I first read this in the Health Service Journal yesterday. The slant I got from there was that the problem was with management of the hospital. There were problems with emergency care, but this didn't seem to be a criticism of clinicians in the ED- problems were things like only one consultant; use of clinical decisions units as dumping grounds to prevent 4 hour breaches; patients nil by mouth for 4 days while waiting for an operation; no experienced (i.e. beyond FY1) surgeon in the hospital past 9 pm and trust board discussions dominated by finance and foundation status rather than clinical care.
The Healtcare Commission report specifically refers to "Emergency healthcare" not "Emergency department": 
"The report states that there were deficiencies at "virtually every stage" in the care of people admitted as emergencies.

The investigation examined the care of emergency patients across their entire hospital visit, from the time they arrived in A&E, care on the Emergency Assessment Unit (EAU) and subsequent admission to a surgical or medical ward."

Reading the report itself, there were criticisms specifically of the ED. These were:

Lack of protocols and pathways
Poor levels of staffing and equipment
Inadequate nursing training and leadership
Too few consultants with 24 hour consultant cover not available (the lack of consultants being made worse when the Associate Specialist was made redundant)
Poor infection control
Poor layout of the department (it had been refurbished at a cost of £800,000 without input from the staff)
Decision by the trust's management board not to implement NICE guidance on head injuries despite concerns expressed by senior ED staff
Non availability of CT scanning out of hours and even when available, required a consultant to consultant referral (which meant the consultant coming in and caused delays: switchboard would not connect a middle grade doctor to a radiologist)
Insufficient staff to triage patients
Acute physicians covering A and E despite not being competent to cover medical let alone surgical emergencies (and refusing to get involved or walking away if they felt they were not competent)
Too few middle grade doctors (the recommended number was 9; there were 2 WTE plus 2.4 WTE locums)
A trial period of no middle grade doctors from midnight to 7 am Monday to Thursday (although the trust later recognised that this was unsafe and abandoned it)
Lack of supervision of FY2 doctors (due to lack of senior and middle grade staff)
Teaching when provided being interrupted by managers or senior nurses because of concerns about 4 hour breaches
Lack of porters in A and E
Some rather odd figures- for example the trust reporting having 7 Band 7 nurses in the ED when they actually had one (they included Band 7s from other areas)
Patients moved inappropriate to the clinical decisions unit (this included patients who needed HDU care and patients with what sounds like unreduced Pott's fractures)
All GP referrals being sent through A and E
No M and M meetings and lack of audit
Lack of appraisals


The only criticism of ED medical staff I can see is: "The remaining consultant described the department as isolated. He was described by many of his medical and nursing colleagues as a poor leader."



Matt Dunn
Warwick


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