Death of baby among latest serious incidents at Watford General Hospital

A patient who died after being given the wrong gas to breathe was one of over 80 serious incidents at Watford General Hospital last year - double the figure from the previous year.

In another incident a stillbirth occurred after doctors had misinterpreted the results of a cardiotocography, and the foetus’ heart rate and movements were not monitored - actions which could have saved its life. ‘Poor documentation’ was also cited.

The deaths are listed in a Serious Incidents 2012/2013 Summary Report as discussed at the July 25 board meeting, when it was revealed 83 serious incidents were recorded last year (compared with just 42 in 2010/11, and 50 the previous year), although last year 28 'serious' pressure ulcers were subsequently downgraded.

The report highlights another serious incident in which a chemotherapy patient had a nasogastric tube misplaced after an x-ray was misinterpreted, and there was a ‘lack of communication from radiology’.

This incident constituted a ‘never event’, which is the term the NHS gives to ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented’.

The case of the wrong gas being administered causing death was also classed as a never event.

The report mentions other serious incidents including:

  • A neonatal death following ‘poor communication and decision making’ and ‘delays in care for infant’
  • A pregnancy complication in which the placenta became detached from the uterus of the mother, after a doctor did not respond to ‘bleeps’ (alarms) for a patient review
  • A patient whose Hepatitis B was reactivated after they underwent chemotherapy because it was not routine to check for the virus (reactivation can be fatal). The hospital reviewed its policy to check whether patients have Hepatitis B pre-chemotherapy
  • Morphine going ‘missing’
  • A ‘near-miss’ in which a patient mistakenly underwent a biopsy (a test) without their identity being checked first
  • An allegation of abuse against a healthcare assistant who, it later transpired, had not been CRB-checked
  • C. Diff cases involving ‘poor communication’ and the patient not being isolated - nor was the area deep cleaned
  • A patient who suffered a fracture from a fall sustained while using a foot pedal to open a bin

Katherine Murphy, chief executive of healthcare charity the Patients Association, said: "As suggested by the name, these sorts of events are utterly unacceptable and pose a huge risk to patient safety and well-being.

"Whilst the Patient Association accepts that accidents will sometimes occur, it is vital that lessons are learnt each time to ensure that they are not repeated.

"This is yet another reminder of the need to properly fund the regulation of healthcare to ensure that it detects patterns of errors such as these, and acts to ensure that no more patients are put at risk."

West Hertfordshire Hospitals NHS Trust’s Medical Director, Dr Mike Van der Watt, said: “We take the safety of our patients very seriously, therefore, incident reports are brought to the trust Board as a way of demonstrating through openness and transparency how we learn from incidents.  We have made appropriate apologies to the patients, family and friends involved in these incidents and shared the reports and lessons learnt as appropriate. However, for legal reasons we have to respect patient confidentiality and therefore have to limit the amount of information published. Incidents are also reported to our commissioners and other appropriate bodies.

“Despite wider reporting requirements over the past year, we have not seen a significant increase in the number of serious incidents, which would have been expected. We are required to report every case of pressure ulcers to our commissioners, prior to investigation. The root cause of each incident is thoroughly explored to determine whether appropriate care had been given to the patient in order to prevent an ulcer occurring. For instance, some patients are more vulnerable to pressure ulcers due to their medical condition. Between April 2012 and March 2013, 28 of the 83 pressure ulcers reported by the trust were subsequently downgraded as the patient was found to have received appropriate care and the pressure ulcer considered to be unavoidable.

“Please be assured that we take each incident very seriously and have a very robust plan in place for dealing with them, which includes thorough investigation, followed by an action plan detailing appropriate lessons to be learnt. In addition we would take the necessary action against staff as appropriate, for instance performance management or dismissal.”

Comments (10)

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9:07am Fri 2 Aug 13

WanderingDynamo says...

You should try being part of the Shrodells outpatients service.

!NIGHTMARE!
You should try being part of the Shrodells outpatients service. !NIGHTMARE! WanderingDynamo

12:11pm Fri 2 Aug 13

MaryWatford says...

Terrible place. MY daughter in law suffered 17 hours of neglect during the birth of my grandson. Eventually a doctor who had come back from being off duty during the day stepped in at the last minute to save my grandson's life. He even said to the nursing staff ' how did you let this happen?'
Terrible place. MY daughter in law suffered 17 hours of neglect during the birth of my grandson. Eventually a doctor who had come back from being off duty during the day stepped in at the last minute to save my grandson's life. He even said to the nursing staff ' how did you let this happen?' MaryWatford

12:35pm Fri 2 Aug 13

Andrew Turpie says...

Had various trips to A&E plus my son was born here, I have found that on all these occasions the staff were excellent and professional. Sorry if this upsets the mud slinging negative baying mob.
Had various trips to A&E plus my son was born here, I have found that on all these occasions the staff were excellent and professional. Sorry if this upsets the mud slinging negative baying mob. Andrew Turpie

3:01pm Fri 2 Aug 13

HornetJJ says...

I personally have not had a problem with Watford General. When my son was born, the staff there were excellent. On the other hand I have heard bad things about the hospital too but to be honest this is likely to be the same at any hospital you go to.
I personally have not had a problem with Watford General. When my son was born, the staff there were excellent. On the other hand I have heard bad things about the hospital too but to be honest this is likely to be the same at any hospital you go to. HornetJJ

11:53am Sat 3 Aug 13

corbindallas says...

Andrew Turpie wrote:
Had various trips to A&E plus my son was born here, I have found that on all these occasions the staff were excellent and professional. Sorry if this upsets the mud slinging negative baying mob.
What others are not allowed a different opinion to yours? Sorry if reality is sometimes negative it's just a fact that the NHS is not the complete service it used to be and it is time these events were addressed, read the report and tell me why the VERY negative events occurred in the first place. I suppose my comments of a bad experience is my own fault and therfore I should not be included incase I get accussed of being a baying mob. The fact I was sick over myself and bedding after an operation and a nurse stated we can't have that and gave me a anti sickness injection and when I woke up in the morning I had the same sick on me and the bedding, or that I had to clean a bath that had a grime dirt ring around it and pubic hairs in it despite having an open wound that needed me to bath, or the fact I was unaware that I had packing up my rear that should have been removed after the operation but they forgot. No I am not negative just angry with the service of supposed health care providers unable to do the basics!
[quote][p][bold]Andrew Turpie[/bold] wrote: Had various trips to A&E plus my son was born here, I have found that on all these occasions the staff were excellent and professional. Sorry if this upsets the mud slinging negative baying mob.[/p][/quote]What others are not allowed a different opinion to yours? Sorry if reality is sometimes negative it's just a fact that the NHS is not the complete service it used to be and it is time these events were addressed, read the report and tell me why the VERY negative events occurred in the first place. I suppose my comments of a bad experience is my own fault and therfore I should not be included incase I get accussed of being a baying mob. The fact I was sick over myself and bedding after an operation and a nurse stated we can't have that and gave me a anti sickness injection and when I woke up in the morning I had the same sick on me and the bedding, or that I had to clean a bath that had a grime dirt ring around it and pubic hairs in it despite having an open wound that needed me to bath, or the fact I was unaware that I had packing up my rear that should have been removed after the operation but they forgot. No I am not negative just angry with the service of supposed health care providers unable to do the basics! corbindallas

4:47pm Sat 3 Aug 13

Andrew Turpie says...

corbindallas wrote:
Andrew Turpie wrote:
Had various trips to A&E plus my son was born here, I have found that on all these occasions the staff were excellent and professional. Sorry if this upsets the mud slinging negative baying mob.
What others are not allowed a different opinion to yours? Sorry if reality is sometimes negative it's just a fact that the NHS is not the complete service it used to be and it is time these events were addressed, read the report and tell me why the VERY negative events occurred in the first place. I suppose my comments of a bad experience is my own fault and therfore I should not be included incase I get accussed of being a baying mob. The fact I was sick over myself and bedding after an operation and a nurse stated we can't have that and gave me a anti sickness injection and when I woke up in the morning I had the same sick on me and the bedding, or that I had to clean a bath that had a grime dirt ring around it and pubic hairs in it despite having an open wound that needed me to bath, or the fact I was unaware that I had packing up my rear that should have been removed after the operation but they forgot. No I am not negative just angry with the service of supposed health care providers unable to do the basics!
I presume you wrote a personal letter of complaint then yes?

I think people (in general) complaining go completely hysterical when doing so saying the whole system is at fault. I personally feel that comments on here should be disabled as no one will give a balanced opinion i.e blaming the whole NHS when really, its just down to one or two bad apples that give the bad experience. Negative comments on public forums do two things, one make the good hard working dedicated NHS staff turn despondent and secondly, possibly sway people who need to have medical attention to make excuses and avoid doing so. I'm sure if we didn't drink our Starbucks whilst doing our Amazon shopping on line that a lot more money could be invested into the health service, but hey coffee and kindles are more important ;-)
[quote][p][bold]corbindallas[/bold] wrote: [quote][p][bold]Andrew Turpie[/bold] wrote: Had various trips to A&E plus my son was born here, I have found that on all these occasions the staff were excellent and professional. Sorry if this upsets the mud slinging negative baying mob.[/p][/quote]What others are not allowed a different opinion to yours? Sorry if reality is sometimes negative it's just a fact that the NHS is not the complete service it used to be and it is time these events were addressed, read the report and tell me why the VERY negative events occurred in the first place. I suppose my comments of a bad experience is my own fault and therfore I should not be included incase I get accussed of being a baying mob. The fact I was sick over myself and bedding after an operation and a nurse stated we can't have that and gave me a anti sickness injection and when I woke up in the morning I had the same sick on me and the bedding, or that I had to clean a bath that had a grime dirt ring around it and pubic hairs in it despite having an open wound that needed me to bath, or the fact I was unaware that I had packing up my rear that should have been removed after the operation but they forgot. No I am not negative just angry with the service of supposed health care providers unable to do the basics![/p][/quote]I presume you wrote a personal letter of complaint then yes? I think people (in general) complaining go completely hysterical when doing so saying the whole system is at fault. I personally feel that comments on here should be disabled as no one will give a balanced opinion i.e blaming the whole NHS when really, its just down to one or two bad apples that give the bad experience. Negative comments on public forums do two things, one make the good hard working dedicated NHS staff turn despondent and secondly, possibly sway people who need to have medical attention to make excuses and avoid doing so. I'm sure if we didn't drink our Starbucks whilst doing our Amazon shopping on line that a lot more money could be invested into the health service, but hey coffee and kindles are more important ;-) Andrew Turpie

5:55pm Sat 3 Aug 13

//GSN//~Angel says...

Personally,ive never encountered any problems with the Maternity wing or A&E...Two natural births and one C-section and at the end i had three beautiful healthy babies,the after care on the ward was excellent too... I've had to visit A&E on occasions and the only negative thing i can say about it is the waiting time,but that's just how it goes.
Personally,ive never encountered any problems with the Maternity wing or A&E...Two natural births and one C-section and at the end i had three beautiful healthy babies,the after care on the ward was excellent too... I've had to visit A&E on occasions and the only negative thing i can say about it is the waiting time,but that's just how it goes. //GSN//~Angel

9:44am Sun 4 Aug 13

Missy03 says...

Watford hospital is under so much pressure as there is so many hospital closing so people are all going to Watford I had my children there and they was good and when I had my op there it was good if they opened hospital then it will make it easy for Watford.
Watford hospital is under so much pressure as there is so many hospital closing so people are all going to Watford I had my children there and they was good and when I had my op there it was good if they opened hospital then it will make it easy for Watford. Missy03

11:07am Tue 6 Aug 13

Cuetip says...

Missy03 wrote:
Watford hospital is under so much pressure as there is so many hospital closing so people are all going to Watford I had my children there and they was good and when I had my op there it was good if they opened hospital then it will make it easy for Watford.
There is an obsession with building super 'health' campuses with their economies of scale using outsourced staff which means there is bound to lead to be management problems and consequently unacceptable losses when it comes to care.
[quote][p][bold]Missy03[/bold] wrote: Watford hospital is under so much pressure as there is so many hospital closing so people are all going to Watford I had my children there and they was good and when I had my op there it was good if they opened hospital then it will make it easy for Watford.[/p][/quote]There is an obsession with building super 'health' campuses with their economies of scale using outsourced staff which means there is bound to lead to be management problems and consequently unacceptable losses when it comes to care. Cuetip

8:54am Thu 8 Aug 13

corbindallas says...

Andrew Turpie wrote:
corbindallas wrote:
Andrew Turpie wrote:
Had various trips to A&E plus my son was born here, I have found that on all these occasions the staff were excellent and professional. Sorry if this upsets the mud slinging negative baying mob.
What others are not allowed a different opinion to yours? Sorry if reality is sometimes negative it's just a fact that the NHS is not the complete service it used to be and it is time these events were addressed, read the report and tell me why the VERY negative events occurred in the first place. I suppose my comments of a bad experience is my own fault and therfore I should not be included incase I get accussed of being a baying mob. The fact I was sick over myself and bedding after an operation and a nurse stated we can't have that and gave me a anti sickness injection and when I woke up in the morning I had the same sick on me and the bedding, or that I had to clean a bath that had a grime dirt ring around it and pubic hairs in it despite having an open wound that needed me to bath, or the fact I was unaware that I had packing up my rear that should have been removed after the operation but they forgot. No I am not negative just angry with the service of supposed health care providers unable to do the basics!
I presume you wrote a personal letter of complaint then yes?

I think people (in general) complaining go completely hysterical when doing so saying the whole system is at fault. I personally feel that comments on here should be disabled as no one will give a balanced opinion i.e blaming the whole NHS when really, its just down to one or two bad apples that give the bad experience. Negative comments on public forums do two things, one make the good hard working dedicated NHS staff turn despondent and secondly, possibly sway people who need to have medical attention to make excuses and avoid doing so. I'm sure if we didn't drink our Starbucks whilst doing our Amazon shopping on line that a lot more money could be invested into the health service, but hey coffee and kindles are more important ;-)
Well clearly one death by mistake is one to many. How you can say no one will give a balanced opinion is beyond me, especially when you go off on a tagent about coffee and Amazon??? Yes there is good and bad in all walks of life but it is the responsibility of the good to ensure the bad don't continue or worse grow. Would you go back to a poor business when you can go elsewhere? No you wouldn't, unfortunatley we don't really have the choice with the NHS apart from going private or moving area but why should we. Nurses are now to superiour to clean, so a new tier of staff are brought in but hang on they also have another tier so they can only deal with this section and not that, to the point it is bloody ridiculous. The NHS needs a back to basics and the biggest obstacles to change are the current staff, if it was working fine there would not need to be any changes but it is not, yes cut backs and red tape cause problems that didn't used to exsist, but a not my job culture is a poor excuse for professional standards and therefore more accountability needs to be placed against staff from top to bottom. Bring back Matrons, bring back proper Ward Sisters and bring back multi tasking nurses, cut out all the deadwood management and so called specialist teams of burecrates like, Infection Control, Health & Safety etc, this should be the responsibility of everyone not seperate teams and above all make sure there is adequate staff and better training, and get rid off sub standard profesional who cannot do the job properly, it really is that simple if people just got on with it.
[quote][p][bold]Andrew Turpie[/bold] wrote: [quote][p][bold]corbindallas[/bold] wrote: [quote][p][bold]Andrew Turpie[/bold] wrote: Had various trips to A&E plus my son was born here, I have found that on all these occasions the staff were excellent and professional. Sorry if this upsets the mud slinging negative baying mob.[/p][/quote]What others are not allowed a different opinion to yours? Sorry if reality is sometimes negative it's just a fact that the NHS is not the complete service it used to be and it is time these events were addressed, read the report and tell me why the VERY negative events occurred in the first place. I suppose my comments of a bad experience is my own fault and therfore I should not be included incase I get accussed of being a baying mob. The fact I was sick over myself and bedding after an operation and a nurse stated we can't have that and gave me a anti sickness injection and when I woke up in the morning I had the same sick on me and the bedding, or that I had to clean a bath that had a grime dirt ring around it and pubic hairs in it despite having an open wound that needed me to bath, or the fact I was unaware that I had packing up my rear that should have been removed after the operation but they forgot. No I am not negative just angry with the service of supposed health care providers unable to do the basics![/p][/quote]I presume you wrote a personal letter of complaint then yes? I think people (in general) complaining go completely hysterical when doing so saying the whole system is at fault. I personally feel that comments on here should be disabled as no one will give a balanced opinion i.e blaming the whole NHS when really, its just down to one or two bad apples that give the bad experience. Negative comments on public forums do two things, one make the good hard working dedicated NHS staff turn despondent and secondly, possibly sway people who need to have medical attention to make excuses and avoid doing so. I'm sure if we didn't drink our Starbucks whilst doing our Amazon shopping on line that a lot more money could be invested into the health service, but hey coffee and kindles are more important ;-)[/p][/quote]Well clearly one death by mistake is one to many. How you can say no one will give a balanced opinion is beyond me, especially when you go off on a tagent about coffee and Amazon??? Yes there is good and bad in all walks of life but it is the responsibility of the good to ensure the bad don't continue or worse grow. Would you go back to a poor business when you can go elsewhere? No you wouldn't, unfortunatley we don't really have the choice with the NHS apart from going private or moving area but why should we. Nurses are now to superiour to clean, so a new tier of staff are brought in but hang on they also have another tier so they can only deal with this section and not that, to the point it is bloody ridiculous. The NHS needs a back to basics and the biggest obstacles to change are the current staff, if it was working fine there would not need to be any changes but it is not, yes cut backs and red tape cause problems that didn't used to exsist, but a not my job culture is a poor excuse for professional standards and therefore more accountability needs to be placed against staff from top to bottom. Bring back Matrons, bring back proper Ward Sisters and bring back multi tasking nurses, cut out all the deadwood management and so called specialist teams of burecrates like, Infection Control, Health & Safety etc, this should be the responsibility of everyone not seperate teams and above all make sure there is adequate staff and better training, and get rid off sub standard profesional who cannot do the job properly, it really is that simple if people just got on with it. corbindallas

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