A surgeon at a private hospital criticised for risking patients' lives operated without gloves in blood-stained shirtsleeves, while a child whose condition was deteriorating was not seen by a paediatrician for seven hours, according to a damning report from the Care Quality Commission.
The full scale of the chaotic and dangerous care at the BMI Mount Alvernia hospital in Guildford, Surrey is revealed in the final report from the CQC, published on its website after several days' delay while negotiations were held with BMI Healthcare. The hospital failed on every measure but one in an unannounced inspection in January which was carried out because of concerns raised by whistleblowers. It met an acceptable standard only on the management of medicines.
The Guardian reported on Wednesday that BMI Healthcare, one of the biggest private providers in Britain, had agreed to stop children's surgery at Mount Alvernia as a result of the findings.
The report tells of a child who was admitted for minor surgery but developed very serious complications: "The child was not transferred to a more appropriate setting with paediatric critical care staff for seven hours. No paediatrician was involved in their care whilst they remained at BMI Mount Alvernia hospital.
"This demonstrated that the service did not provide safe care to children. The child should have been transferred to a more appropriate setting when they first became ill but this was not done. The staff did not follow the corporate policy on transfer in an emergency. The hospital put this child at significant risk of serious harm and did not manage the risks associated with their deteriorating condition safely."
The inspectors discovered that the hospital, which did not regularly deal with very sick children, had no policy or guidance on the care of children; no early warning system to alert staff to a child's deterioration; and no policy on pain management for children. Children's resuscitation equipment was broken and there was only one trained children's nurse.
The report paints a picture of a hospital where surgeons broke the rules and refused to listen to criticism. One surgeon refused to let women patients have chaperones during intimate examinations. Another did not wash his hands between patients. A consultant brought an unannounced visitor into the operating theatre and insisted the list be changed for their convenience, increasing the risk of mistakes.
The same consultant sedated patients and left them without an appropriately trained member of staff to look after them. The consultant would turn up late to theatre and talk on the phone during surgery.
Mistakes were made. One patient had a nerve block on the wrong side of his body. Blood transfusions were not managed safely. "One patient was given two units of non irradiated blood despite irradiated blood being ordered. Another patient was given two units of blood that were past the transfusion time," says the report. Notes from one patient's operation were found in another's medical records. "Another incident report showed that the handover sheet said one patient was admitted for a PIP implant removal (breast surgery) but the theatre list said that the patient was for bilateral lower blephoroplasty (eye surgery)."
Surgery was for a time carried out in an ambulatory care unit, an area outside of the operating theatres, because they were out of use following a ventilation problem. It was unsuitable for surgery under general anaesthetic, but a consultant surgeon insisted on carrying out investigational procedures on two patients there. During one of these, a patient suffered major blood loss and needed immediate abdominal surgery.
"As this area was away from the theatre suite, this had caused considerable distress to the theatre staff because they knew they were putting a patient's life at risk. There had been difficulty transporting equipment from the theatre which was on a different floor to the area and in obtaining additional blood supplies when the patient haemorrhaged. A senior theatre staff member told us that the patients had been put at significant risk and for one patient, there had been a real risk of them dying," says the report.
BMI Healthcare says all the issues at Mount Alvernia have been put right since the inspection. It says it has reviewed all its other hospitals and there are no similar problems elsewhere.