Duty to Tell Spotlight


Duty to Tell

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Today, in a statement to the Assembly,

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Health Minister Edwin Poots

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was talking about solutions to problems

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in the Royal Victoria Hospital in Belfast. He promised

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more staff, better oversight and an improved system for patients.

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But he said that real change will take time.

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Tonight on Spotlight, we speak to some of the families

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for whom time has already run out -

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families whose loved ones died in remarkably similar circumstances

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-ten months apart.

-His clothes were covered in blood,

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his overcoat was absolutely drenched in blood.

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He had bled a lot.

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She had some bruising to her face

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and, clearly, needed treatment.

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We hear from a doctor, who says that change

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is not happening quickly enough.

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I would say that the clinical staff of the minute

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don't have faith in the management team and that

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the only way that faith can be restored

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is if positive changes are made very quickly.

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And we reveal disturbing new evidence which suggests that,

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as recently as three weeks ago,

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patient safety was still being compromised.

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Today, the Minister said it's important that the public still has

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confidence in the emergency medicine system,

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but neither he nor the Health & Social Care Board

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nor the Belfast Trust would agree to be interviewed for this programme.

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This is a story of how systemic failings in the emergency department

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of the Royal Victoria Hospital

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affected some patients and their families.

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It's also an investigation into what's still going wrong.

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Last month, Spotlight investigated the care being provided to patients

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in the emergency department of the Royal Victoria Hospital in Belfast.

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We revealed that last year five serious adverse incident reports

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at the hospital involved deaths where waiting times

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may have been a factor.

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It came as a shock to many.

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Last night's BBC Spotlight programme

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highlighted the cases of five patients.

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In that programme, we asked the Chief Executive of the Belfast Trust

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whether the families involved in two of the incidents had been informed

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that waiting times played a part in the deaths of their relatives.

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I'm not aware of the detail of both, but I know one of the families had.

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-You would expect that a family would want to know...

-Absolutely.

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..if the system played some kind of part in their loved one's death?

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-Yes.

-So, will you be looking into informing the other family, if...?

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If they haven't been informed? Of course, yes.

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It soon emerged that in three out of five cases

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families had been not informed that there were failings

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in how their loved ones were treated. The Health Minister

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quickly announced that all of the families that did not know

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something had gone badly wrong would now be told.

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The treatment and care that those five people had may well have

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fallen short and, therefore, we will have

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an appropriate investigation of that matter.

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Two days after the Spotlight programme was broadcast,

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we were contacted by Grainne and Bronagh Boyle.

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A year earlier, their grandfather Charlie Patterson

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had died in the Royal.

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As far as his family were concerned, he had received the best treatment

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he could have, until Grainne received a call

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from the Royal Victoria Hospital that would devastate her

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and the rest of the family.

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It was the day before Valentine's Day - the 13th, the Thursday.

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And at ten to five, my phone rang.

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There had been a report into my grandfather's death

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and they would like for us, as a family, to come and speak to them

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about that report.

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When five deaths may have a contributory factor...

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'An hour after, I sat down to watch the news'

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and then the full enormity really kicked in and, as I was

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watching these people speak, in my mind, I was thinking,

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"That is us. That's our family."

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And that is shameful. By anyone's standards, that is shameful.

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That was the first time that we had known anything about

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what had occurred.

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Charlie Patterson was 86.

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He lived his life surrounded by a close and loving family.

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Our granda was amazing. He was everything that your granda could be.

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He was our best friend.

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We were like the Three Musketeers, always together.

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Always together. You never seen one without the other two.

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It was unusual for us not to be together

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and every single day, we would go up to granda's in the evening

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and all have our meal together and it was very important,

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at the end of each evening, that we sat together and talk about our day.

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Charlie Patterson had some health concerns associated with old age,

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but he was still very active and went out walking every day.

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SIREN BLARES

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It was after attending Mass on 27 January, 2013

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that Charlie fell and hit his head. An ambulance was called.

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He arrived at the emergency department

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of the Royal Victoria Hospital at 7.10 in the evening.

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He was bleeding from a head wound, but his family were not informed.

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Charlie would lie on a trolley for the next seven hours alone.

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That's something his family find difficult to deal with.

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Personally I'm angry, because he was never alone.

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He was an incredibly social man and to think of him

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sitting there dazed and confused

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and on his own is quite upsetting.

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The details of what happened to Charlie Patterson that night

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are contained in here.

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This is an incident report, compiled not long after he died.

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This wasn't even shown to his family until just a few weeks ago,

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three days after the Spotlight investigation was broadcast.

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But it goes into great detail about the shortcomings in the care

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he received from the moment he entered the emergency department.

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The first problem was at the triage stage.

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Charlie was seen by a nurse 20 minutes

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after arriving in the department.

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She noted that he was confused, but he was able to tell her

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that he was on the blood-thinning drug, warfarin.

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Elderly patients on warfarin are at risk of profuse bleeding

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and haemorrhaging and the report says it would have been appropriate,

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at this point, for Charlie to have been given another drug,

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to reverse the effects of the warfarin.

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But he lay on a trolley for five hours before he was given that drug.

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It almost defies belief, in a way,

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that this could happen in a busy casualty department.

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The report reveals other significant problems with delays.

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A doctor should have examined Charlie within an hour.

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He didn't see one until three and a half hours into his wait.

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He should have received a CT scan soon after arrival

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in the emergency department. That didn't happen for four hours.

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For all of that time, he lay on a trolley alone,

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growing more and more unwell.

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His family had no idea he was there.

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It's just the fact those few hours would have been valuable,

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to say goodbye, to let him know that he wasn't on his own,

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that he didn't need to be afraid -

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the things you imagine you would do for the person you love.

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To bring him his little bits of comfort, like his rosary beads,

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or having his glasses.

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The small, stupid things that weren't probably done for him.

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He would have been confused, as to what was happening around him

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and, undoubtedly, he would have been afraid and I find that just,

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for someone who was so loved, I find that very difficult to reconcile.

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All in all, this report outlines a litany of errors,

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but what runs through it is the problem of delays.

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The reason given here for the delays is that the system was

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under pressure because a large number of patients

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who were in the department that night needed to be admitted

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to hospital and there were not enough beds for them to go to.

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The emergency department was simply log-jammed.

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Eventually, at 2.00am, Grainne and Bronagh

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were informed that their grandfather was seriously ill

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-in the emergency department.

-As soon as I arrived,

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I was immediately taken into a family room,

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but I was brought through the waiting area

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and it was chaos. The trolleys were just everywhere.

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It was like a Third World country, almost.

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It was like walking into a war zone.

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It had been only 12 hours since they had last seen their grandfather

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alive and well and on his way to Mass.

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Now, they were deeply shocked at what they saw.

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He was covered in blood and his clothes were covered in blood.

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He had bled a lot.

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A very nice, but very junior young doctor come in and she explained

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to us that the outcome was likely to be fatal.

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She was very upset. She seemed, sort of, visibly upset.

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As Grainne and Bronagh were shown in to see Charlie,

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other staff seemed upset, too.

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One of the nurses was crying and she had said to us,

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"I'm so sorry, I'm so sorry." We just assumed

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she was sorry because he had died and the end of any life is sad,

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but perhaps now, she was sorry

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because he had been treated so poorly.

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Gareth Martin is the union rep for the Royal College of Nursing.

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He told me that far too many patients,

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particularly the elderly, are suffering because the system

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just isn't working. You say old people

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are waiting in an environment that is not fit for purpose.

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What do you mean, that the emergency department

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at the Royal is not fit for purpose?

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Absolutely. When there's pressures of patients waiting to be admitted

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and you are hearing of large volumes of patients waiting six,

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eight, ten, 12 hours and longer,

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so the ability to provide dignified care is certainly compromised.

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This report explains why the department was overstretched that night.

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But it doesn't really answer the question of how an elderly man

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could have spent hours lying alone in a busy emergency department

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becoming more and more unwell,

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and not get the attention that he needed.

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I think there are numerous reasons he wasn't a priority.

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He sat in the corner quietly.

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He didn't cause a fuss.

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Although the Belfast Trust didn't want to be interviewed

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about Charlie Patterson's case, they did send us this statement.

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They say that what happened was a matter of deep regret to them

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and they say that Charlie's case was fully investigated

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and that they've learnt lessons.

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They also say that their policies and procedures about being open with

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families were not followed in this case and for that they are sorry.

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This statement leaves a lot of unanswered questions,

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particularly for the Boyle family, but because the Trust have decided

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not to do an interview we won't be hearing the answers.

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No-one will ever know for sure whether Charlie Patterson might have

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survived if he had got the treatment he needed in a timely fashion.

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The only thing that is clear is that he didn't get it.

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All the signals were there, all of them.

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And they were missed and they weren't missed once,

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they were missed time and time again.

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There are various opportunities where intervention

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may have had a different outcome,

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but time and time and time again, they just passed.

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What upsets Charlie's family more than anything else

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is that the hospital didn't see fit to inform them

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that so many mistakes had been made until a year after he had died.

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And only then, after the Spotlight investigation had revealed

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details of the five deaths.

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We specifically said to them, had this not broke in the media,

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would you have contacted us? And there was a non-response.

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It wasn't even an apology. They moved on to the next question.

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How did you feel about the fact that you hadn't been told,

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that you were shown this comprehensive report

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a year after he died?

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Angry. You feel resentful

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and disbelief that had the media not broke this story,

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that you would never have been any the wiser.

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We asked the Trust a direct question -

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had they discovered other families who haven't been informed

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about serious, adverse incidents involving their relatives?

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They sent us this statement

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and it says they're satisfied in the vast majority of cases

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families have been informed, but that they have identified a number

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of cases where the level of involvement

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is not what they would expect.

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Now, that sounds like a yes.

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And we would have pressed the Trust on that point in an interview,

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but because they won't meet us face-to-face on camera, we can't.

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This is Peter Walsh.

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Based in London, his charity, Action Against Medical Accidents,

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lobbies for patients' rights in the NHS.

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He's one of the leading patients' advocates in the UK,

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representing about 3,000 patients and their families every year.

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We asked him to come to Belfast to review Charlie Patterson's case

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and some of the others that have come to light.

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I'm really shocked by the circumstances,

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not just of Mr Patterson's death, but the way that the knowledge

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of a whole series of errors was kept from the family

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following his death. It's scandalous

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that this family had to wait over a year to hear

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for the very first time that something went wrong

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with Mr Patterson's treatment.

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Peter Walsh spent years campaigning for what is called

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a legal duty of candour in England, which would force hospitals to admit

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mistakes to families of people who have been harmed.

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This year, new legislation in England will make that a reality.

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But there are no plans to introduce it here.

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He's now written to the Health Minister

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asking that it be introduced in Northern Ireland

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and demanding an independent inquiry into the Royal's emergency department.

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Bronagh and her aunt Anne wanted to meet Peter

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to discuss what happened to Charlie,

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and for privacy reasons, we agreed not to film that meeting.

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What really strikes me about what I have learnt about

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what's happened in Belfast so far

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is the very clear similarities with the root causes of the problems

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that we learnt so much about at Mid-Staffordshire, the big hospital scandal in England.

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The key ingredients of that scandal, that led to it,

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were a lack of good leadership,

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a failure to listen to staff

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and also a culture of denial.

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That's a toxic cocktail.

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In our experience, a hospital that fails to be open and honest

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is likely to be a dangerous hospital.

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The Health Minister, in his statements following the revelations

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about the five deaths, took a very different view.

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Five people dying in hospital of 80,000 being treated

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is not a crisis.

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The Minister did say that he had asked all Trusts to report to him

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on serious adverse incidents going back three years,

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and tell him in how many cases families had not been informed.

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We asked the Department of Health about what that review had found so far.

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They said it's not yet complete.

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I also asked the Minister for an interview about the new information

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that is now emerging, but just as with the first Spotlight programme

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on this subject, he declined to be interviewed.

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Charlie Patterson's death raises other serious issues too

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and that's because it wasn't unique.

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Now that's significant, because this report into his death

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is about how lessons were learnt and new practices put in place

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to prevent anything like it ever happening again.

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But it did happen again. And in remarkably similar circumstances.

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This is Colette Mac Ruagain.

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Five months ago, her mother Brigid, who was 81, was admitted to

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the emergency department of the Royal Victoria Hospital.

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It was ten months after Charlie Patterson's death.

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Brigid, too, had fallen and hit her head.

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One of her daughters came to the hospital with her.

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When Collette arrived soon afterwards, it was obvious

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that the department was under pressure.

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When I arrived, it was extremely busy.

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A lot of people just sitting along the corridor. It was extremely busy.

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Brigid had sustained bruising to her face

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and seemed to have hurt her arm.

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We thought it was a minor injury.

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We weren't aware of the extent of her injuries at that time.

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In fact, Brigid was bleeding from a haemorrhage inside her head,

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but it wasn't spotted.

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The bleeding would have been made much worse,

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because, like Charlie before her,

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Brigid was on the blood-thinning drug, warfarin.

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She should have quickly been given a drug to reverse

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the effects of warfarin, but that didn't happen for six hours.

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Her family thought there was nothing seriously wrong.

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She was clearly very uncomfortable

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and she had some bruising to her face. I mean, she was clearly unwell

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and clearly needed treatment, but nobody was alerting us

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that there was anything major

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or anything that we really needed to worry about.

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Over the next few hours, Brigid began to deteriorate.

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She became confused and disorientated.

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She was seen by a doctor after four hours and a CT scan was ordered.

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But it wasn't carried out for a further hour and a half.

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And when the results finally came, it was very bad news.

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The sister in A&E had said that there was something serious

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that had shown up on the scan,

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and she said to my sister, "We're going to have to go to resus,"

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and she knew then that something terribly was wrong.

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By now, Brigid was unconscious.

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Things escalated very quickly after that.

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The neurosurgeon came down and had viewed Mum's CAT scan,

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and explained just how serious things were and the extent of her injuries,

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of her brain injuries at that time.

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It was obvious to the family that something had been missed.

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They began to ask questions

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and staff admitted that Brigid had waited too long.

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She was rushed to the neurosurgery ward, but it was too late.

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Three days later, Brigid died.

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Her family felt angry.

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Staff at the hospital had already admitted that Brigid had not

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received the care she should have,

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so now the family asked the Trust what exactly had gone wrong.

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They had done investigations, a review into mum's care in A&E

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and outlined and acknowledged the mistakes that they had made

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and told us that they had put significant measures in place

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to ensure that this wouldn't happen again.

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Of course, it wasn't the first time the hospital had said that.

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In fact, they had said it ten months previously in this report

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into the death of Charlie Patterson, another elderly patient

0:19:500:19:54

also on warfarin, who had also waited too long, but incredibly,

0:19:540:19:58

these aren't the only two cases with very similar characteristics.

0:19:580:20:02

That's because Brigid's family were given this document after she died.

0:20:020:20:07

This is a learning letter,

0:20:070:20:09

which is distributed after serious adverse incidents.

0:20:090:20:13

And this says that just a few days before Brigid died,

0:20:130:20:16

yet another elderly patient who was also on Warfarin

0:20:160:20:19

died after waiting too long for treatment.

0:20:190:20:22

So, how many incidents like these two, ten months apart,

0:20:230:20:27

are down to the department being overwhelmed and under-resourced?

0:20:270:20:31

Spotlight has seen documents obtained

0:20:310:20:34

under Freedom of Information legislation.

0:20:340:20:36

They record that 720 incidents of all types occurred in the Royal's

0:20:370:20:41

emergency department in 2012 and 2013,

0:20:410:20:43

although the vast majority were low or medium risk.

0:20:430:20:48

But significantly, 265 of them,

0:20:480:20:51

over a third, were attributed to staffing and resources.

0:20:510:20:55

We wanted to ask the Belfast Trust and the Health Board

0:20:580:21:01

about whether this suggests that the emergency department suffers

0:21:010:21:04

from chronic short staffing

0:21:040:21:07

and whether that is leading to harm for patients.

0:21:070:21:09

But once again, we couldn't, because they would not be interviewed

0:21:090:21:13

for this programme and the statement

0:21:130:21:15

they gave us doesn't address that issue.

0:21:150:21:18

The big question, of course, is

0:21:180:21:19

whether among all of this adverse publicity and embarrassing

0:21:190:21:23

revelations about patient safety, that the situation is now improving.

0:21:230:21:29

Spotlight has been given some information which suggests that

0:21:290:21:32

if that is happening, it isn't happening

0:21:320:21:35

quickly enough for some senior doctors.

0:21:350:21:37

Today, Edwin Poots outlined a range of measures

0:21:400:21:43

that have already been implemented

0:21:430:21:44

to improve conditions in the emergency department of the Royal.

0:21:440:21:48

We are appointing 40 additional nurses to the emergency department

0:21:480:21:52

and that goes back to a report last summer,

0:21:520:21:55

so many of the nurses are actually already in place,

0:21:550:21:58

or being appointed as we speak.

0:21:580:22:00

So, there's courses of work that is happening

0:22:000:22:02

and actions are being taken to ensure

0:22:020:22:04

that we can meet the needs of the public.

0:22:040:22:07

In terms of what we are doing, we are responding to the problems

0:22:070:22:11

that are being identified and we are dealing with the issues.

0:22:110:22:14

But last week, BBC Newsline revealed that just three weeks ago,

0:22:140:22:19

another elderly patient died in the emergency department

0:22:190:22:23

and she too may have waited too long.

0:22:230:22:26

The Belfast Health Trust is investigating the circumstances

0:22:260:22:29

surrounding the death of an elderly patient.

0:22:290:22:31

The Belfast Trust says that waiting times

0:22:310:22:34

did not play a role in this woman's death,

0:22:340:22:37

but Spotlight understands that waiting too long may have

0:22:370:22:41

affected the comfort and dignity of her final hours.

0:22:410:22:44

But we have uncovered disturbing new documentary evidence

0:22:440:22:47

about what was happening in the emergency department

0:22:470:22:50

on the weekend this death occurred.

0:22:500:22:52

This is an e-mail chain dating from the weekend of 22nd February,

0:22:560:23:00

when the death occurred.

0:23:000:23:03

It includes e-mails from three senior consultants

0:23:030:23:06

on duty that weekend.

0:23:060:23:07

These e-mails describe a litany of serious concerns about

0:23:080:23:11

patient safety and dignity during the weekend in question.

0:23:110:23:16

All of it recorded meticulously by the consultants

0:23:160:23:18

and sent up the line to their management.

0:23:180:23:20

Colm Donaghy, the Chief Executive of the Trust, is copied in.

0:23:200:23:25

How can it be that during a period of intense public scrutiny

0:23:250:23:29

and concern about patient safety at the Royal

0:23:290:23:32

that right up until three weeks ago,

0:23:320:23:34

some consultants still thought that the department was unsafe?

0:23:340:23:38

Now, even if there are no quick fixes,

0:23:380:23:40

as the Health Minister pointed out today, these e-mails depicted

0:23:400:23:44

a department that was simply overwhelmed

0:23:440:23:46

and that needed immediate and comprehensive action

0:23:460:23:49

to put things right immediately,

0:23:490:23:51

at least on this weekend in question.

0:23:510:23:53

Now, those are all questions we would have put to the Trust,

0:23:530:23:56

but they have decided not to do an interview,

0:23:560:23:58

so in this programme, we won't be hearing the answers.

0:23:580:24:02

We have also uncovered questions

0:24:020:24:04

about the number of serious incidents

0:24:040:24:06

that occurred last year and whether that number could in fact rise.

0:24:060:24:11

In the last Spotlight programme we asked

0:24:120:24:14

the Chief Executive of the Trust, Colm Donaghy,

0:24:140:24:16

how many serious adverse incidents

0:24:160:24:18

there had been in which waiting times had played a part.

0:24:180:24:21

Well, it's difficult, but it would be single figures.

0:24:210:24:26

We have been told that it could be nine.

0:24:260:24:30

No, it's not as high as nine, no. I think at this point it's about four.

0:24:300:24:35

But I don't have those figures in front of me.

0:24:350:24:38

In how long - in the last six months, the last year?

0:24:380:24:40

No, no, that would be over the last couple of years.

0:24:400:24:44

In fact, it was five deaths in one year.

0:24:440:24:46

Spotlight has now been told that there may be further cases

0:24:470:24:51

currently pending, which could become serious adverse incidents,

0:24:510:24:55

though not all involve deaths.

0:24:550:24:58

Yet that would mean there may be more

0:24:580:24:59

than five serious adverse incidents with waiting times as a factor.

0:24:590:25:04

That's not including the death from three weeks ago.

0:25:040:25:08

Again, we put this to the Trust

0:25:080:25:10

and they say they're not aware of any such incidents.

0:25:100:25:13

We showed our evidence to Peter Walsh.

0:25:150:25:17

Given that this information is coming out in a piecemeal fashion,

0:25:170:25:21

what do you think needs to happen now?

0:25:210:25:24

It underlines even more there needs to be an independent inquiry

0:25:240:25:28

into how this has been allowed to happen,

0:25:280:25:31

and we must have a legal duty of candour.

0:25:310:25:33

Last week, it was revealed that one consultant in the Royal,

0:25:340:25:38

and a patient, are now suing the Belfast Trust for negligence.

0:25:380:25:43

Their lawyers said they have evidence of a toxic environment

0:25:430:25:46

for staff and patients and they're calling for a full public inquiry,

0:25:460:25:50

because they say the hospital has failed in its duty of care.

0:25:500:25:54

Two weeks ago, I wrote to every consultant in emergency medicine

0:25:540:25:58

at the Royal Victoria Hospital.

0:25:580:26:00

I asked them to do on-camera interviews, either as a group,

0:26:000:26:04

or as individuals.

0:26:040:26:05

They declined.

0:26:050:26:07

But some of those consultants did talk to us off-camera.

0:26:070:26:11

They said they couldn't speak out publicly,

0:26:110:26:14

because they feared for their jobs.

0:26:140:26:16

That's despite the fact that in the last Spotlight programme

0:26:160:26:19

on this subject, senior health managers said that they should.

0:26:190:26:24

At the moment, people are scared

0:26:240:26:26

to speak out, both doctors and nurses...

0:26:260:26:28

-They shouldn't be. It's as simple as that.

-But they are.

0:26:280:26:33

But they shouldn't be. They have an obligation to do so.

0:26:330:26:36

If you look at their professional obligations,

0:26:360:26:39

they don't have a choice.

0:26:390:26:40

So, what is the problem?

0:26:400:26:43

Well, the medical and nursing staff we spoke to say that

0:26:430:26:46

the reality is they would suffer for speaking out.

0:26:460:26:50

They say they're operating in a climate of fear

0:26:500:26:53

and that blowing the whistle could destroy their career.

0:26:530:26:57

Even when it comes to patient safety.

0:26:570:27:00

I spoke to a nurse this morning who said to me,

0:27:000:27:03

"There are so many things I'd like to tell you about what

0:27:030:27:06

"I have seen and what I'm still seeing, but I can't do that,

0:27:060:27:09

"because they will get me in the long grass."

0:27:090:27:12

Those were the words she used.

0:27:120:27:14

That is a dangerous and unacceptable situation, isn't it?

0:27:140:27:18

It absolutely is. That's very disturbing to hear a nurse say that.

0:27:180:27:24

It speaks volumes of the culture. That's unacceptable

0:27:240:27:29

and needs to be challenged.

0:27:290:27:31

Medical and nursing staff...

0:27:320:27:34

One doctor did agree to a tape-recorded interview.

0:27:340:27:38

We have reconstructed that interview using an actor

0:27:380:27:41

to protect his identity.

0:27:410:27:42

It will be done in a subtle way, OK?

0:27:420:27:45

They won't necessarily come to you

0:27:450:27:48

and say, "You've spoken out, so I'm suspending you."

0:27:480:27:50

The fear is they'll get us in the long grass.

0:27:500:27:53

We showed this interview to Peter Walsh, who has campaigned

0:27:530:27:57

on behalf of patients involved in

0:27:570:27:58

some of the biggest hospital scandals in England.

0:27:580:28:01

What we are now learning about the failure to listen to or even

0:28:010:28:05

possibly the bullying of whistle-blowers

0:28:050:28:08

and the failure to be open and honest with patients and their families

0:28:080:28:12

when things have gone grievously wrong -

0:28:120:28:15

we need a shock to the system.

0:28:150:28:17

We need a statutory legal obligation to be open and honest,

0:28:170:28:21

with serious repercussions for organisations who don't follow

0:28:210:28:26

that line to make things better.

0:28:260:28:29

Last month, preliminary findings of the regulator, the RQIA,

0:28:290:28:33

talked about allegations of bullying and harassment

0:28:330:28:36

at the Royal Victoria Hospital.

0:28:360:28:38

Added to that now are the voices of doctors,

0:28:380:28:41

who fear if they speak out publicly, they'll be victimised.

0:28:410:28:45

Serious questions for the Belfast Trust,

0:28:450:28:47

and once again, questions we would have put to them

0:28:470:28:50

in the interview they've declined to give.

0:28:500:28:53

On 8th January this year, a major incident was called

0:28:550:28:58

in the Royal's emergency department to deal with congestion.

0:28:580:29:01

It led to intense public scrutiny.

0:29:010:29:04

Spotlight has been told that the term "major incident" won't be used

0:29:040:29:08

again to deal with congestion, to avoid raising public concerns.

0:29:080:29:13

This is simply a rebranding to protect reputation.

0:29:140:29:18

This doesn't help protect patients in any way, because we have had

0:29:180:29:22

circumstances as bad as the night in question,

0:29:220:29:24

since the night in question,

0:29:240:29:26

and there has simply been some rebranding.

0:29:260:29:28

They are papering over the cracks.

0:29:280:29:31

That corresponds to information in the consultants' e-mails

0:29:310:29:34

regarding the weekend of 22nd February.

0:29:340:29:37

In those e-mails,

0:29:370:29:38

two of the consultants say

0:29:380:29:40

that in their opinion, conditions were so unsafe at points

0:29:400:29:43

that a major incident should have been called.

0:29:430:29:47

But that didn't happen.

0:29:470:29:49

Last week, Colm Donaghy, the Chief Executive of the Belfast Trust,

0:29:490:29:53

resigned his position to take up a new post in England.

0:29:530:29:57

Fixing what appears to be a broken system

0:29:570:30:00

will now be a problem for his successor.

0:30:000:30:02

The families involved say it can't come soon enough.

0:30:030:30:06

These are human beings,

0:30:080:30:10

human beings with families, with lives, they're loved.

0:30:100:30:14

They are not just numbers or categories. They deserve better.

0:30:140:30:18

They really do. We all deserve better.

0:30:180:30:21

You just put so much trust in the medical establishment

0:30:210:30:24

that once you enter a hospital,

0:30:240:30:25

you are going to be treated properly.

0:30:250:30:27

You don't expect to be left on a trolley to die.

0:30:270:30:30

There are now serious questions for the Health and Social Care Board,

0:30:340:30:37

the Minister and the Belfast Trust, about the real extent

0:30:370:30:41

of the problems at the Royal Victoria Hospital.

0:30:410:30:44

They chose not to answer them in interviews for this programme.

0:30:440:30:48

The question now is whether somewhere, at some point,

0:30:480:30:51

they are going to have to.

0:30:510:30:53

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