13/02/2014 The View

Tonight, five deaths linked to waiting times at the Royal it is a

shocking story, which has prompted one doctor who worked there to It

has emerged that five patients may have died because they were not

treated quickly enough. Health Minister denied there was a crisis.

He conceded his department needs to learn lessons. The story has not

been out of the headlines in recent months. Staff and patients at the

Royal Victoria hospital said conditions last night were

horrendous. People are contacting the media on her behalf. I wish that

the media would be more mature in how they assess things. It is

already about four. I cannot check. Last year, we identified five cases

where one factor may have been the length of time people waited. The

inspection has confirmed staffing concerns in key areas, allegations

of bullying, staff under pressure, and air -- a system that does not

function like it was meant to. I'm joined from Glasgow by Doctor

Jonathan Miller, who worked in the emergency department. Also with us

is John Compton. Welcome to the programme. Jonathan Miller, you

personally flagged up your concerns on a number of occasions, how did

you do that? As you say, that was over a fairly protracted period of

time, initially, that was through senior staff in the emergency

department, that escalated to senior managers responsible for the

emergency department, and eventually to the medical director. Subsequent

to that we had discussions with the College of emergency medicine on

their admission. Did you feel the concerns were taken as seriously as

they should have been? I did not. I think that is evidenced by the fact

that those concerns are to be raised on repeated occasions. I don't think

I ever felt in a position where they had been adequately addressed. What

kind of issues did you raise and they not take on board? Did they

simply not believe you or did they take it that you were telling the

truth and then not do anything about it? This is about a pattern that was

emerging. Sometimes these concerns would be about individual cases,

generally, these were about patterns, situations that had risen

over time. As to whether or not people believed it, I think the

evidence was certainly there, and we had raised them on sufficient

occasions that people could be left in no doubt. You were talking

specifically about incidents that happened in accident and emergency

where staff simply could not cope with the pressure they were under.

Is that it? I think we are all aware in the profession of length between

-- the link between overcrowding and outcomes for patients. We saw that

played out in real-time. Sometimes that would be about the safety of

patients, the delivery of treatment, sometimes it would be about the

dignity of patients treated in the Department. This all happened some

time ago. Why have you chosen to speak out at this particular time? I

raised these concerns almost until the week I left. I took the decision

to move away from that system, and I hoped when I left that things would

improve and change was in the pipeline, and then in discussion

with colleagues and with people that remained in Belfast, then with the

news of a major incident, and the details that have emerged this week,

I felt that these concerns have not been addressed and patients remain

at risk, and I think I felt a real obligation to bring this to light.

Is it your contention that patients remain addressed at the Royal? --

remain at risk? I don't think anything has changed and there is

evidence for that in terms of performance, there is evidence for

that in terms of having to resort to using a major incident plan to deal

with overcrowding. I think that evidence is clear. In fact, you said

this week the five deaths may be the tip of the iceberg. Do you feel that

strongly? That is based on an appreciation of evidence that has

emerged from all around the developed world, from Australia,

Canada, the United States and from within the UK. There is a really

clear length between the length of stay for a patient in an emergency

department, the level of crowding in an emergency department, and the

ultimate outcome for patients. That is not something that is peculiar to

Belfast, that exists around the world, and such pure performance

there must be mortalities in the system. John Compton said medical

staff should feel they have an obligation to speak out. You have

done that but your colleagues have not done that. Might they now be

encouraged, given what you have done and what has been said, to air their

concerns publicly? I have had a lot of communication over the last 48

hours, with former colleagues and staff who are there, they have

expressed, in some cases, the thanks that I have been able to do this,

but I think some people will still remain very concerned about what the

potential repercussions will be. One final thing, a claim was made by an

MLA that staff felt pressurised to stop the clock in an attempt to give

an impression of improved performance. Is that something you

ever came across? I can only reference the time I had access to

the information, and certainly I think you would find that around a

12 hour target there are an inordinate number of people who were

clocked as having left the Department, and I think that points

towards a situation where numbers may have been managed. You think

those figures are unreliable? I think that would be fair to say.

Yes. Thanks for joining us. Stay with us, we will hopefully come back

to you a little later. Thank you for joining us. You appreciate -- we

appreciate you being here. Let me reiterate on that point, do you know

anything about stopping this clock to hit the targets? I have heard

this allegation but I don't think there is substantial evidence, if

that was the case we would not have any 12 hour targets. We do. Jonathan

has just told us he believes it happens and representatives said

that they believed it. I think the evidence that we have is there maybe

some who do on occasion do things referred to as stopping the clock,

but if you are asking if I think institutionally the system is

designed to work around it, it is not. Nobody is suggesting that. The

suggestion is staff are coming under pressure to stop the clock to hit

the targets. I think the point I would say back to that is the

publicised issue whenever the chief executive articulated that, there

were two patients, one who was about to be breached, the other was a lot

shorter, and the shorter one was placed in a bed because they need

was greater, and I think that is appropriate. Targets are not there

to be met artificially, they are there for a reason. We know the

information about time and we know about management of risk. The reason

is because we know that time is linked to the management of risk and

in any emergency department it is all about the appropriateness of the

management of risk. Of course. The pointers from the public point of

view, these figures only mean anything if they are truthful

figures and they are reliable. There is a doctor who worked in accident

and emergency saying they were unreliable. It is an opinion and he

is giving it on the basis of statistical information, and I

accept that it is genuine and well made. I would say to you on the

other side, I have spoken at length to very senior people, very senior

clinicians inside the Royal Victoria, and I have had an absolute

categorical assurance that there is no attempt to manufacture the

figures, create a system where they are artificially driven. That is not

to say on some occasions individuals might do that. I cannot know how

each individual behaves but I can say the system is not set up for

that. When was the very first time you

became aware that senior doctors in the Royal's department had concerns?

I was aware of the first formal occasion I had, is whenever the

medical let wept to our QIA. In the normal course we would talk to them

about pressures. There's an acknowledge there's pressure in the

system. Something which escalated pressures to the point we are

talking about is a recent phenomenal. You told Spot Light you

had not seen any of these e-mails from doctors. Have you now? No. It

is important to get into position who does who inside the health

service. That is really important. The organisation that I look after

commissions and we buy a certain volume to a certain quality. The

organisation that runs the service on a day-to-day service is the

Belfast Trust. What the doctor has referred to - with hindsight it

might have been appropriate that was escalated to me by the Trust or

escalated a little quicker. A lot quicker. It is always easy with

hindsight to say I should have done this. I don't believe there was any

attempt by the organisation to do anything other than a good job as

far as the population who use that service are concerned. How concerned

are you that only two of the families affected by this situation

currently know about the circumstances of their loved ones

deaths? Two know, three don't know. I was very concerned because we are

very strict on the serious incident procedure. Families are involved,

apart from when a family chooses not to be involved. If that has fallen

short on this occasion, I have said before that we will get that fixed.

It has fallen short. It has fallen short. I know that later today and

during the course of today families have been contacted. We are fixing

the system as a response to finding out it did not work as it should

have on the first occasion. It is to encourage learning to avoid

difficult circumstances into the future. It does seem very slow -

with the greatest of respect, we are having this conversation on Thursday

night - the programme was on Tuesday night. You know about the two

adverse incidents some time ago. You are telling me tonight you have

moved as quickly as possible. The incident, what is important to

understand is of the five we are talking about only one is fully

closed. In other words, the investigation is completed. The

other four are outstanding. Now, and until the thing is fully closed and

the loop is fully closed in that regard, I think we have to wait

until that gets to that position. The reason that the number of five

we are in, is we asked the information, is there any other

cases pending which involve potentially time? That information

has been released. We don't have any desire not to be transparent about

that. What is important about these incidents is they involve the notion

of time. Time could have made a difference. . That is correct. It

could have to the incidents, but it would be wrong to jump to the

conclusion that it was the principal causation of the death. And it is

very easy in this situation, I would like to take the opportunity,

because this is not just about numbers and statistics - this is

about people. It is very difficult not to understand the pressure those

families have been under during this last week. I have tremendous

sympathy for the family who made their position publicly known. Have

you apologised to them? Absolutely. Again, as I said to you, the actual

investigations are not complete. We have to wait until we get tloo u the

system. You -- until we get through the system. You know about five.

Jonathan Miller has told us this is the tip of the iceberg. I would be

disappointed that if the system does not collate that information. There

is an obligation on anybody workings in an emergency department in

Northern Ireland, or the health system, where there is a thing which

is nearly a problem to raise it formally. We encourage - we have 400

incidents raised with us across the whole of the health and social care

on an annual basis. We publish that information twice yearly. Here is

the problem - I wonder how concerned you are to hear that in one of the

two cases where the family do know what happened, the facts only came

to light because family members demanded a full investigation into

their loved one's treatment. If they had not asked they would not have

been told. It is difficult to have a debate about an individual case. I

have resisted doing that. It is not because I don't want to talk about

the case. There are real issues... The woman has been on the

television. She spoke on BBC Newsline tonight. I understand all

of that. In terms of the care and social health system there is a

principal we do not talk about individual sets of circumstances in

the public arena. There is an expectation when people talk to them

that it is confidential. That is a principal adhered to across the

system. In general terms, to answer your point about the issue about why

do we have serious adverse incidents, they can be raised from a

series of issues. A clinician can raise it, a family can raise it and

we will listen to that and we will deal with that. Nobody is suggesting

this is simple and straightforward. We realise it is complex. The

difficulty is what the public see in all of this are dramatic headlines.

They hear from and see overworked medical staff, working for well-paid

managers, who look, with respect, as if they are asleep at the wheel.

Well, I understand that. And I understand how that conclusion can

be drawn. I would say to you that everyone who works inside health and

social care gives their best to deliver the best that we can to the

public at any point in time. We leave it there for now. Thank you.

Let's hear from the SPLP and Dr Black from the British Medical

Association. You have taken an issue in health concerns for a long time.

Are you reassure reassured by anything that you have heard

tonight? I am flabbergasted. I have heard talk about the Royal, as if

this has emerged over the past few days, people have known for months

if not years there has been a problem with Accident Emergency.

We know that resources have not gone into the community to look after the

patients to transform the care. We know that beds are being blocked,

that there are not enough beds in the hospital system. Last Saturday

night, a friend of mine, her father needed a bed and he had to go up

into Northampton to get a bed. There was not one single bed in the whole

of the Belfast trust area. I am aghast at what I have heard tonight.

There does not seem to be any real, honest debate, among our politicians

and where some of the issues are. I would suggest to some of the people

sitting up in Stormont that they talk to the people on the ground,

such as the GP from Scotland, Jonathan, who has been very honest

and has done his colleagues a great service and indeed the patients and

users a tremendous service by coming forward over the past few days. Is

that how you see it? Are you flabbergasted tonight? Do you share

the view that it is not as difficult and awkward as negative a situation

perhaps as some people would care to believe it is? First credit to Dr

Miller for coming forward. To deal with your question, we are in the

middle of the biggest organisation niezational change that we've --

organisational change that we've had in Northern Ireland. The two ends of

the service are at the sharp end, which is A and E and General

practise. We are doing A and E tonight. Have we put the cart before

the horse on that? Have we made changes without having the beds

there and the Care in the Community that would be necessary? The cart

has gone before the horse - that is what a lot of people say. This

minister has shown leadership. He has shown courage. The minister has

denied there's even been a crisis. Do you know, the minister said there

was no crisis over the last few days. The minister and his party has

been dragged screaming to the floor of the Assembly. The First Minister

is coming forward to back him. A couple of years ago they told him to

act within his resources. You will not be surprised to hear that - she

is a political opponent. Why do you think he's got it right when he has

received criticism from many quarters? He's shown courage to

transform the service. We could pretend to have A around the

country or we can consolidate and provide a service. It is difficult

for doctors in A and the Royal. We need to improve the flows of

patients through there. We need... The point is, it is not happening.

That is why wef've had these serioused a -- why we've had these

serious adverse incidents and people dying partly because of waiting

times - how can that be acceptable? It is not acceptable and Dr Miller

is nodding his head, off camera here. Ehe knows we need to get the

-- he knows we need to get the flows through. We need to get patients

straight into the ward and seen. We have been closing hospital beds. We

need to get patients efficiently dealt with in hospitals and out the

other side. The process need toss be better. -- needs to be better. Is

point is, it is not being done. There are patients in recovery ward

in a hospital, two or three days post surgery and there is no bed for

them to go in. Nurses tonight are being told in the hospital they

cannot take their annual leave. When I think again - what is

required here is a degree of calm. To address the point and I do speak

to the trusts. They use the discharge for the day after, so

people are in recovery and in the recovery unit for discharge the next

day dhasmt is a standard issue -- the next day. It is a standard

issue. That is clearly, from the senior people in the organisation,

they have said that to me. I am relating to what I have been told.

It is wrong to sensationalise the thing. There was a crisis for five

families. There's no question about that. Maybe more families. We don't

know at the moment. It is not just the Royal, there are

crisis throughout the hospitals, right across... I don't agree with

that at all. Again, this is the difficulty and we could talk numbers

all evening, couldn't we? At the end, it is people. The numbers are

large. We see 700,000 people across Northern Ireland. 90% of them are

treated and discharged within six hours. There is a problem.

I don't want to ban diy figures about all night. The %age of people

seen within four hours, 94% in England. 72.5% in Northern Ireland.

62% in the Royal Victoria Hospital. That is more than 30% less than it

is in England. Hospital beds in the last five years, Northern Ireland

has lost 18% of its hospital beds. The Belfast trust has lost 20% of

its beds in that time. It does not make sense. It does not when you

present it that way. If you look at who went to do the visit and made

comments, they agreed the model of care in the royal Victoria is the

right care. The medical unit and the speciality unit. The patients flow

through the system. That is the issue and that is the difficulty. If

you think of the detail that occurs from somebody going through their

front door, through hospital, through the emergency department,

through specialist yun knitses and to be -- specialist units and to be

back home - there are 100 processes. People don't understand when you use

a phrase like "the granuality of the details." The individual has to

leave, go via ambulance. They have blood tests. They may have x-rays.

They have to move from there to a ward. That is specific detail which

has to work out to get to the 94%. I want to give the final work to

Jonathan Miller, who has been listening to this. Are you reassured

by anything that you have heard tonight, that this is

sensationalist, is his suggestion, that people need to look at it.

Calmness is different from being sensationalist. I used the word

calm. I think you used the word "sensationalist" as well. The point

is we need to be calm about it? Are youry assured by anything -- are you

reassured by anything that you have heard? I accept these are complex

problems which do not have easy solutions. What has concerned me

over the last 48 hours is there appears to be a reluctance to accept

how big a problem this is. I think the figure you quote tells the whole

story. 60% of our performance. We know that that is associated... The

minister has called for a review of the Royal A and asked for an

examination of the figures as far as adverse incidents are concerned.

Helpful? Yes, any examination of the system. Any learning that can be

learned from data already there is useful. We have seen this in other

parts of the UK and we have to learn the lessons of Mid-Staffordshire.

People have to accept there is a problem before you can build a soe

lulings. -- solution.

The I expect that will dominate the headlines for quite some time to

come. You are retiring next month. Are you counting down the days? I

have enjoyed what I am doing and I have tremendous belief. I access

there are things that need to be done. Nobody is trying to say here

that we have no interest in the people and the use of this system. I

have a tremendous commitment. We will leave it there. Thank you for

joining us. We will make of it what we have been discussing. It is a

welcome back to our commentators. Good evening to you both. An honest

exchange of views, certainly no meeting of minds. I think it was

Enoch Powell who said it was the graveyard of most political careers

and he is right. The NHS, there is never enough money, resources,

staff. Everybody has a story to tell about it. For most people, going to

hospital is one of the scariest things they will face and they come

out more scared. They are saying they are fixing the system, it is a

process of change, and for a lot of people, it is going back years, the

system never seems to be fixed. It is never completed. My view of it is

we are experiencing a crisis despite what was said. It frightened the

hell out of me that doctors and nurses who have had to go to the

media to raise their concerns, some of the stories we have heard, talk

of bullying in hospitals, pressure being placed on staff, we are

hearing the possibility that a number of patients may have died in

accident and emergency while waiting for treatment, there are concerns

going unaddressed, we are hearing about beds being lost, and I think

the health service is in a worrying state so far. We -- the issue about

transforming your care, the minister deserves credit, but the criticism

you hear is that while that is fine, we have not put in place a safety

net to catch people when things go wrong. If you want to put people in

the community and want them to be looked after you need to put

domiciliary care in. A lot of people would argue that has not happened.

Doctor Black is right, Edwin Poots has not been afraid to make

decisions, make himself unpopular, and artists -- that is rare. This is

not my field of expertise, but you will never be able to construct a

net big enough to catch every single person who falls through. It is just

the nature of the system. If you look back to when the NHS was

created, they were arguing you would not need this number. It is

topsy-turvy and it would continue to grow. It is impossible to reach a

moment. Let us pause. We have a question for you to think about, are

the politicians about to set their dues aside in favour of pink? It is

the official colour of the Giro d'Italia. It is just before the

elections, that means there will be a election posters adorning lamp

post. Those tuning in will not expect to see them. What chance is

there that they will ban posters? Weave an opportunity here of a

sporting event televised throughout countries. -- we have. We don't want

the posters in the background, putting up like on the perfect

scenery of Northern Ireland. -- putting a blight. If there is to be

a poster free route there needs to be a cross-party agreement because

there is no point in two or three parties not putting posters up and

the rest spoiling the show. I believe this is a very positive

suggestion. This race has a global audience of 775 million. I have been

told that my days as a poster boy might be over. I will examine a

range of options including a ban. We have two weeks after for the

elections so there will be enough time to see our beautiful faces

before election. At least they have a sense of humour on that. What

chance of this happening? I don't know. It is possible, it could

happen. I think many members of the public would appreciate it, and

believe it was said that politics was show business for ugly people.

This is something that would suit the big parties rather than the

independents, it is the only way of getting the message out there and

raising your profile. It will only work if everybody signs up to it.

Most people won't sign up to it, they will hope most people don't

sign up to it. You cannot this connect politics. -- devolved

politics from this. We should ban election posters and pink lycra.

That is it this week. Apologies we did not bring you the Irish language

story. Thank you for watching.