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Today, in a statement to the Assembly, | 0:00:02 | 0:00:03 | |
Health Minister Edwin Poots | 0:00:03 | 0:00:05 | |
was talking about solutions to problems | 0:00:05 | 0:00:08 | |
in the Royal Victoria Hospital in Belfast. He promised | 0:00:08 | 0:00:11 | |
more staff, better oversight and an improved system for patients. | 0:00:11 | 0:00:16 | |
But he said that real change will take time. | 0:00:16 | 0:00:20 | |
Tonight on Spotlight, we speak to some of the families | 0:00:20 | 0:00:23 | |
for whom time has already run out - | 0:00:23 | 0:00:25 | |
families whose loved ones died in remarkably similar circumstances | 0:00:25 | 0:00:30 | |
-ten months apart. -His clothes were covered in blood, | 0:00:30 | 0:00:33 | |
his overcoat was absolutely drenched in blood. | 0:00:33 | 0:00:35 | |
He had bled a lot. | 0:00:35 | 0:00:37 | |
She had some bruising to her face | 0:00:37 | 0:00:40 | |
and, clearly, needed treatment. | 0:00:40 | 0:00:42 | |
We hear from a doctor, who says that change | 0:00:42 | 0:00:45 | |
is not happening quickly enough. | 0:00:45 | 0:00:47 | |
I would say that the clinical staff of the minute | 0:00:47 | 0:00:50 | |
don't have faith in the management team and that | 0:00:50 | 0:00:52 | |
the only way that faith can be restored | 0:00:52 | 0:00:54 | |
is if positive changes are made very quickly. | 0:00:54 | 0:00:57 | |
And we reveal disturbing new evidence which suggests that, | 0:00:57 | 0:01:00 | |
as recently as three weeks ago, | 0:01:00 | 0:01:02 | |
patient safety was still being compromised. | 0:01:02 | 0:01:04 | |
Today, the Minister said it's important that the public still has | 0:01:06 | 0:01:10 | |
confidence in the emergency medicine system, | 0:01:10 | 0:01:13 | |
but neither he nor the Health & Social Care Board | 0:01:13 | 0:01:15 | |
nor the Belfast Trust would agree to be interviewed for this programme. | 0:01:15 | 0:01:21 | |
This is a story of how systemic failings in the emergency department | 0:01:21 | 0:01:24 | |
of the Royal Victoria Hospital | 0:01:24 | 0:01:26 | |
affected some patients and their families. | 0:01:26 | 0:01:29 | |
It's also an investigation into what's still going wrong. | 0:01:29 | 0:01:33 | |
Last month, Spotlight investigated the care being provided to patients | 0:01:54 | 0:01:57 | |
in the emergency department of the Royal Victoria Hospital in Belfast. | 0:01:57 | 0:02:01 | |
We revealed that last year five serious adverse incident reports | 0:02:01 | 0:02:05 | |
at the hospital involved deaths where waiting times | 0:02:05 | 0:02:08 | |
may have been a factor. | 0:02:08 | 0:02:10 | |
It came as a shock to many. | 0:02:10 | 0:02:13 | |
Last night's BBC Spotlight programme | 0:02:13 | 0:02:15 | |
highlighted the cases of five patients. | 0:02:15 | 0:02:17 | |
In that programme, we asked the Chief Executive of the Belfast Trust | 0:02:17 | 0:02:22 | |
whether the families involved in two of the incidents had been informed | 0:02:22 | 0:02:26 | |
that waiting times played a part in the deaths of their relatives. | 0:02:26 | 0:02:29 | |
I'm not aware of the detail of both, but I know one of the families had. | 0:02:29 | 0:02:34 | |
-You would expect that a family would want to know... -Absolutely. | 0:02:34 | 0:02:38 | |
..if the system played some kind of part in their loved one's death? | 0:02:38 | 0:02:42 | |
-Yes. -So, will you be looking into informing the other family, if...? | 0:02:42 | 0:02:49 | |
If they haven't been informed? Of course, yes. | 0:02:49 | 0:02:52 | |
It soon emerged that in three out of five cases | 0:02:52 | 0:02:54 | |
families had been not informed that there were failings | 0:02:54 | 0:02:58 | |
in how their loved ones were treated. The Health Minister | 0:02:58 | 0:03:00 | |
quickly announced that all of the families that did not know | 0:03:00 | 0:03:04 | |
something had gone badly wrong would now be told. | 0:03:04 | 0:03:06 | |
The treatment and care that those five people had may well have | 0:03:06 | 0:03:10 | |
fallen short and, therefore, we will have | 0:03:10 | 0:03:13 | |
an appropriate investigation of that matter. | 0:03:13 | 0:03:15 | |
Two days after the Spotlight programme was broadcast, | 0:03:15 | 0:03:18 | |
we were contacted by Grainne and Bronagh Boyle. | 0:03:18 | 0:03:21 | |
A year earlier, their grandfather Charlie Patterson | 0:03:21 | 0:03:24 | |
had died in the Royal. | 0:03:24 | 0:03:26 | |
As far as his family were concerned, he had received the best treatment | 0:03:26 | 0:03:30 | |
he could have, until Grainne received a call | 0:03:30 | 0:03:33 | |
from the Royal Victoria Hospital that would devastate her | 0:03:33 | 0:03:36 | |
and the rest of the family. | 0:03:36 | 0:03:37 | |
It was the day before Valentine's Day - the 13th, the Thursday. | 0:03:37 | 0:03:41 | |
And at ten to five, my phone rang. | 0:03:41 | 0:03:43 | |
There had been a report into my grandfather's death | 0:03:43 | 0:03:47 | |
and they would like for us, as a family, to come and speak to them | 0:03:47 | 0:03:50 | |
about that report. | 0:03:50 | 0:03:52 | |
When five deaths may have a contributory factor... | 0:03:53 | 0:03:56 | |
'An hour after, I sat down to watch the news' | 0:03:56 | 0:03:59 | |
and then the full enormity really kicked in and, as I was | 0:03:59 | 0:04:03 | |
watching these people speak, in my mind, I was thinking, | 0:04:03 | 0:04:06 | |
"That is us. That's our family." | 0:04:06 | 0:04:08 | |
And that is shameful. By anyone's standards, that is shameful. | 0:04:10 | 0:04:13 | |
That was the first time that we had known anything about | 0:04:13 | 0:04:16 | |
what had occurred. | 0:04:16 | 0:04:17 | |
Charlie Patterson was 86. | 0:04:22 | 0:04:24 | |
He lived his life surrounded by a close and loving family. | 0:04:24 | 0:04:28 | |
Our granda was amazing. He was everything that your granda could be. | 0:04:28 | 0:04:33 | |
He was our best friend. | 0:04:33 | 0:04:35 | |
We were like the Three Musketeers, always together. | 0:04:35 | 0:04:38 | |
Always together. You never seen one without the other two. | 0:04:38 | 0:04:41 | |
It was unusual for us not to be together | 0:04:41 | 0:04:45 | |
and every single day, we would go up to granda's in the evening | 0:04:45 | 0:04:48 | |
and all have our meal together and it was very important, | 0:04:48 | 0:04:52 | |
at the end of each evening, that we sat together and talk about our day. | 0:04:52 | 0:04:55 | |
Charlie Patterson had some health concerns associated with old age, | 0:04:55 | 0:05:00 | |
but he was still very active and went out walking every day. | 0:05:00 | 0:05:03 | |
SIREN BLARES | 0:05:05 | 0:05:08 | |
It was after attending Mass on 27 January, 2013 | 0:05:08 | 0:05:14 | |
that Charlie fell and hit his head. An ambulance was called. | 0:05:14 | 0:05:17 | |
He arrived at the emergency department | 0:05:17 | 0:05:20 | |
of the Royal Victoria Hospital at 7.10 in the evening. | 0:05:20 | 0:05:23 | |
He was bleeding from a head wound, but his family were not informed. | 0:05:23 | 0:05:29 | |
Charlie would lie on a trolley for the next seven hours alone. | 0:05:29 | 0:05:34 | |
That's something his family find difficult to deal with. | 0:05:34 | 0:05:38 | |
Personally I'm angry, because he was never alone. | 0:05:38 | 0:05:41 | |
He was an incredibly social man and to think of him | 0:05:41 | 0:05:44 | |
sitting there dazed and confused | 0:05:44 | 0:05:46 | |
and on his own is quite upsetting. | 0:05:46 | 0:05:50 | |
The details of what happened to Charlie Patterson that night | 0:05:50 | 0:05:52 | |
are contained in here. | 0:05:52 | 0:05:55 | |
This is an incident report, compiled not long after he died. | 0:05:55 | 0:05:59 | |
This wasn't even shown to his family until just a few weeks ago, | 0:05:59 | 0:06:03 | |
three days after the Spotlight investigation was broadcast. | 0:06:03 | 0:06:07 | |
But it goes into great detail about the shortcomings in the care | 0:06:07 | 0:06:11 | |
he received from the moment he entered the emergency department. | 0:06:11 | 0:06:15 | |
The first problem was at the triage stage. | 0:06:15 | 0:06:18 | |
Charlie was seen by a nurse 20 minutes | 0:06:18 | 0:06:21 | |
after arriving in the department. | 0:06:21 | 0:06:23 | |
She noted that he was confused, but he was able to tell her | 0:06:23 | 0:06:26 | |
that he was on the blood-thinning drug, warfarin. | 0:06:26 | 0:06:29 | |
Elderly patients on warfarin are at risk of profuse bleeding | 0:06:29 | 0:06:32 | |
and haemorrhaging and the report says it would have been appropriate, | 0:06:32 | 0:06:36 | |
at this point, for Charlie to have been given another drug, | 0:06:36 | 0:06:40 | |
to reverse the effects of the warfarin. | 0:06:40 | 0:06:43 | |
But he lay on a trolley for five hours before he was given that drug. | 0:06:43 | 0:06:48 | |
It almost defies belief, in a way, | 0:06:48 | 0:06:50 | |
that this could happen in a busy casualty department. | 0:06:50 | 0:06:53 | |
The report reveals other significant problems with delays. | 0:06:53 | 0:06:58 | |
A doctor should have examined Charlie within an hour. | 0:06:58 | 0:07:02 | |
He didn't see one until three and a half hours into his wait. | 0:07:02 | 0:07:05 | |
He should have received a CT scan soon after arrival | 0:07:05 | 0:07:08 | |
in the emergency department. That didn't happen for four hours. | 0:07:08 | 0:07:12 | |
For all of that time, he lay on a trolley alone, | 0:07:12 | 0:07:15 | |
growing more and more unwell. | 0:07:15 | 0:07:18 | |
His family had no idea he was there. | 0:07:18 | 0:07:21 | |
It's just the fact those few hours would have been valuable, | 0:07:21 | 0:07:24 | |
to say goodbye, to let him know that he wasn't on his own, | 0:07:24 | 0:07:27 | |
that he didn't need to be afraid - | 0:07:27 | 0:07:29 | |
the things you imagine you would do for the person you love. | 0:07:29 | 0:07:33 | |
To bring him his little bits of comfort, like his rosary beads, | 0:07:33 | 0:07:36 | |
or having his glasses. | 0:07:36 | 0:07:38 | |
The small, stupid things that weren't probably done for him. | 0:07:38 | 0:07:41 | |
He would have been confused, as to what was happening around him | 0:07:42 | 0:07:46 | |
and, undoubtedly, he would have been afraid and I find that just, | 0:07:46 | 0:07:51 | |
for someone who was so loved, I find that very difficult to reconcile. | 0:07:51 | 0:07:56 | |
All in all, this report outlines a litany of errors, | 0:07:59 | 0:08:03 | |
but what runs through it is the problem of delays. | 0:08:03 | 0:08:06 | |
The reason given here for the delays is that the system was | 0:08:06 | 0:08:10 | |
under pressure because a large number of patients | 0:08:10 | 0:08:12 | |
who were in the department that night needed to be admitted | 0:08:12 | 0:08:15 | |
to hospital and there were not enough beds for them to go to. | 0:08:15 | 0:08:18 | |
The emergency department was simply log-jammed. | 0:08:18 | 0:08:22 | |
Eventually, at 2.00am, Grainne and Bronagh | 0:08:22 | 0:08:26 | |
were informed that their grandfather was seriously ill | 0:08:26 | 0:08:29 | |
-in the emergency department. -As soon as I arrived, | 0:08:29 | 0:08:31 | |
I was immediately taken into a family room, | 0:08:31 | 0:08:34 | |
but I was brought through the waiting area | 0:08:34 | 0:08:36 | |
and it was chaos. The trolleys were just everywhere. | 0:08:36 | 0:08:40 | |
It was like a Third World country, almost. | 0:08:40 | 0:08:43 | |
It was like walking into a war zone. | 0:08:43 | 0:08:47 | |
It had been only 12 hours since they had last seen their grandfather | 0:08:47 | 0:08:51 | |
alive and well and on his way to Mass. | 0:08:51 | 0:08:53 | |
Now, they were deeply shocked at what they saw. | 0:08:53 | 0:08:57 | |
He was covered in blood and his clothes were covered in blood. | 0:08:57 | 0:09:00 | |
He had bled a lot. | 0:09:00 | 0:09:01 | |
A very nice, but very junior young doctor come in and she explained | 0:09:01 | 0:09:05 | |
to us that the outcome was likely to be fatal. | 0:09:05 | 0:09:09 | |
She was very upset. She seemed, sort of, visibly upset. | 0:09:09 | 0:09:16 | |
As Grainne and Bronagh were shown in to see Charlie, | 0:09:19 | 0:09:22 | |
other staff seemed upset, too. | 0:09:22 | 0:09:24 | |
One of the nurses was crying and she had said to us, | 0:09:26 | 0:09:30 | |
"I'm so sorry, I'm so sorry." We just assumed | 0:09:30 | 0:09:33 | |
she was sorry because he had died and the end of any life is sad, | 0:09:33 | 0:09:37 | |
but perhaps now, she was sorry | 0:09:37 | 0:09:39 | |
because he had been treated so poorly. | 0:09:39 | 0:09:41 | |
Gareth Martin is the union rep for the Royal College of Nursing. | 0:09:43 | 0:09:47 | |
He told me that far too many patients, | 0:09:47 | 0:09:49 | |
particularly the elderly, are suffering because the system | 0:09:49 | 0:09:52 | |
just isn't working. You say old people | 0:09:52 | 0:09:55 | |
are waiting in an environment that is not fit for purpose. | 0:09:55 | 0:09:58 | |
What do you mean, that the emergency department | 0:09:58 | 0:10:01 | |
at the Royal is not fit for purpose? | 0:10:01 | 0:10:03 | |
Absolutely. When there's pressures of patients waiting to be admitted | 0:10:03 | 0:10:08 | |
and you are hearing of large volumes of patients waiting six, | 0:10:08 | 0:10:12 | |
eight, ten, 12 hours and longer, | 0:10:12 | 0:10:15 | |
so the ability to provide dignified care is certainly compromised. | 0:10:15 | 0:10:20 | |
This report explains why the department was overstretched that night. | 0:10:20 | 0:10:25 | |
But it doesn't really answer the question of how an elderly man | 0:10:25 | 0:10:29 | |
could have spent hours lying alone in a busy emergency department | 0:10:29 | 0:10:34 | |
becoming more and more unwell, | 0:10:34 | 0:10:36 | |
and not get the attention that he needed. | 0:10:36 | 0:10:39 | |
I think there are numerous reasons he wasn't a priority. | 0:10:39 | 0:10:42 | |
He sat in the corner quietly. | 0:10:42 | 0:10:44 | |
He didn't cause a fuss. | 0:10:44 | 0:10:47 | |
Although the Belfast Trust didn't want to be interviewed | 0:10:47 | 0:10:50 | |
about Charlie Patterson's case, they did send us this statement. | 0:10:50 | 0:10:53 | |
They say that what happened was a matter of deep regret to them | 0:10:53 | 0:10:56 | |
and they say that Charlie's case was fully investigated | 0:10:56 | 0:10:59 | |
and that they've learnt lessons. | 0:10:59 | 0:11:01 | |
They also say that their policies and procedures about being open with | 0:11:01 | 0:11:04 | |
families were not followed in this case and for that they are sorry. | 0:11:04 | 0:11:07 | |
This statement leaves a lot of unanswered questions, | 0:11:08 | 0:11:12 | |
particularly for the Boyle family, but because the Trust have decided | 0:11:12 | 0:11:15 | |
not to do an interview we won't be hearing the answers. | 0:11:15 | 0:11:19 | |
No-one will ever know for sure whether Charlie Patterson might have | 0:11:20 | 0:11:24 | |
survived if he had got the treatment he needed in a timely fashion. | 0:11:24 | 0:11:29 | |
The only thing that is clear is that he didn't get it. | 0:11:29 | 0:11:32 | |
All the signals were there, all of them. | 0:11:32 | 0:11:34 | |
And they were missed and they weren't missed once, | 0:11:34 | 0:11:37 | |
they were missed time and time again. | 0:11:37 | 0:11:39 | |
There are various opportunities where intervention | 0:11:39 | 0:11:43 | |
may have had a different outcome, | 0:11:43 | 0:11:45 | |
but time and time and time again, they just passed. | 0:11:45 | 0:11:49 | |
What upsets Charlie's family more than anything else | 0:11:53 | 0:11:56 | |
is that the hospital didn't see fit to inform them | 0:11:56 | 0:11:59 | |
that so many mistakes had been made until a year after he had died. | 0:11:59 | 0:12:03 | |
And only then, after the Spotlight investigation had revealed | 0:12:03 | 0:12:07 | |
details of the five deaths. | 0:12:07 | 0:12:09 | |
We specifically said to them, had this not broke in the media, | 0:12:11 | 0:12:13 | |
would you have contacted us? And there was a non-response. | 0:12:13 | 0:12:17 | |
It wasn't even an apology. They moved on to the next question. | 0:12:17 | 0:12:21 | |
How did you feel about the fact that you hadn't been told, | 0:12:21 | 0:12:26 | |
that you were shown this comprehensive report | 0:12:26 | 0:12:28 | |
a year after he died? | 0:12:28 | 0:12:31 | |
Angry. You feel resentful | 0:12:31 | 0:12:33 | |
and disbelief that had the media not broke this story, | 0:12:33 | 0:12:37 | |
that you would never have been any the wiser. | 0:12:37 | 0:12:39 | |
We asked the Trust a direct question - | 0:12:39 | 0:12:42 | |
had they discovered other families who haven't been informed | 0:12:42 | 0:12:45 | |
about serious, adverse incidents involving their relatives? | 0:12:45 | 0:12:49 | |
They sent us this statement | 0:12:49 | 0:12:51 | |
and it says they're satisfied in the vast majority of cases | 0:12:51 | 0:12:54 | |
families have been informed, but that they have identified a number | 0:12:54 | 0:12:58 | |
of cases where the level of involvement | 0:12:58 | 0:13:00 | |
is not what they would expect. | 0:13:00 | 0:13:02 | |
Now, that sounds like a yes. | 0:13:02 | 0:13:05 | |
And we would have pressed the Trust on that point in an interview, | 0:13:05 | 0:13:08 | |
but because they won't meet us face-to-face on camera, we can't. | 0:13:08 | 0:13:11 | |
This is Peter Walsh. | 0:13:14 | 0:13:16 | |
Based in London, his charity, Action Against Medical Accidents, | 0:13:16 | 0:13:21 | |
lobbies for patients' rights in the NHS. | 0:13:21 | 0:13:24 | |
He's one of the leading patients' advocates in the UK, | 0:13:24 | 0:13:26 | |
representing about 3,000 patients and their families every year. | 0:13:26 | 0:13:31 | |
We asked him to come to Belfast to review Charlie Patterson's case | 0:13:31 | 0:13:35 | |
and some of the others that have come to light. | 0:13:35 | 0:13:37 | |
I'm really shocked by the circumstances, | 0:13:37 | 0:13:41 | |
not just of Mr Patterson's death, but the way that the knowledge | 0:13:41 | 0:13:45 | |
of a whole series of errors was kept from the family | 0:13:45 | 0:13:50 | |
following his death. It's scandalous | 0:13:50 | 0:13:53 | |
that this family had to wait over a year to hear | 0:13:53 | 0:13:56 | |
for the very first time that something went wrong | 0:13:56 | 0:14:00 | |
with Mr Patterson's treatment. | 0:14:00 | 0:14:02 | |
Peter Walsh spent years campaigning for what is called | 0:14:04 | 0:14:07 | |
a legal duty of candour in England, which would force hospitals to admit | 0:14:07 | 0:14:11 | |
mistakes to families of people who have been harmed. | 0:14:11 | 0:14:14 | |
This year, new legislation in England will make that a reality. | 0:14:14 | 0:14:18 | |
But there are no plans to introduce it here. | 0:14:18 | 0:14:21 | |
He's now written to the Health Minister | 0:14:21 | 0:14:23 | |
asking that it be introduced in Northern Ireland | 0:14:23 | 0:14:26 | |
and demanding an independent inquiry into the Royal's emergency department. | 0:14:26 | 0:14:30 | |
Bronagh and her aunt Anne wanted to meet Peter | 0:14:30 | 0:14:32 | |
to discuss what happened to Charlie, | 0:14:32 | 0:14:34 | |
and for privacy reasons, we agreed not to film that meeting. | 0:14:34 | 0:14:37 | |
What really strikes me about what I have learnt about | 0:14:38 | 0:14:42 | |
what's happened in Belfast so far | 0:14:42 | 0:14:45 | |
is the very clear similarities with the root causes of the problems | 0:14:45 | 0:14:49 | |
that we learnt so much about at Mid-Staffordshire, the big hospital scandal in England. | 0:14:49 | 0:14:55 | |
The key ingredients of that scandal, that led to it, | 0:14:55 | 0:14:58 | |
were a lack of good leadership, | 0:14:58 | 0:15:01 | |
a failure to listen to staff | 0:15:01 | 0:15:04 | |
and also a culture of denial. | 0:15:04 | 0:15:08 | |
That's a toxic cocktail. | 0:15:08 | 0:15:11 | |
In our experience, a hospital that fails to be open and honest | 0:15:11 | 0:15:17 | |
is likely to be a dangerous hospital. | 0:15:17 | 0:15:20 | |
The Health Minister, in his statements following the revelations | 0:15:20 | 0:15:24 | |
about the five deaths, took a very different view. | 0:15:24 | 0:15:27 | |
Five people dying in hospital of 80,000 being treated | 0:15:27 | 0:15:32 | |
is not a crisis. | 0:15:32 | 0:15:35 | |
The Minister did say that he had asked all Trusts to report to him | 0:15:35 | 0:15:38 | |
on serious adverse incidents going back three years, | 0:15:38 | 0:15:41 | |
and tell him in how many cases families had not been informed. | 0:15:41 | 0:15:46 | |
We asked the Department of Health about what that review had found so far. | 0:15:46 | 0:15:50 | |
They said it's not yet complete. | 0:15:50 | 0:15:53 | |
I also asked the Minister for an interview about the new information | 0:15:53 | 0:15:56 | |
that is now emerging, but just as with the first Spotlight programme | 0:15:56 | 0:16:00 | |
on this subject, he declined to be interviewed. | 0:16:00 | 0:16:03 | |
Charlie Patterson's death raises other serious issues too | 0:16:07 | 0:16:11 | |
and that's because it wasn't unique. | 0:16:11 | 0:16:14 | |
Now that's significant, because this report into his death | 0:16:14 | 0:16:18 | |
is about how lessons were learnt and new practices put in place | 0:16:18 | 0:16:22 | |
to prevent anything like it ever happening again. | 0:16:22 | 0:16:25 | |
But it did happen again. And in remarkably similar circumstances. | 0:16:25 | 0:16:30 | |
This is Colette Mac Ruagain. | 0:16:33 | 0:16:36 | |
Five months ago, her mother Brigid, who was 81, was admitted to | 0:16:36 | 0:16:40 | |
the emergency department of the Royal Victoria Hospital. | 0:16:40 | 0:16:44 | |
It was ten months after Charlie Patterson's death. | 0:16:44 | 0:16:47 | |
Brigid, too, had fallen and hit her head. | 0:16:48 | 0:16:51 | |
One of her daughters came to the hospital with her. | 0:16:51 | 0:16:55 | |
When Collette arrived soon afterwards, it was obvious | 0:16:55 | 0:16:58 | |
that the department was under pressure. | 0:16:58 | 0:17:01 | |
When I arrived, it was extremely busy. | 0:17:01 | 0:17:04 | |
A lot of people just sitting along the corridor. It was extremely busy. | 0:17:04 | 0:17:10 | |
Brigid had sustained bruising to her face | 0:17:10 | 0:17:12 | |
and seemed to have hurt her arm. | 0:17:12 | 0:17:14 | |
We thought it was a minor injury. | 0:17:16 | 0:17:19 | |
We weren't aware of the extent of her injuries at that time. | 0:17:19 | 0:17:23 | |
In fact, Brigid was bleeding from a haemorrhage inside her head, | 0:17:23 | 0:17:27 | |
but it wasn't spotted. | 0:17:27 | 0:17:29 | |
The bleeding would have been made much worse, | 0:17:29 | 0:17:31 | |
because, like Charlie before her, | 0:17:31 | 0:17:33 | |
Brigid was on the blood-thinning drug, warfarin. | 0:17:33 | 0:17:35 | |
She should have quickly been given a drug to reverse | 0:17:35 | 0:17:37 | |
the effects of warfarin, but that didn't happen for six hours. | 0:17:37 | 0:17:41 | |
Her family thought there was nothing seriously wrong. | 0:17:41 | 0:17:44 | |
She was clearly very uncomfortable | 0:17:44 | 0:17:47 | |
and she had some bruising to her face. I mean, she was clearly unwell | 0:17:47 | 0:17:52 | |
and clearly needed treatment, but nobody was alerting us | 0:17:52 | 0:17:56 | |
that there was anything major | 0:17:56 | 0:17:58 | |
or anything that we really needed to worry about. | 0:17:58 | 0:18:01 | |
Over the next few hours, Brigid began to deteriorate. | 0:18:03 | 0:18:06 | |
She became confused and disorientated. | 0:18:06 | 0:18:09 | |
She was seen by a doctor after four hours and a CT scan was ordered. | 0:18:09 | 0:18:13 | |
But it wasn't carried out for a further hour and a half. | 0:18:13 | 0:18:17 | |
And when the results finally came, it was very bad news. | 0:18:17 | 0:18:21 | |
The sister in A&E had said that there was something serious | 0:18:21 | 0:18:26 | |
that had shown up on the scan, | 0:18:26 | 0:18:27 | |
and she said to my sister, "We're going to have to go to resus," | 0:18:27 | 0:18:31 | |
and she knew then that something terribly was wrong. | 0:18:31 | 0:18:35 | |
By now, Brigid was unconscious. | 0:18:35 | 0:18:38 | |
Things escalated very quickly after that. | 0:18:38 | 0:18:40 | |
The neurosurgeon came down and had viewed Mum's CAT scan, | 0:18:40 | 0:18:46 | |
and explained just how serious things were and the extent of her injuries, | 0:18:46 | 0:18:52 | |
of her brain injuries at that time. | 0:18:52 | 0:18:54 | |
It was obvious to the family that something had been missed. | 0:18:54 | 0:18:58 | |
They began to ask questions | 0:18:58 | 0:19:00 | |
and staff admitted that Brigid had waited too long. | 0:19:00 | 0:19:04 | |
She was rushed to the neurosurgery ward, but it was too late. | 0:19:04 | 0:19:07 | |
Three days later, Brigid died. | 0:19:07 | 0:19:09 | |
Her family felt angry. | 0:19:12 | 0:19:14 | |
Staff at the hospital had already admitted that Brigid had not | 0:19:14 | 0:19:18 | |
received the care she should have, | 0:19:18 | 0:19:19 | |
so now the family asked the Trust what exactly had gone wrong. | 0:19:19 | 0:19:23 | |
They had done investigations, a review into mum's care in A&E | 0:19:25 | 0:19:30 | |
and outlined and acknowledged the mistakes that they had made | 0:19:30 | 0:19:34 | |
and told us that they had put significant measures in place | 0:19:34 | 0:19:39 | |
to ensure that this wouldn't happen again. | 0:19:39 | 0:19:43 | |
Of course, it wasn't the first time the hospital had said that. | 0:19:43 | 0:19:46 | |
In fact, they had said it ten months previously in this report | 0:19:46 | 0:19:50 | |
into the death of Charlie Patterson, another elderly patient | 0:19:50 | 0:19:54 | |
also on warfarin, who had also waited too long, but incredibly, | 0:19:54 | 0:19:58 | |
these aren't the only two cases with very similar characteristics. | 0:19:58 | 0:20:02 | |
That's because Brigid's family were given this document after she died. | 0:20:02 | 0:20:07 | |
This is a learning letter, | 0:20:07 | 0:20:09 | |
which is distributed after serious adverse incidents. | 0:20:09 | 0:20:13 | |
And this says that just a few days before Brigid died, | 0:20:13 | 0:20:16 | |
yet another elderly patient who was also on Warfarin | 0:20:16 | 0:20:19 | |
died after waiting too long for treatment. | 0:20:19 | 0:20:22 | |
So, how many incidents like these two, ten months apart, | 0:20:23 | 0:20:27 | |
are down to the department being overwhelmed and under-resourced? | 0:20:27 | 0:20:31 | |
Spotlight has seen documents obtained | 0:20:31 | 0:20:34 | |
under Freedom of Information legislation. | 0:20:34 | 0:20:36 | |
They record that 720 incidents of all types occurred in the Royal's | 0:20:37 | 0:20:41 | |
emergency department in 2012 and 2013, | 0:20:41 | 0:20:43 | |
although the vast majority were low or medium risk. | 0:20:43 | 0:20:48 | |
But significantly, 265 of them, | 0:20:48 | 0:20:51 | |
over a third, were attributed to staffing and resources. | 0:20:51 | 0:20:55 | |
We wanted to ask the Belfast Trust and the Health Board | 0:20:58 | 0:21:01 | |
about whether this suggests that the emergency department suffers | 0:21:01 | 0:21:04 | |
from chronic short staffing | 0:21:04 | 0:21:07 | |
and whether that is leading to harm for patients. | 0:21:07 | 0:21:09 | |
But once again, we couldn't, because they would not be interviewed | 0:21:09 | 0:21:13 | |
for this programme and the statement | 0:21:13 | 0:21:15 | |
they gave us doesn't address that issue. | 0:21:15 | 0:21:18 | |
The big question, of course, is | 0:21:18 | 0:21:19 | |
whether among all of this adverse publicity and embarrassing | 0:21:19 | 0:21:23 | |
revelations about patient safety, that the situation is now improving. | 0:21:23 | 0:21:29 | |
Spotlight has been given some information which suggests that | 0:21:29 | 0:21:32 | |
if that is happening, it isn't happening | 0:21:32 | 0:21:35 | |
quickly enough for some senior doctors. | 0:21:35 | 0:21:37 | |
Today, Edwin Poots outlined a range of measures | 0:21:40 | 0:21:43 | |
that have already been implemented | 0:21:43 | 0:21:44 | |
to improve conditions in the emergency department of the Royal. | 0:21:44 | 0:21:48 | |
We are appointing 40 additional nurses to the emergency department | 0:21:48 | 0:21:52 | |
and that goes back to a report last summer, | 0:21:52 | 0:21:55 | |
so many of the nurses are actually already in place, | 0:21:55 | 0:21:58 | |
or being appointed as we speak. | 0:21:58 | 0:22:00 | |
So, there's courses of work that is happening | 0:22:00 | 0:22:02 | |
and actions are being taken to ensure | 0:22:02 | 0:22:04 | |
that we can meet the needs of the public. | 0:22:04 | 0:22:07 | |
In terms of what we are doing, we are responding to the problems | 0:22:07 | 0:22:11 | |
that are being identified and we are dealing with the issues. | 0:22:11 | 0:22:14 | |
But last week, BBC Newsline revealed that just three weeks ago, | 0:22:14 | 0:22:19 | |
another elderly patient died in the emergency department | 0:22:19 | 0:22:23 | |
and she too may have waited too long. | 0:22:23 | 0:22:26 | |
The Belfast Health Trust is investigating the circumstances | 0:22:26 | 0:22:29 | |
surrounding the death of an elderly patient. | 0:22:29 | 0:22:31 | |
The Belfast Trust says that waiting times | 0:22:31 | 0:22:34 | |
did not play a role in this woman's death, | 0:22:34 | 0:22:37 | |
but Spotlight understands that waiting too long may have | 0:22:37 | 0:22:41 | |
affected the comfort and dignity of her final hours. | 0:22:41 | 0:22:44 | |
But we have uncovered disturbing new documentary evidence | 0:22:44 | 0:22:47 | |
about what was happening in the emergency department | 0:22:47 | 0:22:50 | |
on the weekend this death occurred. | 0:22:50 | 0:22:52 | |
This is an e-mail chain dating from the weekend of 22nd February, | 0:22:56 | 0:23:00 | |
when the death occurred. | 0:23:00 | 0:23:03 | |
It includes e-mails from three senior consultants | 0:23:03 | 0:23:06 | |
on duty that weekend. | 0:23:06 | 0:23:07 | |
These e-mails describe a litany of serious concerns about | 0:23:08 | 0:23:11 | |
patient safety and dignity during the weekend in question. | 0:23:11 | 0:23:16 | |
All of it recorded meticulously by the consultants | 0:23:16 | 0:23:18 | |
and sent up the line to their management. | 0:23:18 | 0:23:20 | |
Colm Donaghy, the Chief Executive of the Trust, is copied in. | 0:23:20 | 0:23:25 | |
How can it be that during a period of intense public scrutiny | 0:23:25 | 0:23:29 | |
and concern about patient safety at the Royal | 0:23:29 | 0:23:32 | |
that right up until three weeks ago, | 0:23:32 | 0:23:34 | |
some consultants still thought that the department was unsafe? | 0:23:34 | 0:23:38 | |
Now, even if there are no quick fixes, | 0:23:38 | 0:23:40 | |
as the Health Minister pointed out today, these e-mails depicted | 0:23:40 | 0:23:44 | |
a department that was simply overwhelmed | 0:23:44 | 0:23:46 | |
and that needed immediate and comprehensive action | 0:23:46 | 0:23:49 | |
to put things right immediately, | 0:23:49 | 0:23:51 | |
at least on this weekend in question. | 0:23:51 | 0:23:53 | |
Now, those are all questions we would have put to the Trust, | 0:23:53 | 0:23:56 | |
but they have decided not to do an interview, | 0:23:56 | 0:23:58 | |
so in this programme, we won't be hearing the answers. | 0:23:58 | 0:24:02 | |
We have also uncovered questions | 0:24:02 | 0:24:04 | |
about the number of serious incidents | 0:24:04 | 0:24:06 | |
that occurred last year and whether that number could in fact rise. | 0:24:06 | 0:24:11 | |
In the last Spotlight programme we asked | 0:24:12 | 0:24:14 | |
the Chief Executive of the Trust, Colm Donaghy, | 0:24:14 | 0:24:16 | |
how many serious adverse incidents | 0:24:16 | 0:24:18 | |
there had been in which waiting times had played a part. | 0:24:18 | 0:24:21 | |
Well, it's difficult, but it would be single figures. | 0:24:21 | 0:24:26 | |
We have been told that it could be nine. | 0:24:26 | 0:24:30 | |
No, it's not as high as nine, no. I think at this point it's about four. | 0:24:30 | 0:24:35 | |
But I don't have those figures in front of me. | 0:24:35 | 0:24:38 | |
In how long - in the last six months, the last year? | 0:24:38 | 0:24:40 | |
No, no, that would be over the last couple of years. | 0:24:40 | 0:24:44 | |
In fact, it was five deaths in one year. | 0:24:44 | 0:24:46 | |
Spotlight has now been told that there may be further cases | 0:24:47 | 0:24:51 | |
currently pending, which could become serious adverse incidents, | 0:24:51 | 0:24:55 | |
though not all involve deaths. | 0:24:55 | 0:24:58 | |
Yet that would mean there may be more | 0:24:58 | 0:24:59 | |
than five serious adverse incidents with waiting times as a factor. | 0:24:59 | 0:25:04 | |
That's not including the death from three weeks ago. | 0:25:04 | 0:25:08 | |
Again, we put this to the Trust | 0:25:08 | 0:25:10 | |
and they say they're not aware of any such incidents. | 0:25:10 | 0:25:13 | |
We showed our evidence to Peter Walsh. | 0:25:15 | 0:25:17 | |
Given that this information is coming out in a piecemeal fashion, | 0:25:17 | 0:25:21 | |
what do you think needs to happen now? | 0:25:21 | 0:25:24 | |
It underlines even more there needs to be an independent inquiry | 0:25:24 | 0:25:28 | |
into how this has been allowed to happen, | 0:25:28 | 0:25:31 | |
and we must have a legal duty of candour. | 0:25:31 | 0:25:33 | |
Last week, it was revealed that one consultant in the Royal, | 0:25:34 | 0:25:38 | |
and a patient, are now suing the Belfast Trust for negligence. | 0:25:38 | 0:25:43 | |
Their lawyers said they have evidence of a toxic environment | 0:25:43 | 0:25:46 | |
for staff and patients and they're calling for a full public inquiry, | 0:25:46 | 0:25:50 | |
because they say the hospital has failed in its duty of care. | 0:25:50 | 0:25:54 | |
Two weeks ago, I wrote to every consultant in emergency medicine | 0:25:54 | 0:25:58 | |
at the Royal Victoria Hospital. | 0:25:58 | 0:26:00 | |
I asked them to do on-camera interviews, either as a group, | 0:26:00 | 0:26:04 | |
or as individuals. | 0:26:04 | 0:26:05 | |
They declined. | 0:26:05 | 0:26:07 | |
But some of those consultants did talk to us off-camera. | 0:26:07 | 0:26:11 | |
They said they couldn't speak out publicly, | 0:26:11 | 0:26:14 | |
because they feared for their jobs. | 0:26:14 | 0:26:16 | |
That's despite the fact that in the last Spotlight programme | 0:26:16 | 0:26:19 | |
on this subject, senior health managers said that they should. | 0:26:19 | 0:26:24 | |
At the moment, people are scared | 0:26:24 | 0:26:26 | |
to speak out, both doctors and nurses... | 0:26:26 | 0:26:28 | |
-They shouldn't be. It's as simple as that. -But they are. | 0:26:28 | 0:26:33 | |
But they shouldn't be. They have an obligation to do so. | 0:26:33 | 0:26:36 | |
If you look at their professional obligations, | 0:26:36 | 0:26:39 | |
they don't have a choice. | 0:26:39 | 0:26:40 | |
So, what is the problem? | 0:26:40 | 0:26:43 | |
Well, the medical and nursing staff we spoke to say that | 0:26:43 | 0:26:46 | |
the reality is they would suffer for speaking out. | 0:26:46 | 0:26:50 | |
They say they're operating in a climate of fear | 0:26:50 | 0:26:53 | |
and that blowing the whistle could destroy their career. | 0:26:53 | 0:26:57 | |
Even when it comes to patient safety. | 0:26:57 | 0:27:00 | |
I spoke to a nurse this morning who said to me, | 0:27:00 | 0:27:03 | |
"There are so many things I'd like to tell you about what | 0:27:03 | 0:27:06 | |
"I have seen and what I'm still seeing, but I can't do that, | 0:27:06 | 0:27:09 | |
"because they will get me in the long grass." | 0:27:09 | 0:27:12 | |
Those were the words she used. | 0:27:12 | 0:27:14 | |
That is a dangerous and unacceptable situation, isn't it? | 0:27:14 | 0:27:18 | |
It absolutely is. That's very disturbing to hear a nurse say that. | 0:27:18 | 0:27:24 | |
It speaks volumes of the culture. That's unacceptable | 0:27:24 | 0:27:29 | |
and needs to be challenged. | 0:27:29 | 0:27:31 | |
Medical and nursing staff... | 0:27:32 | 0:27:34 | |
One doctor did agree to a tape-recorded interview. | 0:27:34 | 0:27:38 | |
We have reconstructed that interview using an actor | 0:27:38 | 0:27:41 | |
to protect his identity. | 0:27:41 | 0:27:42 | |
It will be done in a subtle way, OK? | 0:27:42 | 0:27:45 | |
They won't necessarily come to you | 0:27:45 | 0:27:48 | |
and say, "You've spoken out, so I'm suspending you." | 0:27:48 | 0:27:50 | |
The fear is they'll get us in the long grass. | 0:27:50 | 0:27:53 | |
We showed this interview to Peter Walsh, who has campaigned | 0:27:53 | 0:27:57 | |
on behalf of patients involved in | 0:27:57 | 0:27:58 | |
some of the biggest hospital scandals in England. | 0:27:58 | 0:28:01 | |
What we are now learning about the failure to listen to or even | 0:28:01 | 0:28:05 | |
possibly the bullying of whistle-blowers | 0:28:05 | 0:28:08 | |
and the failure to be open and honest with patients and their families | 0:28:08 | 0:28:12 | |
when things have gone grievously wrong - | 0:28:12 | 0:28:15 | |
we need a shock to the system. | 0:28:15 | 0:28:17 | |
We need a statutory legal obligation to be open and honest, | 0:28:17 | 0:28:21 | |
with serious repercussions for organisations who don't follow | 0:28:21 | 0:28:26 | |
that line to make things better. | 0:28:26 | 0:28:29 | |
Last month, preliminary findings of the regulator, the RQIA, | 0:28:29 | 0:28:33 | |
talked about allegations of bullying and harassment | 0:28:33 | 0:28:36 | |
at the Royal Victoria Hospital. | 0:28:36 | 0:28:38 | |
Added to that now are the voices of doctors, | 0:28:38 | 0:28:41 | |
who fear if they speak out publicly, they'll be victimised. | 0:28:41 | 0:28:45 | |
Serious questions for the Belfast Trust, | 0:28:45 | 0:28:47 | |
and once again, questions we would have put to them | 0:28:47 | 0:28:50 | |
in the interview they've declined to give. | 0:28:50 | 0:28:53 | |
On 8th January this year, a major incident was called | 0:28:55 | 0:28:58 | |
in the Royal's emergency department to deal with congestion. | 0:28:58 | 0:29:01 | |
It led to intense public scrutiny. | 0:29:01 | 0:29:04 | |
Spotlight has been told that the term "major incident" won't be used | 0:29:04 | 0:29:08 | |
again to deal with congestion, to avoid raising public concerns. | 0:29:08 | 0:29:13 | |
This is simply a rebranding to protect reputation. | 0:29:14 | 0:29:18 | |
This doesn't help protect patients in any way, because we have had | 0:29:18 | 0:29:22 | |
circumstances as bad as the night in question, | 0:29:22 | 0:29:24 | |
since the night in question, | 0:29:24 | 0:29:26 | |
and there has simply been some rebranding. | 0:29:26 | 0:29:28 | |
They are papering over the cracks. | 0:29:28 | 0:29:31 | |
That corresponds to information in the consultants' e-mails | 0:29:31 | 0:29:34 | |
regarding the weekend of 22nd February. | 0:29:34 | 0:29:37 | |
In those e-mails, | 0:29:37 | 0:29:38 | |
two of the consultants say | 0:29:38 | 0:29:40 | |
that in their opinion, conditions were so unsafe at points | 0:29:40 | 0:29:43 | |
that a major incident should have been called. | 0:29:43 | 0:29:47 | |
But that didn't happen. | 0:29:47 | 0:29:49 | |
Last week, Colm Donaghy, the Chief Executive of the Belfast Trust, | 0:29:49 | 0:29:53 | |
resigned his position to take up a new post in England. | 0:29:53 | 0:29:57 | |
Fixing what appears to be a broken system | 0:29:57 | 0:30:00 | |
will now be a problem for his successor. | 0:30:00 | 0:30:02 | |
The families involved say it can't come soon enough. | 0:30:03 | 0:30:06 | |
These are human beings, | 0:30:08 | 0:30:10 | |
human beings with families, with lives, they're loved. | 0:30:10 | 0:30:14 | |
They are not just numbers or categories. They deserve better. | 0:30:14 | 0:30:18 | |
They really do. We all deserve better. | 0:30:18 | 0:30:21 | |
You just put so much trust in the medical establishment | 0:30:21 | 0:30:24 | |
that once you enter a hospital, | 0:30:24 | 0:30:25 | |
you are going to be treated properly. | 0:30:25 | 0:30:27 | |
You don't expect to be left on a trolley to die. | 0:30:27 | 0:30:30 | |
There are now serious questions for the Health and Social Care Board, | 0:30:34 | 0:30:37 | |
the Minister and the Belfast Trust, about the real extent | 0:30:37 | 0:30:41 | |
of the problems at the Royal Victoria Hospital. | 0:30:41 | 0:30:44 | |
They chose not to answer them in interviews for this programme. | 0:30:44 | 0:30:48 | |
The question now is whether somewhere, at some point, | 0:30:48 | 0:30:51 | |
they are going to have to. | 0:30:51 | 0:30:53 |