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