Tuesday, 14 June 2016

North Middlesex hospital A&E faces closure on safety grounds

Exclusive: Move would be first in NHS history, as internal documents seen by the Guardian show junior staff often left in charge of casualty unit
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 Ambulances outside A&E at North Middlesex hospital. Photograph: Dinendra Haria/Rex/Shutterstock

An A&E unit has been threatened with closure on safety grounds for the first time in the NHS’s history, amid fears that its 500 patients a day are at what the medical regulator calls “serious risk” of suffering harm.
The General Medical Council, which regulates doctors, and Health Education England, the NHS’s staffing agency, have both issued the unprecedented warnings to North Middlesex hospital over what one local MP described as “a catalogue of failings” in its emergency department.
Unpublished internal confidential NHS documents seen by the Guardian reveal widespread alarm in the NHS locally and nationally that some of the hospital’s A&E doctors lack the basic skills to do their jobs, and that young, inexperienced doctors have been asked to perform tasks they were not qualified to undertake.
There are also occasions on which, despite their lack of experience, “junior staff [are] being left in charge of the [emergency] department, highlighting a probable risk to patients”, a private meeting of NHS chiefs was told last month. There is also serious concern that just two of the 26 junior doctors in training in the A&E have ever worked in an emergency department before and that care in the unit overnight is described as “an area of significant risk” to patient safety.
The hospital has been given until the end of this month to resolve its main problems or risk either the GMC or HEE, both of which play a key role in ensuring patient safety, removing all 26 doctors from the A&E. Such a move would leave it so short-staffed that it would have to shut. But other nearby hospitals have warned that they would not be able to cope with sudden influxes of A&E patients from the North Middlesex because they are already so overstretched themselves.
North Middlesex has yet to explain the death of an unidentified patient in the A&E unit on 15 December as a result from what the hospital has privately admitted were “serious failings in management and care”. There are also concerns that children attending the unit could receive inadequate care and that some of its equipment is sub-standard. 
The hospital, which serves some very deprived parts of London, blames its problems on a chronic lack of A&E doctors. It struggles to recruit medical staff because of the nationwide shortage of A&E consultants and the fact that it is not a regional trauma centre and is based in Enfield, a high-cost part of outer London.
“We are extremely concerned about the standards of training and support for trainee doctors in the emergency department of this hospital. Without adequate support and supervision there is a serious risk that their patients are being put at risk”, Niall Dickson, the GMC’s chief executive, told the Guardian.
“Together with Health Education England we have set out what the trust must do to put matters right and together we will monitor the situation. Ultimately we will not allow postgraduate training to continue in this department if the appropriate action is not taken”, he added.
The situation at the North Middlesex is so serious that – in a highly unusual move – NHS England is desperately trying to persuade other hospitals in the capital to lend it some of their own A&E medics for six months to avert the possibility of its emergency department being closed. It has so far signed up five of the 10 being sought, but the NHS’s general lack of such doctors is hampering its efforts.
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North Middlesex hospital has been ordered to improve its A&E by NHS bosses. Photograph: Dinendra Haria/Rex/Shutterstock
The GMC is so worried about patients coming to harm that on 20 May, for the first time, it sent HEE a pre-statutory letter threatening to remove the 26 junior doctors in A&E – in effect closing the department. It told HEE that it had “significant concerns and that we were considering our regulatory option, including the withdrawal of approval for the posts in the emergency department”, a spokesman said. HEE itself has also threatened the North Middlesex that it will use its own powers to stop the 26 from working there.
That came when HEE identified eight major failings at the hospital during a “quality visit” on 15-16 March. HEE has taken a tough stance before with the North Middlesex over the conditions faced by trainee doctors. In February and March last year, it removed 11 NHS anaesthetists from the hospital “because the department was failing to deliver high quality and safe training”. None of the trainees has returned and training is still suspended 16 months later.
An HEE briefing paper on the hospital, written after that inspection, said its inspectors had found worrying evidence of “paucity of effective clinical leadership; culture of bullying; extreme workload; deficiencies in basic emergency department equipment; [and] deficiencies in basic emergency department comptencies amongst trust doctors”. The document, written by Julie Screaton, its regional director for London and the south-east, also cited: “inadequate cover arrangement for paediatric emergency department; poor levels of staffing in comparison to establishment’ [and] poor levels of clinical supervision to very young junior doctors in training”.
A spokesman for the hospital said: “We are committed to creating a positive working environment for all our staff and trainees. Where concerns have been raised we always investigate fully. We have recently adopted a bullying and harassment resolution pathway to support this important work.”
HEE concluded after its visit that North Middlesex was “an unsafe learning environment and an inadequate educational experience” for young doctors. It then issued three notices, called immediate mandatory requirements, obliging the hospital to take action right away to tackle three “immediate areas of concern: equipment deficiencies (assurance received); staffing levels and supervision by competent doctors (serious concerns remain); paediatric ED cover (serious concerns remain).” 
An HEE spokeswoman said: “Patient safety is the primary concern for HEE ands is underpinned by our responsibility for the welfare of junior doctors. We will not hesitate to act if we feel that doctors in training are not being supervised properly as that would mean they may not be able to deliver safe and effective care.” 
Anxiety among an array of NHS organisations about North Middlesex is also detailed in a chronology of its problems and attempts to address them prepared for participants in a “risk summit” on 25 May, and the minutes of an intelligence-sharing teleconference, also involving local NHS bodies as well as regulators, which was held on 20 January. 
The Care Quality Commission last week served a warning notice on the hospital telling it to make “significant improvements in the quality of the healthcare it provides in the emergency department”. The watchdog’s inspectors were concerned to find “delays in the initial assessment of patients, in their assessment by a doctor and in moving them to specialist wards and that there were insufficient middle grade doctors and consultants”. 
Julie Lowe, the hospital’s chief executive, said that it had only seven of the 15 A&E consultants it was meant to have and just seven of 13 middle-grade medics. “It’s a strain on our A&E team and it’s making waiting times for some patients unacceptably long”, she admitted.
The ex-Labour health minister David Lammy, the MP for Tottenham, said: “I’m worried about the safety of patients at this hospital because the information that’s now been made available to me has caused serious alarm.” Lammy is one of five MPs in the north London boroughs of Haringey, Enfield and Barnet whose constituents view the North Middlesex as their local hospital. He was angry that he had learned of the extent of its problems from the Guardian and not directly from the trust, he added.
“This is an absolute scandal that effectively five London constituencies affected by this hospital have been in effect kept in the dark about the very serious problems there and the lack of supervision of emergency doctors just out of university.”
Lammy said the A&E’s problems began in late 2013 when the emergency department at nearby Chase Farm hospital was shut down. But the hospital says that it was meeting or almost meeting the target to treat 95% of A&E patients within four hours until July 2015, when the lack of doctors became critical.
In a statement to the Guardian, Lowe admitted that the trust was currently not training its A&E junior doctors properly but blamed it on its acute shortage of senior medics. “We fully accept our partners’ concerns about the quality of training we can provide in our emergency department when there is a shortage of consultants who can provide it.
“We are committed to providing a safe service for patients, getting waiting times back to the national target and providing excellent training for doctors. However, we need more emergency department doctors to be able to deliver all three at once which is why achieving this is our current priority.”
Patricia Mecinska, chief executive of Enfield Healthwatch, a local patient watchdog, said that North Middlesex “provides vital support to Enfield’s residents, particularly in cases of emergency, with more than 500 individuals visiting the A&E department on a daily basis.” Local people would oppose any “drastic decision” to shut the A&E, she stressed.
Haringey clinical commissioning group, the local GP-led body that holds the NHS budget for the borough, sought to reassure patients. “The problems in A&E are serious but being urgently addressed. Patients who are attending A&E will be cared for safely by qualified and appropriately supervised staff”, it insisted.
Tuesday 14 June 2016 17.35 BST  

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