Wednesday, April 30, 2014

Sorry Gillian



“It was a wholly avoidable and tragic death of a vulnerable patient admitted to hospital for care but who died because of a lack of it”.. so said Mr Justice Haddon-Cave while pronouncing the verdict on the case of Gillian Astbury. If you don’t know that name by now, then throw away all the leaflets you have collected about “safe patient care”, the courses you have attended learning about the 6 Cs or even joyfully pledging to be part of NHS Change Day. Because if you don’t know that name then all of what you have done are gimmicks and you have learnt nothing.

Gillian Astbury, was a 66 year old lady who dies in 2007 in Mid Staffordshire hospital because of not being given her insulin. She was the lady whose case Francis reviewed and criticised the Health and Safety Executive, whose case finally provoked the HSE to bring criminal prosecution against the Trust- which concluded with the judgement as above associated with a fine of £200,000. I won’t go through the details of what the Francis report said but it cannot get any more damning. To all those who say Mid Staffs was over-reported, I say read this case and then suggest have a humble moment- and then reflect how different it is to Mel Gibson’s drunken rants about the Holocaust.

But you know what’s astonishing? Even today 7 years later, even after the Francis report, these occurrences are regular. Ask any diabetes team inside a hospital; ask patients who are afraid to go to the hospital…reason? Diabetes still continues to be an ignored pathology within hospital trusts. Look at the National Inpatient audit results..and the results are stark. Evidently education will solve all- I can absolutely assure you it doesn’t-sadly.

Most hospitals still run a 5 day service- with patients openly saying their worry about going to hospitals on weekends, we still dither, we still stall. As a specialist, it has made me angry in the past- but reading that news made me pledge never to brook any resistance to what must be done. Is it my role to appease others or to pledge to Gillian’s family that we have learnt and we now will treat patients with diabetes with the respect they deserve? Today, publicly, I choose the latter and lucky to have local Commissioners and Trust senior executives who support this- so no more obstacles, no more meetings, this now must happen. Patients with diabetes don’t choose a 5 day service and neither should we deliver one

Finally a word to all the so called diabetes professional organisations. Sometimes it’s a good thing to simply say sorry, take responsibility for our lack of passion as specialists that we haven’t been able to show the leadership needed to fight the battle for patients with diabetes. I have yet to see a single statement from the specialist diabetes body ABCD, Diabetes UK..in fact anyone acknowledging this horrible error which we must not let happen again, saying something on the day when the judgment was pronounced, something which shows a williingness to learn and make amends.

So you know what? I don’t stand for any organisation but to Gillian’s family- I say sorry. I swear I will do anything within my powers to make sure this doesn’t happen where I work. And if you want to stand in the way of that, stand in the way of what patients need to avoid another Gillian Astbury, then I am afraid your role in whatever capacity in a healthcare setting is defunct.

Lets do what needs to be done, shall we?

2 comments:

  1. Well done - fantastic! When I was last in hospital I was a) given a pre procedure sedative far too late, was left in corridor and had a panic attack, then left alone in a private room (half asleep from sedative), given no food al day, then had a hypo. Saved when hubbie arrived late afternoon and fed me. Never want to be in patient again without him by my side 24/7 to watch what they do! And God forbid them if they take my D kit away...

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  2. Diabetes UK published a report on in-patient care within the last 12 months. It was well-researched & terrifying.

    In many hospitals, 20% of in patients have diabetes of one type or another. Having sufficient diabetes specialist staff 24/7 for those patients is a huge resourcing issue. Even at hospitals like King's, who do have 24/7 diabetes specialist cover, it only works if the clinicians in charge of that patient's care contact the diabetes team. The diabetes team apologised when I went in at 3am with a hypo & they weren't called. The second time, I waited from 5am to 11am to see a diabetes specialist nurse & was told by an A&E nurse that only 2 DSNs were employed & both were on annual leave. I walked, with security guards behind me (wearing my vomit stained pyjamas - bad hypo), to the diabetes clinic & explained why I was there and what had happened. I was told that King's employed 10 DSNs & all were at work. When they came to CDU, I got a new pen.

    Specialist diabetes wards are often a joke. I cannot fathom how a Dr (the most DAFNE trained group under the sun) can determine a bolus without looking at the meal. I estimated the carbs in the meal I brought my Aunt & asked the nurse, but she told me the Doctor's instructions.

    A friend of mine was unhappy that she had no support with managing her diabetes when she was giving birth to her daughter. Fortunately, her birth partner (her Mum), called her husband and he monitored her blood sugars and administered insulin & orange juice.

    The families of people with diabetes are an often-overlooked care resource. Yes, the NHS should engage better with diabetes, but until then, if a patient has to go into hospital, they have to bring in whatever support they can.

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