably long waiting times
0:01:27 > 0:01:30have played a part in serious incidents
0:01:30 > 0:01:32in which two patients died.
0:01:32 > 0:01:36Have we evidence that shows that what we're dealing with
0:01:36 > 0:01:38- is safe or not safe?- Yes, we do.
0:01:38 > 0:01:40Here's a letter that talks about how waiting times
0:01:40 > 0:01:42have contributed to two deaths.
0:01:42 > 0:01:44One of the main considerations here
0:01:44 > 0:01:48is that these people waited too long and they died.
0:01:48 > 0:01:49Yeah, and we need to learn from that.
0:02:02 > 0:02:06HEARTBEATS
0:02:06 > 0:02:07When Carol Toland woke up
0:02:07 > 0:02:10on the morning of Wednesday the 8th of January,
0:02:10 > 0:02:12she knew that something was wrong.
0:02:12 > 0:02:15I was having pains in my chest,
0:02:15 > 0:02:17which was very unusual for me
0:02:17 > 0:02:18and I felt breathless
0:02:18 > 0:02:22and I said to Martin, "I don't feel the best at all."
0:02:22 > 0:02:24But I phoned my GP surgery.
0:02:24 > 0:02:26Carol's GP saw her immediately
0:02:26 > 0:02:29and decided she should go to hospital for tests.
0:02:29 > 0:02:32That would mean going to the Emergency Department
0:02:32 > 0:02:34of the Royal Victoria Hospital
0:02:34 > 0:02:38- and to get there, Carol needed an ambulance.- Ambulance Service.
0:02:38 > 0:02:42This is the headquarters of the Northern Ireland Ambulance Service.
0:02:42 > 0:02:46These dispatchers deal with up to 400 calls a day,
0:02:46 > 0:02:48with about 50 of those being emergencies.
0:02:48 > 0:02:51Tell me exactly what's happened.
0:02:51 > 0:02:54Wednesday the 8th of January started off as an average day
0:02:54 > 0:02:57for Brian McNeill, director of the Ambulance Service,
0:02:57 > 0:03:00but these days, with increasing demand and limited resources,
0:03:00 > 0:03:03even an average day is a busy one.
0:03:03 > 0:03:07We've doubled our 999 calls from 2000, the year 2000,
0:03:07 > 0:03:10- we've doubled the amount of 999 calls.- Why would that be?
0:03:11 > 0:03:15I think it's a combination - people are confused
0:03:15 > 0:03:18about how to access the system.
0:03:18 > 0:03:20The public's expectations are higher, I believe,
0:03:20 > 0:03:23and they demand an immediate response.
0:03:23 > 0:03:25SIREN BLARES
0:03:25 > 0:03:28In an emergency, an ambulance will still get to you
0:03:28 > 0:03:30in an average time of ten minutes.
0:03:31 > 0:03:34But Carol's chest pains had subsided,
0:03:34 > 0:03:36so her case wasn't an emergency.
0:03:36 > 0:03:40She would have to wait considerably longer for her transfer to hospital.
0:03:40 > 0:03:43It was just two hours we had to sort of kill,
0:03:43 > 0:03:45waiting on the ambulance coming.
0:03:45 > 0:03:49The ambulance arrived at 2pm and transferred Carol the short distance
0:03:49 > 0:03:52to the Emergency Department of the Royal Victoria Hospital.
0:03:53 > 0:03:56She was brought in on an ambulance trolley.
0:03:57 > 0:03:58To Carol and Martin,
0:03:58 > 0:04:02it was obvious that the department was under pressure.
0:04:02 > 0:04:04Once they'd stationed me on the trolley,
0:04:04 > 0:04:07my back was to the action, but Martin was standing beside me
0:04:07 > 0:04:13and he says, "God, Carol, all you can see is beds and wheelchairs."
0:04:13 > 0:04:18There was no room even for Martin to get a chair to sit down beside me.
0:04:18 > 0:04:22The nurses and doctors were swerving in and out of beds sideways.
0:04:22 > 0:04:24At the nurses' station,
0:04:24 > 0:04:28there was ten trolleys sitting there with people on them.
0:04:28 > 0:04:32There was wheelchairs sitting beside them as well.
0:04:32 > 0:04:35The nursing staff couldn't actually move.
0:04:37 > 0:04:40Carol and Martin settled in for a long wait.
0:04:40 > 0:04:45As the afternoon went on, they saw other patients waiting in distress.
0:04:45 > 0:04:48The wee lady beside me was blind. She wanted to go to the toilet.
0:04:48 > 0:04:52She kept shouting she'd been there from 9am.
0:04:52 > 0:04:55She obviously knew when someone was walking past her
0:04:55 > 0:04:57and she kept calling for someone,
0:04:57 > 0:04:59"I want to go to the toilet."
0:04:59 > 0:05:03Eventually a nurse took her to the toilet.
0:05:03 > 0:05:06It's not acceptable, is it, that people should be in that situation?
0:05:06 > 0:05:07No, it's not.
0:05:07 > 0:05:10It's not, and I wouldn't sit here and say for one second
0:05:10 > 0:05:12that it's acceptable.
0:05:12 > 0:05:15By the late afternoon, three and a half hours into Carol's wait,
0:05:15 > 0:05:18pressure on staff and resources was building.
0:05:18 > 0:05:21The Chief Executive of the Belfast Trust was informed
0:05:21 > 0:05:25that the Emergency Department, or ED, was unusually busy.
0:05:25 > 0:05:29I was in our Emergency Department from about half four.
0:05:29 > 0:05:31At that point in the evening,
0:05:31 > 0:05:35we did have in the high 20s of trolley waits
0:05:35 > 0:05:38and we had just over 80 people in our Emergency Department.
0:05:38 > 0:05:41That brings with it a lot of pressure.
0:05:41 > 0:05:45I left the site at about half six.
0:05:45 > 0:05:48By that stage there were a few more trolley waits
0:05:48 > 0:05:51and there were over 90 people in our ED department.
0:05:52 > 0:05:5515 minutes later, at 6:45pm,
0:05:55 > 0:05:57dispatchers at ambulance headquarters were asked
0:05:57 > 0:06:02by the Royal's Emergency Department to divert non-emergency ambulances
0:06:02 > 0:06:04to other hospitals.
0:06:04 > 0:06:08By 7pm, the Royal issued a request that is very rare.
0:06:08 > 0:06:11Even emergency ambulances, from some parts of Belfast,
0:06:11 > 0:06:13were asked to stay away.
0:06:15 > 0:06:20999 diverts are more the exception than the norm, very infrequent,
0:06:20 > 0:06:23because of the consequences and the risks to patients.
0:06:23 > 0:06:26So they are very, very infrequent and only in extremis.
0:06:26 > 0:06:28FRANTIC CHATTER
0:06:30 > 0:06:32By now there were over 100 people
0:06:32 > 0:06:34in the Emergency Department waiting room
0:06:34 > 0:06:37and 42 waiting on trolleys.
0:06:37 > 0:06:38Carol was one of them.
0:06:38 > 0:06:40She says the situation was chaotic.
0:06:41 > 0:06:46They kept calling me by another name. They kept getting patients mixed up.
0:06:46 > 0:06:48"Are you Mrs So and So?" "No."
0:06:48 > 0:06:51The nurses were going up and down these lines looking for...
0:06:53 > 0:06:56It kept reminding me of a war picture
0:06:56 > 0:06:58where they shout out a name.
0:06:58 > 0:07:01You know, like a disaster film where they shout out a name,
0:07:01 > 0:07:02"Yes, that's me."
0:07:02 > 0:07:05That's what it was like, "Are you Mrs So and So?" "No."
0:07:05 > 0:07:08I was confident it wasn't chaotic and disorganised.
0:07:08 > 0:07:12At 8:30pm, Colm Donaghy convened a conference call
0:07:12 > 0:07:14with senior clinical staff.
0:07:14 > 0:07:15By now it was clear
0:07:15 > 0:07:18that there weren't enough doctors and nurses in the hospital
0:07:18 > 0:07:19to deal with the patients.
0:07:19 > 0:07:23Part of the issue was, for example, we'd exhausted the wards,
0:07:23 > 0:07:25we'd exhausted our bank.
0:07:25 > 0:07:28The agencies were indicating to us that they couldn't provide
0:07:28 > 0:07:31nurses of sufficient skill to us to open additional beds,
0:07:31 > 0:07:34so we didn't open additional beds.
0:07:34 > 0:07:38At 9:28pm, a major incident was declared.
0:07:38 > 0:07:41One minute later, off-duty staff were contacted by pager
0:07:41 > 0:07:44and told to report for work immediately.
0:07:44 > 0:07:46My initial reaction was one of surprise,
0:07:46 > 0:07:50because we've never had a major incident declared
0:07:50 > 0:07:51from an ED department,
0:07:51 > 0:07:54as a consequence of congestion.
0:07:54 > 0:07:57I was surprised by that, but major incidents come
0:07:57 > 0:08:00in a whole variety of guises and forms.
0:08:00 > 0:08:03I think it is for the staff at that point in time
0:08:03 > 0:08:06and we're very clear about that, it is their call.
0:08:06 > 0:08:09They are the people who are right beside the issue.
0:08:09 > 0:08:10The plan worked.
0:08:10 > 0:08:15Within an hour, 9 consultants and 24 nurses had joined the team
0:08:15 > 0:08:18and they worked frantically to clear the congestion.
0:08:18 > 0:08:21By midnight, most people had been moved off trolleys
0:08:21 > 0:08:22and into the hospital.
0:08:22 > 0:08:24Carol was one of them.
0:08:24 > 0:08:27She says that despite her nightmare wait,
0:08:27 > 0:08:30she has nothing but admiration for the staff.
0:08:30 > 0:08:33They kept stopping and asking how much pain I was in.
0:08:34 > 0:08:35Was I in any discomfort.
0:08:37 > 0:08:41So what exactly happened that day at the Royal Victoria Hospital?
0:08:41 > 0:08:44What was it that turned what should have been a routine mid-week shift
0:08:44 > 0:08:46into a major incident?
0:08:46 > 0:08:48Well, that depends on who you talk to.
0:08:49 > 0:08:51The day after the major incident,
0:08:51 > 0:08:53Health Minister Edwin Poots said it was
0:08:53 > 0:08:56an unusual and unpredictable event
0:08:56 > 0:08:58that didn't mean the system was in crisis.
0:08:58 > 0:09:01Well, there is 100 people in ED and 42 on trolleys.
0:09:01 > 0:09:05The response was to get more staff there to deal with the backlog.
0:09:05 > 0:09:06The backlog was dealt with.
0:09:06 > 0:09:08So we had an unusual spike,
0:09:08 > 0:09:13an unreasonable spike in the numbers that were coming through.
0:09:13 > 0:09:15Health service managers are keen to point out
0:09:15 > 0:09:17the incident doesn't point to a wider problem.
0:09:19 > 0:09:22I don't think there is a crisis in emergency medicine.
0:09:22 > 0:09:25They are very busy at times and they can be congested
0:09:25 > 0:09:30and occasionally the personal experience for individual patients
0:09:30 > 0:09:33can be unpleasant and I'm sure it also feels very stressed
0:09:33 > 0:09:34and pressurised for staff
0:09:34 > 0:09:37but I don't believe "crisis" is the right word.
0:09:37 > 0:09:39We asked the senior medical consultants
0:09:39 > 0:09:43at the Royal's Emergency Department to take part in this programme.
0:09:43 > 0:09:48Some raised serious concerns but none was prepared to speak publicly.
0:09:48 > 0:09:52At the moment people are scared to speak out, both doctors and nurses.
0:09:52 > 0:09:53They shouldn't be.
0:09:53 > 0:09:55They shouldn't be, it's as simple as that.
0:09:55 > 0:09:58- But they are.- But they shouldn't be.
0:10:00 > 0:10:04Irrespective of whether they feel a sense of intimidation
0:10:04 > 0:10:08in the employment system and whatever,
0:10:08 > 0:10:10or not, they have an obligation to do so.
0:10:10 > 0:10:13If you look at their actual professional obligations,
0:10:13 > 0:10:15they don't have a choice in the matter.
0:10:15 > 0:10:17They have an obligation to do so.
0:10:17 > 0:10:19The consultants did, however, provide us
0:10:19 > 0:10:21with this written statement,
0:10:21 > 0:10:23passed on to us on the understanding
0:10:23 > 0:10:26that it was on behalf of all the staff consultants
0:10:26 > 0:10:27in emergency medicine.
0:10:27 > 0:10:29In this statement, the consultants say...
0:10:36 > 0:10:39They welcome the recent review ordered by Edwin Poots
0:10:39 > 0:10:40and they say...
0:10:46 > 0:10:50We were given a more detailed insight into those complaints.
0:10:50 > 0:10:53The medical staff we spoke to didn't want to appear on camera
0:10:53 > 0:10:58but we have been shown e-mails from a range of senior doctors
0:10:58 > 0:11:00to senior managers at the Belfast Trust.
0:11:00 > 0:11:03These e-mails date back several months
0:11:03 > 0:11:04and they specifically point out
0:11:04 > 0:11:09how understaffing and excessive trolley waits have been, at times,
0:11:09 > 0:11:11compromising the safety of patients.
0:11:12 > 0:11:15Colm Donaghy admits that he and his staff got the e-mails.
0:11:15 > 0:11:18Some of the e-mails would highlight that they feel
0:11:18 > 0:11:20when we are under extreme pressure
0:11:20 > 0:11:22that sometimes safety can be compromised.
0:11:22 > 0:11:24We accept that.
0:11:24 > 0:11:26So you accept...
0:11:26 > 0:11:29They're saying safety is compromised at periods of extreme pressure
0:11:29 > 0:11:30and you accept that is the case.
0:11:30 > 0:11:33It has to be managed. It's managed by them professionally.
0:11:33 > 0:11:36It is not being managed well enough, is it?
0:11:36 > 0:11:38We've seen some of this correspondence.
0:11:38 > 0:11:40It goes back months
0:11:40 > 0:11:44and we're told some of it goes back years.
0:11:45 > 0:11:47This doesn't look good for you, does it,
0:11:47 > 0:11:49or the Trust, if you have senior medical consultants,
0:11:49 > 0:11:52over a period of years,
0:11:52 > 0:11:54saying this place is unsafe at times.
0:11:54 > 0:11:56Well, over those years, Declan,
0:11:56 > 0:11:59what you can't ignore is the level of reform
0:11:59 > 0:12:03and the changes that we have brought about in Belfast
0:12:03 > 0:12:06to manage services more safely.
0:12:06 > 0:12:09One of those e-mails was sent on the 7th of January,
0:12:09 > 0:12:12the day before the major incident was declared.
0:12:12 > 0:12:15It's from a consultant, addressed to his bosses.
0:12:15 > 0:12:17He is talking about some of the things
0:12:17 > 0:12:20he witnessed during his shift in the Emergency Department.
0:12:20 > 0:12:22He says,
0:12:22 > 0:12:25"The most appalling example was an elderly patient
0:12:25 > 0:12:27"found hanging off the end of an ED trolley
0:12:27 > 0:12:30"with fresh faeces dripping down her legs.
0:12:30 > 0:12:32"This is one of the most disgraceful things
0:12:32 > 0:12:36"I have had the misfortune of witnessing in my entire career."
0:12:36 > 0:12:39That's appalling that someone has to write a letter like that
0:12:39 > 0:12:40up the chain.
0:12:40 > 0:12:43I think it's not acceptable that something like that would happen
0:12:43 > 0:12:47and that would be the experience that a patient would have in her ED.
0:12:47 > 0:12:50I'm very keen that that's not repeated
0:12:50 > 0:12:52and that's not something that we accept
0:12:52 > 0:12:56as a part of the ongoing care we provide for patients in our ED.
0:12:56 > 0:12:59What would you say to that lady or her family?
0:12:59 > 0:13:02I would apologise to them for the experience they've had.
0:13:02 > 0:13:05The e-mail, like others we've seen,
0:13:05 > 0:13:09goes on to raise concerns about the safety of patients.
0:13:09 > 0:13:12How many times have medical and nursing staff
0:13:12 > 0:13:16complained to the Trust and the board that safety
0:13:16 > 0:13:19is an issue and patients are at too much risk?
0:13:19 > 0:13:24I think I have never heard anybody say very directly to me,
0:13:24 > 0:13:26"I am working in an unsafe place",
0:13:26 > 0:13:28because, frankly, I don't believe
0:13:28 > 0:13:31that professionals would continue to work in that way.
0:13:31 > 0:13:33I think they would do different things
0:13:33 > 0:13:36and they would be obligated to do different things.
0:13:36 > 0:13:38But isn't it the case that over several months,
0:13:38 > 0:13:40if not years, there have been e-mails,
0:13:40 > 0:13:42and I've seen some of those e-mails,
0:13:42 > 0:13:44where clinical staff, consultants
0:13:44 > 0:13:49and nursing staff have been telling their bosses this is unsafe, at times?
0:13:51 > 0:13:54I'm sure you have that sort of information.
0:13:54 > 0:13:56I guess the difficulty about that is,
0:13:56 > 0:13:57as you know yourself,
0:13:57 > 0:14:01e-mails are a conversation and people can have a conversation
0:14:01 > 0:14:05and the word "safety" can come into the conversation and that's different
0:14:05 > 0:14:08from actually having an absolute statement about safety or otherwise.
0:14:08 > 0:14:12These e-mails certainly read like absolute statements.
0:14:12 > 0:14:15They come from a number of consultants and the concern
0:14:15 > 0:14:18they all have in common is patient risk and patient safety.
0:14:18 > 0:14:20They are addressed to managers in the Trust
0:14:20 > 0:14:23and copied to their fellow doctors.
0:14:23 > 0:14:26One of them, which alleges chronic understaffing,
0:14:26 > 0:14:27is copied to Colm Donaghy,
0:14:27 > 0:14:31the Chief Executive of the Belfast Trust.
0:14:31 > 0:14:33When you get these e-mails from consultants
0:14:33 > 0:14:36talking about potential safety compromises,
0:14:36 > 0:14:41do you pass those up to John Compton at the board or to the minister?
0:14:41 > 0:14:42No, not the actual e-mails.
0:14:42 > 0:14:45We have the conversations about the pressures
0:14:45 > 0:14:49that exhibit as a part of that and I've had discussions
0:14:49 > 0:14:53with the Health and Social Care Board, including John,
0:14:53 > 0:14:54in relation to some of the e-mails
0:14:54 > 0:14:57but I haven't shared the actual e-mails with him.
0:14:57 > 0:15:01He says he hasn't seen them.
0:15:01 > 0:15:04Isn't it the case that, as the Healthcare Commissioner,
0:15:04 > 0:15:07or indeed the minister, people like that should be made aware
0:15:07 > 0:15:10of those concerns because they are safety concerns?
0:15:10 > 0:15:11They are very serious.
0:15:11 > 0:15:15They are serious concerns and we deal with them as a part of our system.
0:15:15 > 0:15:18What we make the Health and Social Care Board aware of
0:15:18 > 0:15:21is the fact that the concerns have been raised with us
0:15:21 > 0:15:25and that we need to work through a process. That's where we are.
0:15:26 > 0:15:29Spotlight has also been speaking to nurses,
0:15:29 > 0:15:32who say that they are working under intolerable pressure
0:15:32 > 0:15:34and that the system is to blame.
0:15:34 > 0:15:36They've asked us to hide their identities
0:15:36 > 0:15:39so we've reconstructed their interviews using actors.
0:15:39 > 0:15:42The system is at complete breaking point.
0:15:42 > 0:15:45The Health Minister needs to stop the party line of,
0:15:45 > 0:15:48"We're all working hard and we're all coping."
0:15:48 > 0:15:50The first thing people would appreciate
0:15:50 > 0:15:53is acknowledgement that we're in trouble.
0:15:53 > 0:15:54For the staff we spoke to,
0:15:54 > 0:15:58the biggest issue by far was trolley waits -
0:15:58 > 0:16:01patients who had been processed by the Emergency Department
0:16:01 > 0:16:03and who are waiting for a bed in hospital.
0:16:03 > 0:16:06They are all coming in the front door but then the back door isn't open
0:16:06 > 0:16:08so it clogs and clogs.
0:16:08 > 0:16:11You also don't have the cubicle space to treat your patients
0:16:11 > 0:16:14with the respect and dignity that they deserve.
0:16:14 > 0:16:18The nurses we spoke to said the system is having a serious effect
0:16:18 > 0:16:20on the morale of Emergency Department staff.
0:16:21 > 0:16:23We are the ones who have to face people and say,
0:16:23 > 0:16:25"I'm sorry your 90-year-old mother
0:16:25 > 0:16:27"is still on a trolley at 11 hours."
0:16:28 > 0:16:32You can imagine saying that to somebody time and time again
0:16:32 > 0:16:34over the space of a few years.
0:16:34 > 0:16:36How would that make you feel?
0:16:36 > 0:16:37In the last five years,
0:16:37 > 0:16:42Northern Ireland has lost 18% of its hospital beds.
0:16:42 > 0:16:46The Belfast Trust alone has lost 20% of its beds in that time.
0:16:46 > 0:16:49Isn't it the case that there just aren't enough beds?
0:16:49 > 0:16:51The reason why there are so many trolley waits
0:16:51 > 0:16:54is that beds are being lost, year on year,
0:16:54 > 0:16:57there aren't enough beds to take people out of emergency departments
0:16:57 > 0:16:58and put them into hospital.
0:16:58 > 0:17:01I don't think you can say that or come to that conclusion.
0:17:01 > 0:17:04The changing pattern of medical care is tremendous
0:17:04 > 0:17:07so the dependence on beds is not what it was once
0:17:07 > 0:17:11in terms of the ability to treat and manage individuals.
0:17:11 > 0:17:13The death rate has stayed very static over...
0:17:13 > 0:17:15This is Hugh McCloy.
0:17:15 > 0:17:18He's a campaigner for better health provision in Northern Ireland.
0:17:18 > 0:17:21Over the years, he's built up contacts inside hospitals
0:17:21 > 0:17:24who tell him when the system is struggling.
0:17:24 > 0:17:25This is where we are now.
0:17:25 > 0:17:27On the week beginning the 5th of January,
0:17:27 > 0:17:30Hugh noticed that something worrying was happening
0:17:30 > 0:17:33in emergency departments across Northern Ireland.
0:17:33 > 0:17:36Antrim's Emergency Department had to open up an extra ward
0:17:36 > 0:17:38because it became inundated with patients.
0:17:38 > 0:17:41Soon afterwards, Altnagelvin and Craigavon hospitals
0:17:41 > 0:17:43had to turn away ambulances.
0:17:43 > 0:17:48So, first of all, on Sunday the 5th of January 2014,
0:17:48 > 0:17:53you see Antrim opening up a second assessment unit and importing beds.
0:17:53 > 0:17:59- Yes.- And then you have Altnagelvin - starts to turn away ambulances.- Yep.
0:17:59 > 0:18:01Then you have a major incident at the Royal.
0:18:01 > 0:18:03It's almost like it feels like a domino effect.
0:18:03 > 0:18:07It is. Quite simply, when one hospital closes its doors,
0:18:07 > 0:18:08the patients have to go elsewhere.
0:18:08 > 0:18:12So, whenever Antrim began to limit its admissions,
0:18:12 > 0:18:15people started going to the Causeway, Altnagelvin, Craigavon
0:18:15 > 0:18:16and the Royal.
0:18:16 > 0:18:19It's quite simple. If there was a larger incident happening,
0:18:19 > 0:18:20only knows what would happen.
0:18:20 > 0:18:23I think the incident you refer to in Altnagelvin
0:18:23 > 0:18:26was a major incident because there was a five-car pile-up.
0:18:26 > 0:18:29and they were unclear early on from the five-car pile-up
0:18:29 > 0:18:32about how many major casualties they would receive
0:18:32 > 0:18:34in the middle of all of that.
0:18:34 > 0:18:37That's normal business for emergency departments.
0:18:37 > 0:18:40I don't think that you could conclude
0:18:40 > 0:18:43that that was a sign that, in Northern Ireland, if you like,
0:18:43 > 0:18:46the emergency system was teetering.
0:18:46 > 0:18:49The emergency system was working in its normal way.
0:18:50 > 0:18:52So, what is normal?
0:18:52 > 0:18:54Well, according to the health care professionals
0:18:54 > 0:18:55we've been speaking to,
0:18:55 > 0:18:59periods of extreme pressure are becoming the norm
0:18:59 > 0:19:03and while declaring a major incident may have been a unique response,
0:19:03 > 0:19:06the pressures which led to it are all too common.
0:19:07 > 0:19:12It is not a one-off in terms of an ED department being as busy as that.
0:19:12 > 0:19:13It happens frequently.
0:19:15 > 0:19:17It was a one-off in that it was declared as a major incident.
0:19:17 > 0:19:21That's what made it unique on that night.
0:19:21 > 0:19:23The figures tell their own story.
0:19:23 > 0:19:27Emergency departments in England see just under 94% of people
0:19:27 > 0:19:28within four hours.
0:19:28 > 0:19:29By December last year,
0:19:29 > 0:19:33hospitals here in Northern Ireland were seeing just 72% of people.
0:19:35 > 0:19:37In the same month, the Royal Victoria Hospital
0:19:37 > 0:19:41managed to deal with just 62% of people within four hours.
0:19:42 > 0:19:45Dr Brian Fisher was an Emergency Department consult
0:19:45 > 0:19:47at the Royal Victoria Hospital.
0:19:47 > 0:19:49He retired three years ago.
0:19:49 > 0:19:54Even then, he says the system was constantly on the verge of crisis.
0:19:54 > 0:19:56The nursing staff in the department
0:19:56 > 0:19:58are not only trying to deal with the patients
0:19:58 > 0:20:01who are coming into the department that they should be dealing with,
0:20:01 > 0:20:04but also trying to do the job of a ward nurse
0:20:04 > 0:20:07in looking after these people as well.
0:20:07 > 0:20:11Were you surprised when the major incident was declared at the Royal?
0:20:11 > 0:20:16I'm retired now three years, but even whenever I was working
0:20:16 > 0:20:17there were times when the department
0:20:17 > 0:20:21was very close to complete saturation,
0:20:21 > 0:20:24and therefore it wasn't a surprise to hear that
0:20:24 > 0:20:28it had got behind crisis point, shall we say.
0:20:28 > 0:20:31The doctors we've been speaking to here, still working at the Royal
0:20:31 > 0:20:33today, say that at times the pressures here
0:20:33 > 0:20:37can reach crisis point, and that's a particular problem at weekends
0:20:37 > 0:20:39and during out-of-hours periods.
0:20:39 > 0:20:41The big question, of course,
0:20:41 > 0:20:45is whether those pressures have ever compromised patient safety.
0:20:45 > 0:20:48The medical and nursing staff we've been speaking to say that
0:20:48 > 0:20:53most of the time the Emergency Department in the Royal is safe,
0:20:53 > 0:20:57but at weekends and out of hours it can become unsafe
0:20:57 > 0:20:59and has done in the past. Do you accept that?
0:20:59 > 0:21:04No, well, what I would say is that the risks are higher out of hours.
0:21:04 > 0:21:06Which means it has become unsafe.
0:21:06 > 0:21:08No, it doesn't necessarily mean it's become unsafe,
0:21:08 > 0:21:12because as I said, we avoid the department becoming unsafe.
0:21:12 > 0:21:15So, for example, the reason I took the decision
0:21:15 > 0:21:19to call the major incident or trigger the major incident protocol
0:21:19 > 0:21:22was to avoid the department becoming unsafe.
0:21:22 > 0:21:25But we've uncovered further disturbing evidence that excessive
0:21:25 > 0:21:30waiting times have had serious consequences for patients.
0:21:30 > 0:21:33This document was distributed to all Trusts in Northern Ireland
0:21:33 > 0:21:36after two serious incidents at the Royal Victoria Hospital's
0:21:36 > 0:21:38Emergency Department.
0:21:38 > 0:21:41We were given it by someone who's concerned about patient safety
0:21:41 > 0:21:45and who believes that incidents like this need to be exposed.
0:21:45 > 0:21:48This document describes how two patients died
0:21:48 > 0:21:50after receiving substandard care.
0:21:50 > 0:21:54It's what's known in the profession as a Serious Adverse Incident.
0:21:54 > 0:21:56The document is known as a learning letter,
0:21:56 > 0:21:58distributed widely to medical professionals
0:21:58 > 0:22:02and hospital managers so they can learn lessons from what went wrong.
0:22:04 > 0:22:07Now, in these incidents, which we're told happened last year,
0:22:07 > 0:22:10there were delays in diagnosing what was wrong
0:22:10 > 0:22:13with two separate patients, but those initial delays
0:22:13 > 0:22:16were compounded by the fact that the patients then had to wait longer
0:22:16 > 0:22:19than they should have to get treated.
0:22:19 > 0:22:20Now this report is very clear.
0:22:20 > 0:22:24One of the contributing factors in these Serious Adverse Incidents
0:22:24 > 0:22:26was waiting times.
0:22:26 > 0:22:30Have we evidence that shows that what we're dealing with
0:22:30 > 0:22:34in terms of our services is safe or not safe?
0:22:34 > 0:22:35Yes, we do. Here's some.
0:22:35 > 0:22:38That's a Serious Adverse Incident learning letter
0:22:38 > 0:22:42that talks about how waiting times have contributed to two deaths.
0:22:42 > 0:22:46But of course you have an issue of a Serious Adverse Incident.
0:22:46 > 0:22:48You'll appreciate I know the case
0:22:48 > 0:22:50and I can't talk of the detail of the case.
0:22:50 > 0:22:53Serious Adverse Incidents, in my experience, are a combination
0:22:53 > 0:22:55- of events.- But my question is...
0:22:55 > 0:23:00Here is a learning letter regarding a Serious Adverse Incident,
0:23:00 > 0:23:03two different ones, two different patients, two different deaths.
0:23:03 > 0:23:06Waiting times implicated as one factor.
0:23:06 > 0:23:09My question is how many other Serious Adverse Incidents
0:23:09 > 0:23:13in the last six months have had waiting times as a factor?
0:23:13 > 0:23:15Erm... I can't give you an exact number.
0:23:15 > 0:23:20I can tell you the numbers in terms of whether there is waiting times
0:23:20 > 0:23:25or not. But the issue for me is that we have 700,000 people go through
0:23:25 > 0:23:26our ED departments.
0:23:26 > 0:23:30The ability for us to go through with 700,00 people in the year
0:23:30 > 0:23:33and not have an adverse incident, I think everyone will understand that's
0:23:33 > 0:23:36highly improbable and unlikely.
0:23:36 > 0:23:39And therefore, I think, is the scale of that huge?
0:23:39 > 0:23:43No, the scale of that is not huge. It is absolutely not huge.
0:23:43 > 0:23:46The learning letter is the only documentary evidence that we have
0:23:46 > 0:23:51of a Serious Adverse Incident which had waiting times as a factor,
0:23:51 > 0:23:53but we've been led to believe it's not the only time
0:23:53 > 0:23:55that that's happened.
0:23:55 > 0:23:57How many more Serious Adverse Incidents have there been
0:23:57 > 0:23:59where people have waited too long?
0:23:59 > 0:24:04Well, it's difficult, but it would be single figures.
0:24:04 > 0:24:07I mean, we've been told it could be nine. Would that be...?
0:24:07 > 0:24:12No, it's not as high as nine. I think at this point it's about four.
0:24:12 > 0:24:14But I don't have those figures in front of me.
0:24:14 > 0:24:17In how long? In the last six months? The last year?
0:24:17 > 0:24:19No, that would be over the last couple of years,
0:24:19 > 0:24:22and that's in the context that over that period of time
0:24:22 > 0:24:25we would've had about 160,000 attendances in our ED.
0:24:25 > 0:24:28But nobody should be dying because they're waiting too long.
0:24:28 > 0:24:31Well, actually, there's a multiple of factors. It wasn't just...
0:24:31 > 0:24:34When you read that you'll see there's a multitude of factors
0:24:34 > 0:24:38that pertain to those particular cases. Not just the waiting...
0:24:38 > 0:24:41The waiting time was a contributing factor, but not the only factor.
0:24:41 > 0:24:44We interviewed Colm Donaghy yesterday.
0:24:44 > 0:24:47This morning, his subordinate medical director, Dr Tony Stevens,
0:24:47 > 0:24:51pointed out that the true figure for deaths involving waiting times
0:24:51 > 0:24:53was five in the past year alone.
0:24:54 > 0:25:00I asked you earlier, did the department ever become unsafe?
0:25:00 > 0:25:04Now, clearly, this shows that it did.
0:25:04 > 0:25:09For that individual, yes, the department was at a point
0:25:09 > 0:25:13where it had an impact on the outcome for that individual patient.
0:25:13 > 0:25:14That's right.
0:25:14 > 0:25:18Whether or not that meant the entire department was unsafe
0:25:18 > 0:25:20is something that I wouldn't agree with.
0:25:20 > 0:25:23But, obviously, it's a matter for interpretation.
0:25:23 > 0:25:27Hospital policy and good practice dictate that in incidents like this,
0:25:27 > 0:25:29both the family of the person involved
0:25:29 > 0:25:32and the coroner should be informed.
0:25:32 > 0:25:35Have you informed the families who are involved here
0:25:35 > 0:25:38that waiting times played a part in these incidents?
0:25:38 > 0:25:43I'm not aware of the detail of both, but I know certainly
0:25:43 > 0:25:44one of the families had been...
0:25:44 > 0:25:46It was subject of a Root Cause Analysis for us
0:25:46 > 0:25:49and one of the families has been very involved in relation to that.
0:25:49 > 0:25:51The other family, I'm not sure.
0:25:51 > 0:25:55But certainly it would be a part of our policy now that we would inform
0:25:55 > 0:25:57families of the reasons.
0:25:57 > 0:26:00- You would expect that a family would want to know...- Absolutely.
0:26:00 > 0:26:04..if the system played some kind of part in their loved one's death?
0:26:04 > 0:26:06Yes.
0:26:06 > 0:26:10So, will you be looking into informing the other family, if...
0:26:11 > 0:26:15If they haven't been informed? Of course, yes.
0:26:15 > 0:26:16What about the coroner?
0:26:16 > 0:26:19Does the coroner need to investigate something like that?
0:26:19 > 0:26:22Well, we work very, very closely with the coroner,
0:26:22 > 0:26:26working out the criteria and the details of when a case
0:26:26 > 0:26:29should be referred to the coroner or when the coroner should be involved.
0:26:29 > 0:26:30And has this one been referred?
0:26:30 > 0:26:33Well, I'm not sure whether it has or not. I don't know.
0:26:33 > 0:26:36It's something that I could look into,
0:26:36 > 0:26:39but I'm not sure if it's been referred to the coroner.
0:26:39 > 0:26:42This afternoon, the Belfast Trust confirmed that the coroner
0:26:42 > 0:26:43has been made aware.
0:26:47 > 0:26:50Last week, Health Minister Edwin Poots announced a review.
0:26:50 > 0:26:54He said he asked the hospital regulator, the RQIA,
0:26:54 > 0:26:56to look at how the acute medical department was working.
0:26:56 > 0:27:00In fact, we've learned that before the minister made that request,
0:27:00 > 0:27:04the medical consultants themselves had already written to the RQIA
0:27:04 > 0:27:06asking that they intervene.
0:27:06 > 0:27:09The regulator inspected the department and interviewed staff
0:27:09 > 0:27:11over the first weekend of February.
0:27:11 > 0:27:15That preliminary report by the RQIA was damning.
0:27:16 > 0:27:20The inspector spoke to more than 100 staff across a range of roles
0:27:20 > 0:27:23and functions. The inspection has confirmed concerns
0:27:23 > 0:27:27about staffing levels in key areas, allegations of bullying,
0:27:27 > 0:27:30staff under intolerable pressure and a system of care
0:27:30 > 0:27:34that does not function fully as it was set up to do.
0:27:34 > 0:27:42You must be concerned if you have the RQIA finding what they found
0:27:42 > 0:27:44two weeks ago. You have Serious Adverse Incidents
0:27:44 > 0:27:47in which patients are waiting too long, and you have
0:27:47 > 0:27:50your own senior consultants in the Emergency Department
0:27:50 > 0:27:53releasing a statement saying there needs to be an urgent transformation
0:27:53 > 0:27:55in the system.
0:27:55 > 0:27:58It all adds up to something that must be quite worrying for you?
0:27:58 > 0:28:00Yeah, it is quite worrying,
0:28:00 > 0:28:05but we're taking forward very strong action at this point in time.
0:28:05 > 0:28:08Some of it which we were already in training.
0:28:08 > 0:28:11So, for example, we'd already reviewed our nurse staffing levels
0:28:11 > 0:28:14in our ED prior to Christmas.
0:28:14 > 0:28:18We're now in a position to increase the numbers of nurse staffing
0:28:18 > 0:28:21in our ED. So we're employing an additional 14 nurses.
0:28:21 > 0:28:26We also wanted to ask Edwin Poots about the RQIA review,
0:28:26 > 0:28:29amongst many other things, such as why three weeks ago
0:28:29 > 0:28:32he sought to reassure the public that politicians and the media
0:28:32 > 0:28:35were exaggerating the crisis in the emergency departments,
0:28:35 > 0:28:38but now he has issues of serious concern about
0:28:38 > 0:28:42how the Royal Victoria Hospital's Emergency Department is run.
0:28:42 > 0:28:46We also wanted to ask him whether he knew of doctors' concerns
0:28:46 > 0:28:50about patients' safety, and if not, why not?
0:28:50 > 0:28:53But the minister declined to be interviewed for this programme.
0:28:53 > 0:28:57He did, however, give us a statement in which he said that he recognises
0:28:57 > 0:29:00the gravity of the situation, but that he wants to reassure the public
0:29:00 > 0:29:04that the Belfast Trust will continue to manage the risks
0:29:04 > 0:29:08and provide emergency services with the help of its dedicated staff.
0:29:09 > 0:29:12The medical and nursing staff we spoke to wanted to make it clear
0:29:12 > 0:29:15that most of the time the Emergency Department here at the Royal
0:29:15 > 0:29:19is safe for patients. But they said that during busy times
0:29:19 > 0:29:23and at weekends, that's not always the case.
0:29:23 > 0:29:25Politicians and health service managers are now rushing
0:29:25 > 0:29:28to change that, with new staff being added to the rota
0:29:28 > 0:29:31and a major review ongoing.
0:29:31 > 0:29:34But there's no doubt that some staff here think it should have happened
0:29:34 > 0:29:38a long time ago. And for some patients, it's too late.
0:29:39 > 0:29:42The people that work in this building, and others like it
0:29:42 > 0:29:43across Northern Ireland,
0:29:43 > 0:29:48deal with the rest of us during some of the worst moments of our lives.
0:29:48 > 0:29:53They do so day-in, day-out, often in stressful and difficult conditions.
0:29:53 > 0:29:57Now, many of them say, they have their own emergency,
0:29:57 > 0:30:00and finding a remedy for them should matter to us all.