The fourth anniversary of my father’s death under HSCNI. I wonder if those who caused you harm remember you and I wonder how long it will take to get the truth. You were golden and your life was priceless.
#Delirium treatment is much more complex: treat the cause(s) - usually more than 1, optimise physiology (e.g. hydrate), detect & treat distress, prevent complications (e.g. falls, pressure sores, aspiration), communicate with family, rehabilitate, etc.
#meded
@hughlaurie Thank you for giving us the inimitable Dr House. I have lovely memories of watching it with my late dad. Your post on your beautiful Bailey, and your like on my comment and pic of my own boy, Max, stay with me. Have the best next trip around the sun, sir, and many more beyond.
Just when you think you’ve seen or experienced the lowest level of inhumanity when dealing with bereaved relatives. The not so hidden side of the caring profession.
Fighting for access to our own data; an NHS official responded to concerns with a 👎 emoji.
This is how a bereaved parent is treated. Doors shut. Appeal after appeal, further trauma inflicted. 8 years still without answers; many formal complaints, regulators and Ombudsman.
''If one person had done their job correctly, Mason would still be alive'
Mason Scott McLean was just three days old when he died in April 2023.
He was killed by sepsis that multiple healthcare professionals failed to identify, treat, or act on in time.
In the years since, Mason’s mum, Julie Keegan, an ICU nurse herself, has been fighting NHS Greater Glasgow and Clyde over the significant adverse event review into her son's death 👇
@Juliekeegs@PaulJSweeney@jackiebmsp@AConstance23@willie_rennie IMO, it’s not about training but failures to follow the sepsis protocol. It isn’t rocket science; it’s a basic but life-saving step-by-step process that a first aider could follow. Failures to follow it should be explained, not whitewashed as “missed opportunities”.
💯. The ‘no blame’ culture is the inbred sacred cow of health & social care, designed to block transparency, responsibility & accountability at all costs, including patient safety. It is the root cause & perpetrator of a vicious, unbreakable circle of preventable harm & death.
@alice_toppingx@EmilyJBarley@jamesmurray_ldn@DHSCgovuk@Keir_Starmer Alice, please don’t get me started on MNSI’s “no blame” culture — it’s only 6am! Anyone who thinks a “no blame” culture is safe in maternity care should take a long, hard look in the mirror and at the destruction left in its wake.
Until we stop struggling with the idea that some health setting cultures are rotten and some practitioners do not practice with compassion and dignity, we will never improve them
"I sit in the constitution realms" (whatever that means): Watch Jayne Brady's rambling response to Opposition leader Matthew O'Toole's simple question - 'Are you accountable for the state of the civil service?'.
https://t.co/rqJk6TnfcP
So is hospital imposed ‘incontinence’. Not answering call buttons; sticking pads on pts, for an easier life for staff.
I once told a manager,if she needed help to use a toilet and it wasn’t provided, she would eventually wet herself and that’s not incontinence. Blank look back.
@mancunianmedic I’m not fam with the initiatives you ref but guidance often isn’t followed, even basic but critical guidance that can make the diff b/n life & death for elderly pts, eg delirium, not followed for my dad in ED or ward.If it doesn’t start well, it prob won’t end well and it didn’t.
Good, succinct article. Ed’s is where the decline starts. An imp factor missing though, IMO and based on my experience - it isn’t just about capacity, resources etc. Most detrimental is a desensitisation to the needs of frail elderly people. I would go as far as to say ageism.
@mancunianmedic 💯 fair comment. I’m referring to staff who are simply desensitised, cold. It’s as if they don’t exist but they do & are detrimental to frail elderly people. IMO, even with the real challenges for staff, basic compassion creates the best pathway for older people to survive hosp.
Expect no substantive answers on this latest scandal. HSC staff are lauded as so god-like & irreplaceable that even failures in plain sight are excused & covered up. The ‘reviews’ & ‘Lessons Learnt’ are pages of empty. As long as the truth stays buried, that’s all that matters.
“The Belfast Trust said Lau remained an employee but had not seen patients in the past 3 years while the review was ongoing”
What then has he been doing for 3 years??
More precious health expenditure wasted on his salary, cost of recall & likely claims😩 https://t.co/cjLukZaDfM
Same old lessons learnt🥱. No accountability. Again. The managers of the Southern Trust, PHA & every other HSC org will clink their wine glasses to the health minister, breathe a collective sigh of relief & force the Ladies With Letters to fight on.
https://t.co/w4RkmnfPQh
Datix forms are also anonymised in NI. My father’s fall was dated as opened & closed the next day, no investig. We were told, oops sorry, it was backdated. Broken hip at 85, died, logged as moderate harm, ‘oops sorry’. No transparency = no accountability. The name of the game.
@LittlePersonDoc When raising a clinical concern on the Datix system, I do so - at risk - under my full name. The response is often null.
The responding manager's details are anonymised by the system, and I do not have the privilege to ask for them.
This is patient safety, in @NHSEngland.
“When an institution cuts itself off from every difficult truth in order to preserve its reputation, power, and possessions, it creates a cycle of cover-up”
How & why NHS managers swing into the same actions against pts, families & staff who raise serious life & death concerns.
One of the most painful experiences of speaking truth to abusive power is watching the discussion slowly shift away from the harm itself and toward your motives, tone, credibility, and loyalty.
Eventually, the landscape is turned upside down and the truth-teller becomes the problem.
My latest article: https://t.co/lxRMgbf9Ue
This reads like a checklist of every failure my gentle, suffering father experienced. Ended in a horrific death for him. Has left us traumatised. All wrapped up with the bow of “missed opportunities”. All so easily treatable.
Sedated for "agitation." Pelvic fracture found 2 days later.
The agitation was pain. It very often is, especially in surgical patients.
When someone is agitated & delirious, the first question isn't "what do we give them?" - It's "what's causing this?"
Pain. Infection. Urinary retention. Constipation. Hypoxia. The list of treatable causes is long.
↳ A systematic head to toe approach is always needed when evaluating the possible triggers.
#delirium #medtwitter
Shocking but not surprising. Not minuting MDT meetings or not even bothering to put an MDT team in place, surely screams neglect of complex patients, resulting in harm to them & others. Cue attempts to normalise it by excuses of small team, v.busy, used white board etc.
I’m still reeling from yesterday’s evidence.
Nottingham Healthcare Trust have Multidisciplinary Team (MDT) Meetings that are not minuted. So how do you document patient progress, or input from the multi-professionals about what has to be done etc etc.
MDTs are an enormously powerful tool when used properly. They give a 360 degree view of a patient from all angles and all professionals. They’re incredibly important. To have weekly MDTs and then treat them like a joke is a total failure of governance by the Medical Director, Chief Executive and all of the senior management team.
No wonder they have got so much and so badly wrong.
MDTs aren’t a knees up with a cup of tea & biscuits, having jokes, they are very serious meetings.
Any Mental Health Trust not formally recording/minuting your MDTs please under duty of candour, report yourselves to the CQC.
Corporate failure is what this is at every level. No one at any level questioned this practice.
I can’t quite believe it.
@CareQualityComm @nottslive @Alison1mackITV@EmilyMayTV