A PATIENT at Princess Alexandra Hospital has testified to senior management about her treatment at the Harlow hospital. A treatment that the heads of the hospitals have described as “shocking” and say that they “shocked” when they heard it.
Anne Weersing (AW) spoke at a recent public meeting of the Board of Directors held at their Kao Park offices in Harlow.
His testimony was recorded in the minutes of the meeting.
The record said:
“THE The key issues for her that day were the hospital’s response/approach when things were not going well for patients and the support provided after that. She would also like to hear from the teams involved what has been learned from the complaint.
The Associate Director of Patient Engagement added that the story raised questions about how respected the patient’s voice was in the organization and the potential problem of excessive reliance on technology.
AW informed members that he had long-standing urethral and bladder strictures.
low activity leading to chronic urinary retention.
On 29.05.21 he had attended the Trust for a routine elective day surgery procedure. She had met the treating consultant for the first time at the preoperative consultation that day, and he had stated that the diagnosis of urethral stricture was incorrect.
The previous procedures and diagnoses had been performed at a different hospital and the consultant did not have access to their notes that day.
His request to be allowed to go home with a catheter in place (after previous complications with dilations) was denied.
Discharging her home without a catheter was later found to be against Trust policy.
The procedure went well and AW had been released to the day stay recovery unit later that day.
afternoon. Over the next several hours, AW drank about 2.8 liters of fluid, but was unable to pass.
urine. So she knew (from previous experience) that she was going to have urinary retention.
and told the nurses. As a nurse, she suggested getting a fluid balance chart done.
started but was told they had been replaced by bladder scans. She also asked for some
pain relief, but was told that pain was to be expected after the procedure and that she should try
walk to alleviate that.
Two bladder scans were then performed over the next few hours which showed low amounts
of urine in the bladder. Then they told her that she was ready for discharge and her husband
arrived around 5:30 p.m. find her crying in pain and anguish.
Several attempts were made to alert the medical team, the urology registrar on call, and the surgical team on call to catheterize her.
The latter responded but were in the emergency department.
The matron on call also received a beep to get approval from the nursing staff to perform the catheterization, but that was denied due to the nature of the procedure and she was catheterized by a doctor later that night.
AW confirmed that she was then transferred to a ward overnight where her catheter was drained
three liters of water. This had caused significant AW pain and indeed the bladder had
broken
The next morning she had been visited by the same consultant who had been
I was surprised to see her and learn that she had had acute urinary retention. your order
refused to go home with a catheter on the grounds that it was not safe for AW to remove it
the catheter herself.
Later that day a nurse removed the catheter and AW was able to urinate but in severe pain. She was released to her home later that day.
Over the next 14 hours, AW realized that something was not right, which resulted in his
after being admitted to Addenbrooke hospital for three nights, where a scan revealed a 7mm
tear in your bladder.
Three more weeks of conservative treatment then followed.
Following this, his confidence in the NHS was shattered, his mental health deteriorated and he had shown
signs of PTSD.
I had found the PAHT complaint process frustratingly slow as far
ended up contacting the Ombudsman eight months after filing his first
complaint to the Trust.
Just before Easter 2022, she was offered a resolution meeting with Trust colleagues that both she and her husband found completely cathartic and then had received a final response letter from the senior urology consultant confirming that the care he received that resulted in his bladder rupturing was well below the standard expected by the organization.
The DoN&M thanked AW for sharing what was a heartbreaking story and she asked for a little
reflection of surgical colleagues.
In response, the surgical midwife (SM) updated that the senior urology consultant had spoken with the consultant in question.
The nurses involved had done a thoughtful piece and the beep system involved at the time had recently been upgraded to a new, more efficient one.
Since then, the continence nurses had changed the processes around the use of the bladder scanner and fluid charts were now being recorded on a recently introduced electronic system in the ED known as the Nerve Centre.
AW commented that it meant a lot to her to hear that changes had taken place.particularly the process around the use of the bladder scanner and not forgetting basic training skills, for example in terms of basic patient examination.
In response to the above, the TC requested that a report on lessons learned and their integration be submitted through the Quality and Safety Committee (QSC) in October.
The DoN&M agreed.
Several board members gave the following responses after hearing about Ms. Weersing’s experience:
Non-Executive Director (NED) Rob Gerlis stressed that for him the lack of physical patience
exam was worrisome along with the pushy approach from staff.
NED george wood he commented that he had been shocked by what he had heard.
He was concerned about the time it took to address the complaint and requested a review of it.
process is included in the document for QSC.
He thanked AW for bringing his story and confirmed that the organization would now patch things up to ensure the mistakes weren’t repeated.
In response, AW reiterated how cathartic it had found the resolution meeting. It was very
It is important that patients are heard.
NED helen glenister He commented that there was much broader learning for the organization and agreed that the complaints process also needed to be further considered. As QSC President, she would greatly appreciate the report described above to ensure this experience is not repeated.
NED helen howe agreement on broader learning. listen and respect
patient were key and if a change in the culture was required, then that was what should happen.
He noted that patient stories should be shared across the organization, particularly among
juniors
ANED Juan Pedro he said that he had found the story difficult to listen to. ‘patient in
heart’ was the first of three Trust values and the hospital had not done well. He would do
Tirelessly monitor now how people lived the Trust’s values and how they treated patients.
In response, AW commented that she was pleased to learn that the nurses involved had been asked to
write a reflective piece. She questioned whether the consultant involved in her care
He also writes a reflective piece.
At this point in the meeting the Medical Director (MD) Fay Gilder confirmed the story had shocked himr
and the Board.
The incident would be registered in internal systems (Datix) and declared as
a serious incident (SI).
There had been a number of flaws in the case from the evaluation.
The consultancy would be scrutinized following the ‘Just Culture’ approach and deeply regretted AW’s experience.
The consultant would now be asked to write a reflection and it would be included in their evaluation.
The surgical supervisor confirmed that the AW experience had been recorded in Datix and submitted to the Trust’s Incident Management Group.
ANED Anne Wafula-Strike commented that she was I’m so sorry to hear about the experience and thanked AW for articulating what had happened so the Board was aware.
the CEO Lance McCarthy also reiterated his thanks to AW for articulating a poor set of experiences in
Hospital.
He showed the power of a story when things were not going well and was pleased to hear the positive response from the surgical team.
The key piece now would be to remove all actions to avoid a similar experience for others and also take the broader learning about communication and behavior in general and for it to be tracked and articulated to colleagues.
He noted that patient stories were shared at the division level. He was pleased to update that the previous week had seen the start of a work program to address culture and behaviors in theaters where communication, oral expression and common sense were key elements.
Now I would also look to the Patient Experience team to understand how the complaints process could be improved (responsiveness).
“He thanked AW for his time and apologized again on behalf of the organization for his experience.”
