Mary Greaves - 'My brother Peter'
Mary Greaves, the sister of Peter O’Donnell, gave this moving account of Peter’s death following treatment as an NHS patient in a private hospital to an audience at the HSJ Patient Safety Congress in Manchester in July 2019.
The Coroner who led the investigation into Peter’s death wrote to the then Secretary of State for Health and Social Care Jeremy Hunt identifying what he saw as systemic safety failings in the treatment of patients in private hospitals.
This led to Jeremy Hunt writing to the private hospital sector asking them to make improvements in the quality of care provided in May 2018.
We are re-publishing this statement in order to provide an understanding of how policy and regulation impact directly on the lives of patients and their families.
My brother Peter
Peter was my older brother and my best friend. Following the early death of my husband, Peter and I lived together for 23 years. Peter enjoyed all sports and played football and cricket well into his thirties, later taking up golf. He was a fit and well man. We had many holidays together and enjoyed walking in the Dales and the Lake District. The day before his operation Peter drove us to Skipton, where we spent the day exploring the town.
During 2016 Peter had developed problems with his hip and the consultant recommended a total hip replacement. I have had both hips replaced so I was familiar with the procedure and I encouraged Peter to go ahead, telling him he would be up and about in no time.
So in January 2017 Peter was admitted for surgery as an NHS patient but at a private hospital. The operation took place late on the Saturday afternoon and all went well. I visited him on the Sunday afternoon and he seemed fine, but when I returned in the evening he appeared very sleepy and somewhat confused.
On the Monday he was no better. I had to wake him several times during our conversation and he remained confused. At this point I became alarmed that his recovery wasn’t going as it should.
When I expressed my concern, the nurse told me they suspected he had a chest infection. I asked about his treatment and was told that they would have to contact the consultant before it could go ahead.
However on the Tuesday things were no better. I was by now very worried. Peter actually seemed to be getting worse and I felt that there was something seriously wrong. I again asked what was happening and was again told it was a suspected chest infection.
I believed, at this time, that Peter was in the hands of professionals, receiving appropriate treatment and the best possible care.
The following day, on Wednesday at 11.00am, I received a telephone call to say that Peter had had problems with his oxygen saturations during the night and they had decided to transfer him to the local NHS Hospital where they said he could be better cared for, as the private hospital had no intensive care facilities.
I was told Peter was fine and not to worry, but I was very worried that things were not alright.
I was there when Peter was admitted to A & E at the NHS hospital. Initial tests were done, and at 3.0 pm he had an X-ray. I asked about the results and was told he had pneumonia. The staff said they thought I had been told this previously: I said I had no idea he was so seriously ill.
In fact, I only found out during the coroner’s inquest that Peter’s oxygen levels had been unstable and below 90% throughout most of the previous night, requiring oxygen to be given frequently.
At 10.40 that morning they had dropped to 78%, which was when the emergency ambulance was called.
At 7.00pm Peter was transferred to a general assessment ward. At 10.00pm I was asked to leave. I arrived home, but as I entered the house the telephone was ringing: it was the hospital asking me to return, as Peter had suffered a cardiac arrest and they were trying to save him.
When I arrived back at the hospital they were trying to resuscitate him and did eventually get a heartbeat. I asked the doctor how he was and she said he had been without oxygen for at least 20 minutes and that the prognosis for any recovery was very poor. Peter was transferred onto ICU.
Sadly, over the next two days he showed no signs of regaining consciousness or recovery, and on the Saturday it was decided to withdraw treatment and allow him to die with dignity. I stayed by my brother’s side until his death.
There was a post mortem followed by a coroner’s inquest. This finally concluded, after a three day hearing, that the primary causes of death were multiple organ failure, sepsis, and hospital-acquired pneumonia following hip replacement.
But since Peter’s untimely death I have been made aware of many concerns about both the nursing and the clinical care afforded to Peter in the private hospital, including some I would like to share with you, in the hope that in the future no one else will have to go through what I had to:
There was no formal agreement setting down the circumstances in which a consultant should be recalled to the hospital to review a patient’s condition.
The sole clinician providing post-operative care to patients was a junior doctor (the Resident Medical Officer). He was on duty 24 hours a day for a full week at a time. He asserted that a daily review of each patient would be adequate (though this was dependent on the patient).
A full set of physiological observations was not taken each time observations were required, which resulted in inaccurate and at times misleading NEWS (National Early Warning) Scores. Documentation was also inadequate, and as a result opportunities were missed to increase the frequency of observations and to ‘escalate’ care; there was a delay in giving Peter antibiotic therapy.
There was ineffective communication between the staff responsible for Peter’s care, and difficulty in contacting the consultant, who was working during the week at an NHS Hospital. Consequently Peter’s deterioration went unrecognised until his situation was so bad that the decision was made to transfer him to an NHS Hospital.
On top of this no protocols or procedures existed for the transfer of unwell patients from the private hospital to an NHS hospital. Handover documentation was also incomplete, so that no reliable statement of how things were with Peter, in real terms, existed.
More generally I believe there should be concerns about the responsibility the private sector has for managing the healthcare professionals working in their hospitals. A report written in 2017 entitled “No Safety Without Liability” by the Centre for Health and the Public Interest makes recommendations that I would fully endorse: private hospital companies should directly employ the surgeons, anaesthetists and physicians, and the junior RMOs who work at their hospitals and should be responsible for monitoring their activities and appraising their performances. And private hospitals should be required to adhere to the same reporting requirements as NHS Hospitals: there should no difference between the level of care provided to NHS patients treated in NHS hospitals and private hospitals.
I believe that there needs to be much more joined-up thinking of policy and practice between the NHS and private hospitals if further tragedies such as Peter’s death are to be avoided in the future.
Finally, I would like to end on a more positive note. I have the greatest respect for all those who work in the healthcare profession. The dedication of staff, often working in difficult situations, can only be admired. Yet there are times when systems fail, and this needs to be at the forefront of how we address the often more uncomfortable issues.
Focussing mainly on policy and procedure can make us forget or neglect the “human face” of healthcare. For me, my brother Peter is that “human face,” and I miss him. I hope that by telling you his story today his death may in some way help to raise awareness and bring about much needed changes.
