Nursing Home Report on Conditions at Brighton and Sussex University Hospitals NHS Trust

The following report is based on extensive observation of the conditions for patients living at the Brighton and Sussex University Hospitals NHS Trust. While some patients received moderate care, overall, the quality of care in this facility was appalling. All patients -- all people -- deserve to be treated with dignity, and this was far from the case. The conditions were especially distressing given that in general they could be fixed or at least ameliorated relatively easily. Not all of the ills of old age or disability can be remedied, of course. Pain and fear will be present even with the best possible care. Given that this is true, all possible efforts must be made to reduce fear, anxiety, and pain to the greatest degree possible.

The facts that this report is based on were documented by Margaret Haywood, a state-registered nurse who served in an undercover capacity at this facility. The decision to employ this approach, Ms. Haywood notes, was not an easy one. Considering herself primarily a nurse, she found it difficult to change hats and become a detective, essentially spying on her fellow medical professionals. This role was especially uncomfortable when she had to watch patients being mistreated. However, she believes, there was no other way in which an accurate and systematic record could be made of the problems at this facility, and without such a record, there was no possible way in which a plan could be put into place to remedy them.

It should be noted that Ms. Haywood was brought up on disciplinary charges when her role in the investigation was revealed. She lost her license as a result (Reasons for the substantive hearing of the Conduct and Competence). Her case was examined by Grant (2010), who described the investigation as "a morally ambiguous situation in which both the protagonist and the organisation compromised their core values." He judged that Haywood "used individuals as a means to a 'higher' end" and the Brighton and Sussex University Hospitals NHS Trust "deviated from the ethical to the business map, in a contradiction of what the health service represents."

This record of the problems at this facility can be used much more broadly to help improve the quality of all long-term care facilities, whether state-funded or privately supported. It should be noted that the director of the care facility stated that he believes that the feature film based on Ms. Haywood's findings (upon which this report is also based) did not present an accurate view of the totality of care that the facility provides its patients (Online bulletin).

The problems that Ms. Haywood documented can be divided in several larger categories. These include:

1) Lack of clear communication between staff and patients. Because a number of the patients were unable to state their needs clearly, many of them did not receive the care that they needed. She describes the situation:

Recommendation: While there is likely to be some problem with communication in any facility in which there are patients with cognitive problems, careful charting of each patient's needs would reduce the chronic miscommunication that Ms. Haywood witnessed. This improvement would take some changes in staff work habits, of course, but is a change that would take overall little if any more time for each patient, add little if any cost, and greatly improve the lives of the patients. It would also reduce stress for the staff and therefore improve their work experience as well.

2) Neglect in terms of treating pain. Ms. Haywood said that the most haunting, disturbing experience that she had was an example of this. She writes: "The memory which will haunt me for the rest of my life, is of a lady who was terminally ill with cancer, crying out in pain because she hadn't been given her pain relief on time. That was just so heartbreaking, it really upset me. When I did a couple of shifts in a row, I was able to...

There was no good reason why it hadn't been given to her. Staff were busy and no one had checked, which is awful."
Recommendation: It is vital to differentiate such lack of providing appropriate pain relief with a conscious decision made between limiting pain medications for sound medical reasons and simply neglect. There is a range of philosophies on how much pain medication should be provided to patients. While no consciousness medical professional wants to see a patient in unnecessary pain, how to define "unnecessary" is complicated. Pain medications are powerful drugs and they have problematic side effects. For example, many pain medications can suppress respiration. This can hasten death, which some professionals and some patients believe is problematic either ethically or in terms of personal goals for the patient. Moreover, suppression of respiration (even when accompanied by a reduction in pain) can be very frightening and anxiety-producing for patients who may feel that they are unable to get enough oxygen. (Although this feeling may, of course, be alleviated in many patients by the use of supplementary oxygen.)

What happened at this facility was not based on the kind of careful, sophisticated analyses suggested above; rather it arose as a result of short staffing and a certain lack of caring on the part of some members of the staff.

3) A very easy change that would greatly improve the quality of life of the patients would be a change in the clothes that they wear. Recommendation: Rather than forcing the residents to wear hospital-style robes that open up the back and are both uncomfortable and disrespectful, most residents can wear "normal" pajamas or lounging clothes and others can wear more comfortable modified clothing. Such a change, which will have an initial cost, but a relatively small one in terms of potential benefits, will likely improve the emotional and psychological state of the residents, which will have a ripple effect on their physical health.

4) Most of the more serious problems at the facility arose from too few staff. This is an endemic problem throughout the long-term care sector, and one that extends throughout the industrialized world. There is no easy fix for this problem. However, there are some changes that could at least reduce the problem. The first of these is that a more organized work hierarchy that takes into account the real conditions of such facilities would help.

Haywood describes this situation:

One of the ladies who'd had a stroke had been given a fluid chart but all it had on it was the date. Nothing had been filled in at all. This poor lady couldn't speak because of her stroke, so sorting out the fluid recording was the first thing I had to do. (Margaret Haywood's diary)

Recommendation: The current situation requires the floor nurses and other medical staff to receive permission from the charge nurse for tasks that they have the knowledge and skills to take on. The resulting work flow looks something like this:

Patient asks for optional but approved medication of attendant (

Attendant goes to charge nurse's office (

Charge nurse is busy in another part of the facility (

Attendant waits ten minutes for charge nurse and then goes on break (

Charge nurse returns but there is no note about requested medication (

Attendant returns from break to have several urgent demands from patient and forgets request for medication (

When attendant remembers the request, charge nurse is once again busy outside of her office.

Here is how the above process could be revised so that the current staff-to-patient ration might be managed more efficiently. Having more staff would be a much better solution, but is probably beyond the resources of the National Health Service in the immediate future.

Patient asks for optional but…