FINAL OUTCOME. October 2024.

Witness the full text of the interview I gave to BBC Radio Gloucestershire (November, 2024), in the wake of the receipt (1 October 2024), after a final twelve months of stalling, of GHNFT’s  Stage 6 complaint response.

Read it and weep!

WHAT HAPPENED TO YOUR MOTHER?

Well, my mother, Olive, Olive Smith, spent three weeks of lock down (visiting rights revoked) in the April, three years ago, and so, 2021, on a hospital Elderly Care Ward to which she had never previously been admitted. Suffering principally from intermittent delirium (cause unknown), also occasionally feeling faint, when sometimes her blood pressure would reduce; always the same, upon sitting down, after standing up, from a starting position, of lying down (postural hypotension).

Ward 4a elderly care ward (now defunct), Tower Block, Gloucestershire Royal.

Yet she then emerged from lock down with no fewer than five, deep, dressed tears and gashes (even gouges) to the skin on her arms and legs, as noted (and furthermore photographed), within just 12 hours of discharge, by the District Nursing Sister which the ward itself had now called in (and, critically, within the context of my complaint, had recorded it had), in order that her colleagues could start coming to the house to change the dressings the ward itself had hitherto been applying and re-applying during my mother’s stay (and again, critically, had been noting that it had been).

And so it was obvious that the Trust, from the very outset, had been fully aware that these injuries had accrued on the hospital’s own watch. AND what type they were.

WHAT IS YOUR GRIEVANCE WITH GLOUCESTERSHIRE HOSPITALS TRUST?

And yet there then began three years and three months of failure to acknowledge they HAD occurred, DURING admission. And also failure to disclose (deny rather there were any) associated records in my mother’s ward files, from the time.

The Trust’s initial, strange ploy was even decisively to attempt to spin away from the concept of actual injury altogether, and treat of nothing more than bruising instead. Which had also extensively occurred. Big bruises, as well.

Once I got the Trust back on track, by confronting them with the district nursing records, that detailed not just the bruising, but also the tears and wounds to the skin, all the Trust’s Complaints Department did was relate this back to me. Of all of which, of course, I was already aware.

It passed on this, and three subsequent opportunities I was to give it, itself to marry this up with the many entries to the same effect that it fell to me to establish had been in the hospital’s own, admission, notes, also.

The Trust would only respond, ‘There is no mention, of skin tears, in the notes’. And persevered, the same. With the CEO attempting to foreclose, ‘The only information we can provide for events…is taken from your mother’s health records and we have provided you with that information already’; then spin back, to bruising, solely, again.

HOW DID YOU DISCOVER THE TRUTH?

Well, it had always been clear there were just two possibilities here. Either no entries had been being made for the injuries, during admission, a serious malpractice, or the Trust was being ‘disingenuous’, to put it tactfully. So not disclosing relevant entries. And accountability thereby avoided.

Towards the autumn of last year, and so 2023, well over TWO years into complaining, I had to apply for my own copy of my mother’s medical file, under a procedure known as SAR (Subject Access Request).

WHAT DID YOU FIND?

Well, after a further twelve months of continuing to stall, now, FINALLY, comes acknowledgement from the Trust of the omissions from the files of which they had been guilty. And remember, without my own extensive investigation and efforts, none of this would ever have been prised from their grasp at all.

For the first time, it was admitted they had hitherto fed me ‘inaccurate information’ (their own term).

That ‘breakages to the skin’ (again their own terminology) HAD been received, DURING admission. Even one, as I’d known, recorded as ‘deep and bleeding’, at the time!

That sixteen such references – only the one to an actual ‘skin tear’, with the others alternatively secreted away in the files as ‘wounds’ (with of course multiple references to their subsequent re-dressing), or referenced in the files instead as flaps of skin, which had been lifted, from my mother’s arms and legs – well, in short, all these had been in the files all the time, but had never been disclosed.

Although the one injury my mother HAD told me about herself, distressed, over the phone (confirmed to me by ward staff at the time) had NOT been recorded. Meaning, as increasingly large numbers of us are coming to recognise, in the culture of the NHS, and its often all too compliant regulators – if the NHS didn’t record it, it NEVER HAPPENED!

What was never denied was that, not long into admission, my mother, for the first time in her life, and for lack of proactive care on the ward, had sustained what is therefore termed a ‘hospital acquired’ pressure sore, at the base of the spine (the coccyx)… and so, lower back. But what HAD been denied all along was the District Nurse’s assessment of a ‘wound on the coccyx’, on discharge. ‘No mention, in the notes’, the Trust claimed.

But it has now additionally finally been conceded there WAS a ‘breakage to the skin’, in that area, in the file.

Same as for the arms and legs, I was this time able to count up a total of TWENTY entries, directly related in the files either to the coccyx itself, or to the immediate vicinity, and indicative of damage.

TWENTY opportunities passed up to give open, honest and transparent acknowledgement, as to the extent of the documentation of what was happening, in this site.

WHAT WERE THEIR EXCUSES?

I have been urged to accept the frailty of my mother’s skin was such as to render damage to it inevitable during any admission. Yet, whilst the ward still maintains its moving and handling of my mother was ‘reasonable and appropriate’, the Trust has now finally conceded they themselves probably (undoubtedly, to my mind) did contribute to the damage, in this regard.

But I do not buy into this notion, of inevitability. Least of all when not a single tear to the skin, nor one wound (nor even one bruise) had ever accrued during stays on a sister elderly care ward alongside. Nor did, upon discharge, at the hands of the ambulance service, or the district nurses, nor myself, fully involved in Olive’s handling, too, as I was now, nor of an assistant live-in carer I had fetched in, in order to be able get her out of hospital, keep her out of care, and back home.

As regarded non-disclosure of the injuries, as I had thought to be the case all along, the Trust appeared to be relying on nit picking, cheese paring semantics. Deny references in the records, with complaints founded upon particular phrases, such as in my case, ‘skin tears’, and ‘wound on coccyx’ , if those phrases, THEMSELVES, do not ACTUALLY appear there, in the exact format – and so, the same, WORD-FOR-WORD – upon which the complaint was based.

I most certainly do NOT accept their excuse also that a complaints department and Matron combined had lacked the basic competence and common sense to look beyond just the first couple of pages of a hefty, sizeable ward record functionally and solely dedicated to the condition of my mother’s skin during her stay – and had therefore MISSED, SO MANY references! Err, thirty-six?! Might any reasonable person not assume they were just chancing their arm, and relying on these omissions never being identified?

WHERE DO WE GO FROM HERE?

Potential misrepresentation of this sort is answerable nowhere (nor even when it features in follow-up, so called, ‘Local Resolution’ talks, that can be granted, directly, face-to-face, with relevant staff).

This is to make a mockery of the whole system, and even for defilement of genuinely aggrieved, or, worse still, mourning, complainants. Like myself.

There is no requirement anywhere, legal or otherwise, that Trusts refrain from their increasingly frequent recourse to the dark practices, when responding to complaints, of withholding information, spinning, avoiding, delaying, obfuscating, issuing self serving, and therefore brazenly irresponsible, knee-jerk, unsupportable denials, in SUPPORT, of staff – or even going on what they, wrongfully and misguidedly, regard as counter-ATTACK. All this they can do at will, and with impunity.

Which is why there are several national movements currently to enforce this Duty of Candour so badly missing from the NHS complaints procedure, by pressing for their handling to be taken away from the Trusts and entrusted instead to a single, new, truly independent external regulator.

A small ‘awareness event’ is presently scheduled for Cheltenham town centre, one Saturday, before year’s end. Under the auspices of a group calling itself ‘Campaign For Positive Change For A Better NHS’. Three similar events are to be held across the country, concurrently, in South Wales, London and Manchester.

There then followed a ‘plug’, for the role of independent NHS Complaints Advocates, PohWER, based in Birmingham, in bringing the Trust back to the table, at a point at which it was seeking to let the matter of ‘Local Resolution’ talks slide into abeyance. These it had been actively scheduling – but had pulled out, once they were told their point was to confront them, with their omissions from the files.

Listeners were invited to make contact through the Facebook group, ‘Carers Want Competence’, or via its email, [email protected]; or through the radio station itself.

(Earlier update) Gloucestershire Hospitals NHS Foundation Trust, in its complaint responses, ‘mistakenly’ (although it has not yet admitted it) referenced the photographs of my mother’s wounds held by the Gloucestershire Health and Care NHS Foundation Trust, and taken by the  latter’s district nursing team, as dating from May 29th (2021). As I however recollected, and have now determined from GHCNFT, they in fact did relate rather to a much EARLIER home visit – on May 2nd (2021). As such, they show conclusively (and this is backed up by the written record, twice) that there were wounds photographed on May 2nd (2021) that had already partially scabbed over. Which, of course, could not have have happened in the 15 hours that was all that had elapsed since her discharge, the previous evening, from Gloucestershire Royal, on May 1st (2021); and which, together with the absence of any note of tears and gashes upon her person, on admission, at either its A & E Department, on April 8th (2021), or by the GRH ward to which she was admitted the next day, April 9th (2021), and where she stayed for the next three weeks, until May 1st (2021), places the ball vis-a-vis origin of these injuries unequivocally in the lap of GHNFT. Who have claimed ‘they cannot help’. Do you think they will admit (non-financial) liability now? Do turkeys vote for Xmas?! No they will simply let this ride. 

The Carer In The Cotswolds has just reported Gloucestershire Hospitals NHS Foundation Trust to the Care Quality Commission as, down the last five years, I have now identified three different cases of deficiencies in records kept by its two lead hospitals in respect of injuries sustained by, and sedation applied to, the elderly on their wards. My parents.

It was during, I complained, her admission to such a ward at Gloucestershire Royal Hospital, in April last year (2021), that my late mother sustained what were finally conceded, a year on, at ‘Complaint Stage 2’, as being multiple skin tears (five) to her right limbs and left shin; she also had a ‘wound on the coccyx’ (bony area at bottom of spine). This concession to the truth only arose at all after I had myself had to refer the Trust to the district nurses they had seconded to treat my mother back out in the community, on discharge; so how did the Trust, anyone reasonable might well ask, come to propound the following ‘misconception’ in the first place, as their initial response to my complaint? (It should be noted GHNFT simply reported this (of all of which I was of course already aware) back to me; it accepted no responsibility for the injuries, and made no attempt to marry its ‘sister’ Trust’s records up with the many entries to the same effect, already existing in its own ward notes, for my mother, during her stay).

For the Trust’s initial, ‘Stage 1’, response (after a wait of four and a half months, and my mother now gone) curiously did not admit of anything other than ‘bruises’. It then spent considerable time asserting how it had now been to considerable trouble getting ‘bumpers’ fitted to rails on beds to avoid this in future (”learning”). It also suggested this ‘bruising’ had been caused by my mother thrashing about when her intermittent delirium was present. To which I replied that, over the nine and a half months during which I had been caring for my mother at home, this condition had never once caused her to ‘thrash’ in such a manner. Nor would it once have been seen by the agency nurses I employed over the last two and a half of these, to assist me.

In January 2022 I asked that the Trust search their records for further details, giving my own best guess as to how, and the date on which, in the April (2021), the gashes were most likely to have occurred. Immediately prior, there was to have been a fleeting reunion with my mother, ten minutes at the Ward entrance, after separation due to lock down. When this was not possible,  as she had fainted, I was then advised not only could I not actually briefly come in instead (understandable, no visiting allowed), but that I should refrain from trying to contact her by telephone for the rest of that day (not so).

End of June 2022, at Stage 2, the Trust merely replied they had requested further information from the original respondents within the Trust, but concluded ‘There is nothing further we can add’.

Not good enough.

I would now ask how it is that such a discrepancy (bruising, as opposed to gashes and tears) could arise in response to this issue, and subsequent feedback, when, in preparation for my mother’s return home, on May 1st 2021 (and this bears noting a second time), it was the Ward itself that would have made the referral to Gloucestershire NHS Health and Care Trust for the community (district) nursing team attendance that followed to treat her (two months’ worth was required, twice weekly). And the ward that would have had to indicate, on referral, what was wrong (district nurses do not attend for bruising, so the Trust certainly did not represent this to them). It is additionally to be noted that, of course, dressing of these injuries would have had to commence on the ward, during admission (and their nature would therefore not have been unknown). The Trust, at Stage 2, has not addressed how these common sense points were simply glossed over at Stage 1…

Conversely, all reference to these injuries on Olive’s ward discharge sheet (copy from hospital to daytime practice) was excluded, if I recall. The Trust was asked to check this at Stage 2; it has made no comment. The Trust did not add the tears and gashes to the Discharge Sheet For Practice Nurses And Community Nurses, either.

Neither has it commented on how such injuries, given the continuing mystery of their origin, cause and date, were never logged as they occurred. On January 7th 2022, I reported this to the CQC, and they (through a National Care Standards Commission Customer Advisor) replied, four days later:

” We would certainly expect NHS hospitals to log the incidents you’ve described. We also expect services which are regulated by us to complete a CQC notification form for anything considered a serious injury, or an allegation of abuse.

The hospital itself should have reporting processes in place, and you can find some information on the NHS England website – Report a patient safety incident ”

The Trust has now indirectly attempted to distance itself from these serious injuries having been caused during the admission, by dint of what I report as their failure to enter them into the records in the first place. It cites their first, it spins, documentation as having been by the district nurses, on the morning of May 2 2021. A mere twelve hours after my mother arrived home, under the safe escort of an ambulance crew, and into the arms of her devoted son/carer, also a 24 hour agency nurse. Perhaps it would like to speculate how these originated, other than in their own care? Such recent provenance would correspond neither to the clinical progression of what the nurses would have uncovered, and described, on the 2nd (and I believe photographed)…nor to the (professional) dressings on the wounds already needing changing (dating them again back to admission). How convenient, just exclude anything iffy or suspicious from records, and you’ll never face accountability!

Regrettably, this was not mine and my mother’s first experience of such shortcomings at Gloucestershire Royal. In February 2019 (memorable date – my birthday), the self same (minor) medical incident befell her during our attendance at Gloucestershire Royal A & E as above – she fainted. I had not been separated from her at all at this point, and, at the juncture referenced, was observing – with a doctor – through the cubicle curtain. My mother fainted whilst sitting upright (on a commode), and was then transferred to the floor – and thence to another area – by, and in full view of, numerous medics, including doctors. Medical staff were warned her skin was fragile when they were lifting.

On arrival on an elderly care ward (not the one above), it was discovered similar tears and gashes had been inflicted to Olive’s limbs as in 2021. The reason given, in writing, by A & E? Incurred whilst falling off the commode (to the floor).

It being accepted by us at the time they were incurred, in good faith, during provision of urgent care, this pattern would still suggest, I venture public spiritedly, that disinclination to establish (and thereafter, if appropriate, accept) blame has been around this Trust for years; one – in this instance – (appearing to be) exacerbated by a culture of the Trust ”’departing from the facts”’ – proactively. The common theme being that this is wholly untoward.

It is my genuine opinion, over repeated such scenarios with both parents (below), that this is a culture far too widespread within the Trust. It seems to be known staff will be supported against complainants.

Furthermore, the entire NHS complaints process, at Trust level and beyond, when it is a matter of more serious issues, is in my experience a case of your report of events simply being overlaid with their own selective, superior (and of course definitive) spin on them. It is a nightmare. Blame, responsibility and accountability are notions that were swept off the NHS table long ago. As a senior figure once told me, ‘We are not accountable to anyone’. But they are tax payer funded – not some kind of private members’ club.

Last word. ‘Unfortunately, the community staff (district nurses) are unable to speculate on how the skin tears were sustained’, came the Trust’s reply. I do remember they were appalled (and took photos).

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Now my report of further unexplained, anomalous, record keeping within GHNFT, this time, at Cheltenham General, in 2017, when sedation was administered to my father – again on an elderly care ward. I would wish for reassurance there is not a clear and dangerous trend here, down many years, and at both the Trust’s main hospital sites.

This is important, as it was administered when he struck a bank nurse in the middle of the night. Nursing staff were then co-opted into a decision (half taken on the basis of his proving too difficult a patient, with his dementia – I have this in writing from a senior colleague of ‘our’ consultant’s, who spoke of ‘behavioural problems’) abruptly to withdraw active medical treatment just a couple of days later (early February). Who will convince me this had no bearing on impartiality – even subconscious? Is that an illogical assumption?

I was informed of this incident twice the next morning, once over the telephone, and once in person, as I arrived, by the same Staff Nurse (name known), in charge of the ward that day. No mistake – NO ‘misunderstanding’ (a favourite ploy)  The Mental Health Team had had to be called out to sedate him , I was told (God forbid they could have got on the phone to me to turn out and try and help).

We also wished to know what type of sedative had been applied, as he was already on a cocktail of medication (including – without our knowledge – continuation of (a month’s worth of) anti-psychotics, a ‘dreadful chemical cosh’ (another Consultant’s words) we had been warned off weeks before, on another ward, and to which we had therefore expressed our opposition at source)…and there was always the danger, we thought, this had contributed to the ‘downturn’ (clearly not insurmountable, as even his consultant admitted, but from which they withdrew their (active) medical support nevertheless – again regardless of bitter protests) that occurred so shortly after.

We asked for this information in June 2018. I was finally told – over a year later, August 2019! – that no such incidents had been ‘documented’; along with what we read as the withering, pitying hope that we were able to find peace as to what had actually happened (i.e. there is no point scratching around trying to incriminate us).

These are very serious issues. I combine them with others, concerning historical assignment of some of their aged charges (often with dementia) to end of life care, where anomalous application and statistical outcomes have been clearly identified, but where the representations I have been making to GHNFT for five years have never been directly addressed, rather swept under the carpet, to call for an independent review of clinical care of the elderly (COTE) on relevant wards at both major sites in recent times. This I have done, to the Department Of Health And Social Care (link – ‘Home’ – below).

Have our loved ones been as safe as they could have been?

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