CATEGORY OF PAPER
Specific action required: / Provides Assurance: /  / For Information: /  /
BOARD MEETING – 26/01/2017
Report title: / Staff or Patient Story /
Purpose of report: / The purpose of the report is to provide the Board with a reflection of our service delivery through a patient experience or staff perspective, with a view to using these experiences to continually improve the services delivered. /
Key issues:
(key points of the paper, how this supports the achievement of the Trust’s corporate objectives, overview of risk implications, main risk details on page 2) / This report details the experience of a patient who was transported home from a hospice so he could die at home as per his wishes. The story has been shared by the patient’s wife and demonstrates the impact the service provided had on the patient, family and friends.
The patient’s wife raised a complaint through the Patient Experience Team describing the crew as having ‘no people skills, no compassion or empathy for her dying husband’.The patient’s wife has shared her story as she does not want anyone else to have the same experience.
This experience demonstrates the importance of having the appropriate staff to transport patients at the end of life. /
Issue previously considered by:
Recommended actions: / The board is asked to review the report and ask any questions as to the learning. /
Sponsor / approving director: / Joanne Baxter, Director of Clinical Care and Patient Safety /
Report author: / Gillian Summers, Complaints Manager, Patient Experience Team /
Governance and assurance
Link to trust corporate objectives:
(please tick) / 1 / 2 / 3 / 4 / 5 / 6
 /  /  /  /  /  /
Link to CQC / KLOE:
(please tick) / Caring / Responsive / Effective / Well Led / Safe
 /  /  /  /  /
Any relevant legal / statutory issues?
(Such as relevant acts, regulations, national guidelines or constitutional issues to consider) / None identified
Equality analysis completed
If this is not relevant please explain why: / Yes / No / Not Relevant
 /
None identified
Key considerations / Details
Confirm whether any risks that have been identified have been recognized on a risk register and provide the reference number: / N/A /
Please specify any Financial Implications
Please explain whether there are any associated efficiency savings or increased productivity opportunities? / N/A /
Are any additional resources required e.g. staff capacity? / N/A /
Is there any current or expected impact on patient outcomes/experience/quality? / No
Specify whether appropriate clinical and/or stakeholder engagement has been undertaken:
(stakeholders could include staff, other Trust departments, providers, CCGs, patients, carers or the general public) / Meeting with patient’s wife and family friend. /
Are there any aspects of this paper which need to be communicated to our stakeholders (internal or external)?
(Please tick – if ‘yes’ then please complete all boxes.Please briefly specify the key points for communication and ensure the Comms team are informed via mailto:) / Yes / No / Positive / Negative
 /
Proactive / Reactive / Internal / External
 /
Please enter specified points /

*The Trust corporate objectives are:

  1. To continuously improve the quality and safety of our services, ensuring the CQC fundamental standards are achieved and patient outcomes are improved.
  2. To achieve financial break-even position in 2017/18.
  3. To improve organisational culture, aligned to Trust mission, vision and values to achieve delivery of our strategy.
  4. Develop a future workforce with the correct staffing levels and skill mix across both clinical and non-clinical functions to support safe, effective and compassionate care and employee well-being.
  5. To deliver the agreed Transformational and Vanguard programmes.
  6. To plan, agree and implement a front line operational delivery model aligned to current and future need and planned performance improvement.

Board Meeting

Staff or Patient Story

26th January 2017

Background:

A complaint was received from the patient’s wife (Mrs X) via Newcastle Gateshead CCG. A summary of their experience was detailed which concluded with Mrs X describing describing the crew as having ‘no people skills, no compassion or empathy for her dying husband’.

A meeting was arranged at Mrs X’s home with the Patient Transport Service (PTS) team manager and the author of this report; a friend of Mrs X was also at the meeting to provide support. Mrs X had written notes on events that occurred once her husband had been settled in at home so that she could raise her concerns when she felt able to do so.

This is Mrs X’s story of events on the day her husband was transported home from the hospice at the end of November 2016. Please note it is not verbatim and is taken from notes of meeting:

It all started 2 years 3 months ago when R (patient) was ill while on a cruise; R was stuck in Spain in hospital, which was deplorable, and when we did get home, he attended the stroke clinic as they initially thought he had suffered a stroke. As part of a trial R underwent a full body scan where it was discovered he had a brain tumor. This was removed and found to be a malignant grade 4 tumor. It came back in February (2016) and caused a bleed which resulted in R being paralysed down his right side. I looked after R at home but in November the Macmillan Nurse saw I was struggling and suggested that I needed some respite and arrangements were made for R to spend some time in a hospice; at this point both his legs had gone.

R did not want to go into a hospice, his chosen place to die was at home but he agreed; the hospice staff and care received was great but he wanted to come home; the hospice moved mountains to get him home, arranging for a hospital bed and air flow mattress to be set up in the house. Carers were organised for 4 times a day, along with a district nurse; he had 2 syringe drivers and had started to have fits. We had only used emergency services up to this point and the paramedics were always ‘second to none’ with everyone; R, me and family and friends that were there. The two [crew] that took him to the hospice were ‘lovely, wonderful’.

I was very protective, we have no children and R was my life. He had just had a birthday while at the hospice and his godchildren had boughtballoons. When they said he could come home he wanted to bring the balloons; staff at the hospice commented ‘you should have seen their faces, the crew were not happy’. They also had a bag of dressings, bag of medication and an overnight bag as well as 5 balloons.

When they arrived home I ran to meet them at the bottom of drive and was shouting ‘you are home flower’. One of the crew brought in the bags and balloons and I helped and said sorry about the balloons, I kept shouting ‘you are home flower you are home’. Never once did the crew speak to R, never said you are home or acknowledged him at all. He was on a stretcher in his pyjamas with a thin sheet over him. He was pushed to the front door and the 2nd crew member said ‘we were told it was easy access, but there’s a step’, his colleague said we will manage to get him over there but the other crew member said ‘I can’t do that with my bad back, don’t know what we are going to do’. I could see R was getting agitated and I told them I had ramps in the garage from when he was in his wheelchair. I got the ramps, hooked them on and he was taken into hall. They then asked where he was to be taken and I showed them to where the bed was set up; again the 2nd crew member said ‘We’ll not get him in there what do you suggest we do’, I told him paramedics had taken R out of same room by stretcher; he said ‘no no impossible no way did they get him out of there’.They then asked if I could take the radiator cover off, but I explained did not know how to or where the tools were, the2nd crew member said ‘what do you suggest we do, take him back’. I said I would call my brother and he would come over, they also asked if we could take sitting room door off; I said I had called my brother and he was coming;I could see R was getting more agitated.

I asked if the stretcher did not fold down, as the surgery I worked in had thin corridors and I had seen the stretchers adjusted. They asked if I had a screw driver and again I said brother was on way; the 1st crew member said ‘had never heard of dropping stretcher’ and then tried and cut finger trying to loosen bolts. The two men then proceeded to push stretcher into lounge and they then saw the two carers waiting. The 2nd crew member said we ‘can’t lift onto that bed it’s not at the right angle’sothe carers loosened the brakes and pulled the bed sideways.

The 2 men placed the slide board and then the 2nd crew member said ‘come on lasses, lift him across’, so we did (Mrs X and the carers).

When asked Mrs X said the first crew member held the board but the 2nd crew member ‘just stood back’. The 2 carers said they had never experienced anything like it, they had been trained that all agencies should work together. The carers and I slid R across with the sheet. At that point the 1st crew member, holding the slide, just raised his eyebrows at me. The 2nd crew member then said ‘have you got a sledge hammer’, I asked what for and he said ‘so you canbreak this up [stretcher] and take it to the tip’. I don’t know whether this was meant to be a joke but it was not appropriate.

They then wheeled the stretcher out without a problem. The 1st crew member came back and apologised that they had scraped paint work and that the ramps were still outside; I said not to worry I’ll see to the ramps.

Brother arrived having passed the crew at the end of the street, once R was settled we then looked at the damage; radiator cover has a dint, door stencil and wall damaged.

When my friend arrived later, she suggested I get everything written down. Mrs X used her notes written shortly after incident to relay events.

Mrs X said she feels the crew let the rest of the service down and it is not fair to the rest of them (NEAS crews). Mrs X said as a practice manager she had seen both sides of the service and commented ‘I did not want to know about his bad back; my husband was coming home to die’. Mr X passed away at home with his wife at his side 11 days later.

Mrs X said ‘they had no idea how to handle the situation’ and that she does not want this to happen to anybody else

When asked, Mrs X advised that prior to getting her husband off the vehicle the crew did not come to look at how they were going to manage getting him into the house (no dynamic risk assessment).

Mrs X queried their lifting and handling training and empathy training and reiterated that she did not want another patient and family to have the same experience. This was discussed and Mrs X is happy for the crew to attend a reflection and learning event with the PTS team manager where a full review of events will take place and any additional training for the crew will be identified. Feedback will be given to Mrs X by the PTS team manager.

Before leaving Mrs X asked that I ensure that the crew that transported her husband to the hospice 2 weeks earlier receives feedback; Mrs X said they were ‘absolutely wonderful, they raised the seat so he could see out of the window. They were lovely to R and me and a pride to the service. R was so upset at going to the hospice but they were wonderful, second to none’. The crew identified was a third party provider on behalf of NEAS and the appreciation registered.

Actions:Team manager to carry out a reflective learning event to encompass incident review, coaching and identify any additional training required for the crew.

Recommendations / Assurances

The board is asked to review the content of the reported case which highlights the impact crew have when dealing with patients and their family and friends in end of life care and the importance of having the right staff available to transport patients to their chosen destination.

Document Information

Author Name: / Gillian Summers
Author Title: / Complaints Manager, Patient Experience Team
Sponsor Name: / Joanne Baxter
Sponsor Title: / Director of Clinical Care and Patient Safety
Last Saved / 2017-01-12 15:11:00
Save Location / N:\Public\Complaints\Complaints reports\Board Papers\Patient Stories\2016-17\Staff or Patient Story November 2016.docx
Word Count / 2144

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