Coroner slams Tameside hospital over death of child!

Where does the buck stop at Tameside hospital, when it comes to taking responsibility for hospital failures and incompetence? For years now, we have hardly seen a week go by where we've not read about the death of an hospital in-patient brought about by incompetence, negligence, and systemic failure. And yet, in spite of this catalogue of failure, many on the hospital board and senior managers at the hospital, have continued to remain in their positions.

Last week, the tragic death of 12-year-old Emma Stones, from Dukinfield, who died at Tameside hospital last February, was reported in the press and on the TV, after the local coroner criticised the inadequate care the hospital had given her. Emma who suffered from cerebral palsy, was admitted to the hospital on the advice of a community nurse, but died the next day of blood poisoning. The inquest heard that no blood sample had been taken because a registrar had been too busy to attend and that a team of nurses, - who should have observed her every four hours - had failed to regularly monitor Emma throughout the night. It also heard that the "lack of observation in the morning had been appalling" and that she "may have died almost four hours before her father saw her."

Giving evidence to the inquest, Dr. Nelly Ninis, a consultant paediatrician at St. Mary's Hospital in London, said there had been 'systems failure' and that it was 'probable', "Emma would have survived if her symptoms had been recognised and treated on the evening before she died." She added:

"The system that didn't work at all is the system of recording there is a sick child on the ward."

When asked if she believed that Emma had been dead for some time, she replied:

"I think so, unfortunately. My reason is the fact that she was noted to be ice cold and there was some evidence of rigidity and some rigor mortis present." Her father, Mike Stones, had been told by hospital staff that Emma had died at 8.50am but she was "ice cold to touch when he was allowed to see her 10 minutes later."

Recording a narrative verdict, the coroner John Pollard, said:

"The nursing and medical care of Emma fell below the standard that most people would consider satisfactory...the inevitable conclusion was that the care was inadequate to such a degree that it played a part in Emma's death."

Mike Stones and his family say they are "disgusted and appalled" by the care given to their daughter by Tameside hospital who they believe, left her to die in hospital. The family are considering taking legal action and hope that lessons can be learned from what as happened to their daughter so as to prevent a similar situation arising in the future.

Although the hospital's medical director, Tariq Mahmood, says the hospital "has taken every possible step to prevent any re-occurrence" it seems likely that such a tragic event could happen again, given the hospital's recent history and management.

As far back as 2002, the 'Commission for Health Improvement' said that morale and patient care had been compromised at Tameside hospital by poor communication. In 2005 Milton Pena, a consultant orthopaedic surgeon at the hospital spoke out publicly about how staff shortages at the hospital, were putting lives at risk. After disciplinary action was taken against him, other consultants said they had no confidence in hospital management. In September 2006, the coroner John Pollard, called care at the hospital 'absolutely despicable' and 'chaotic' after inquests into the deaths of four elderly people in one day. The hospital responded by making a complaint to the Office of Judicial Complaints(OJC) that the coroner had insulted staff and had added to the distress of families. The OJC rejected the hospital's complaint.

In their latest report released in May, the local health watchdog Tameside LINk, put Tameside hospital on the critical list. Although the LINk report says there was significant improvement in some areas, the hospital was given the lowest-possible 'red' rating in three out of five domains - 'leadership and complaints', 'getting the right care at the right time', and 'communication and information'. The report says that many of the LINk's concerns that were raised two years ago, have not yet been eradicated and that patients are still not getting basic help with washing, bathing, toileting and assistance they require with feeding. Pointing out that there had been an unprecedented level of formal complaints, the report says:

"The fact that we still have these concerns suggests to us that the hospital's leadership culture, systems and processes have not been effective. Executive Directors must take full responsibility. They must initiate urgent remedial action and hold to account those charged with devolved responsibility for its effective implementation at all levels. They themeselves must in turn, be held to account by the Board's Non-Executive Directors."

In its report on the death of Emma Stones, the Manchester Evening News, is calling for heads to roll at the hospital and had dubbed Tameside hospital 'shameside'. This is a view that many people share.