Your Life In My Hands--a Junior Doctor's Story

by Rachel Clarke

  This is a story of appalling and unnecessary suffering of hundreds of people. They were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety.

  There was a lack of care, compassion, humanity and leadership. The most basic standards of care were not observed, and fundamental rights to dignity were not respected. Elderly and vulnerable patients were left unwashed, unfed and without fluids. They were deprived of dignity and respect. Some patients had to relieve themselves in their beds when they were offered no help to get to the bathroom. Some were left in excrement stained sheets and beds. They had to endure filthy conditions in their wards. There were incidents of callous treatment by ward staff. Patients who could not eat or drink without help did not receive it. Medicines were prescribed but not given. The accident and emergency department as well as some wards had insufficient staff to deliver safe and effective care. Patients were discharged without proper regard for their welfare.8

  The first Francis report was published in 2010, my inaugural year as a qualified doctor. Like many other doctors in my hospital, I felt deeply ashamed of the press coverage, tainted by association, and keen to distance myself from the findings as far as possible. The more fervently we condemned what had gone on, the more clearly we signalled – or so we hoped – that we were a different, better breed of clinician.

  ‘This could never happen here,’ our consultant stated emphatically to us. ‘It’s inconceivable. This is a classic example of poor leadership. A culture was allowed to flourish when it should have been stamped out immediately.’

  Barely six months a doctor, feeling uncharacteristically timid on this occasion about speaking up, I reluctantly kept quiet. I imagined similar pronouncements being made in doctors’ messes up and down the country. The defensiveness was understandable, but the truth wasn’t so simple. I knew, for example, that what my grandfather had endured in an entirely different hospital echoed the testimony provided by relatives of the patients who had died in Mid Staffs. That meant the inhumanity was not an isolated incident. In at least one other NHS hospital, the one in which my grandfather had died, staff were also failing – albeit perhaps on this one occasion alone – in their basic duty of providing safe, humane care. My consultant may have dismissed as inconceivable a repeat of Mid Staffs in our hospital, but conceivability, one could argue, reflects the mind of the conceiver as much as the world around them. Indeed, Sir Robert Francis singled out denial among the workforce at Mid Staffs as one of the drivers of the unchecked cruelty: staff had closed their eyes and ears to what was unfolding around them.

  Arriving home from the hospital that night, I planted myself on the sofa with a large glass of wine and read the full report cover to cover. After a while, the cumulative effect of reading account after account of relentless mistreatment started to feel sickening. Invariably, it was the most vulnerable patients, the frail and elderly, who had been robbed of their dignity. The sister-in-law of a retired academic who could have been my grandfather described his deep humiliation at being left in soiled squalor in Mid Staffs:

  The nurses there weren’t unkind to him, but they were overworked. We often felt that if we asked them if they would clean him up … it would be hours before they came back to clean him up, and in that time he was just lying in a dirty bed with dirty nightwear on, and he didn’t want me to go in the room, even. He would say: don’t come near me, don’t come near me, I smell; and he was a very fastidious man and he really was left lying in his own excrement.9

  Late at night now, with most of the bottle of wine gone, I ruminated on how it is that good staff turn bad, though still skirting the obvious question: could this, one day, be me? Even if not quite yet, was I capable of becoming the kind of doctor who, at best, turns a blind eye to suffering and, at worst, behaves in ways that cause it? Francis had identified a large number of different causes of the scandal, not least a bullying culture in which many staff were too afraid to speak out and those who did felt their concerns were ignored. My own timidity earlier in the day – too compliant to disagree in public with my boss’s declamations – hardly reflected well in that context. Suppose that day in, day out, my ward were an environment devoid of humanity. Would I put myself on the line by taking a stand, or would I quietly conform, following the lead of my colleagues?

  The testimony given by one junior doctor to Francis nagged away at me. He described his shock, on arriving at Mid Staffs from another hospital, at the woefully inadequate care that his fellow doctors and nurses in the Emergency Department seemed to accept as normal:

  I think it had been an incremental thing where things had become harder and harder and harder and [the other staff] didn’t actually realise just how far off acceptable standards things had slipped to, and I don’t think that any of them would have let that happen if it had happened overnight. I think they would have been up in arms, but I think it was just so gradual that they didn’t recognise it.9

  I thought back to an incident on my own ward a few weeks earlier. The SEU, or Surgical Emergency Unit, had a reputation for being something of a patient-crunching factory. If you didn’t earn yourself an operation pretty damn quickly, it often seemed, you were spat out as swiftly as the surgeons could manage. Infirmity was no excuse. If you weren’t robust enough for home, there were a thousand ways to turf you into the hands of a less single-minded speciality, with the acute general medics invariably being targeted as the dumping ground of least resistance.

  This surgical stereotype neglects, of course, the systemic factors that can force such a dizzying throughput of patients. One reason an acute surgical unit turns over patients so rapidly is because, if surgeons don’t do this, they cannot accept the next patient in need of an operation. Instead, surgically unwell patients who cannot get into the unit either wait inappropriately in A&E or – possibly worse – are sent to medical wards where they can receive inadequate surgical nursing and usually a longer wait before review by a surgical consultant. Acute surgical beds are acute – as short stay as possible – precisely because they are required for patients who desperately need an operation from only those clinicians, the surgeons, who can give them one.

  Nevertheless in this context, one surgeon’s morning ward round had been exceptional. The night before, I’d admitted an elderly man to the SEU. Brought by ambulance to the hospital in excruciating abdominal pain, Mr Skipton had been rushed straight to the CT scanner. Haggard, gaunt and frightened, he’d asked me not to leave him even as the porters were wheeling him away down the corridor.

  The next morning, just prior to meeting the patient for the first time, my consultant surveyed the CT scan. Everyone jostled for a view of the computer monitor tucked away behind the nurses’ station.

  ‘Well,’ said the surgeon, after a brief pause. ‘He’s fucked, isn’t he?’

  The scans were indeed bleak, though the surgeon’s bluntness made me wince. My patient’s pain was being caused by a huge tumour obstructing his bowel and aggressively invading the rest of his abdomen. His liver was riddled with metastatic cancer. At ninety-three, active treatment of his malignancy was not going to be an option.

  Mr Skipton was now being fed and watered through a drip in his arm and a tube down his nose. He stared up in trepidation as my boss, impatient to get to theatre as quickly as possible, alighted at the bedside. I hastily drew the flimsy curtains. Without so much as an introduction, he broke the news to the patient of his terminal illness by turning away to the bedside entourage and muttering, perfectly audibly, ‘Get a palliative care nurse to come and see him.’ No one had even told ‘him’ he had cancer.

  As panic began to rise in Mr Skipton’s face, I remember catching the ward sister’s eye to see her cringing alongside me. But trying to undo the damage would take so long and the ward round was already sweeping on. I had a moment in which to act decisively. I could have chosen to earn my consultant’s wrath by remaining at my patient’s bedside. Instead, to my shame,
I scuttled dutifully after my boss, leaving someone else to pick up the pieces.

  All that stood between Stafford Hospital and this sorry encounter was a missing family member – a wife, perhaps – who, years later, through bitter tears, might go on to describe the lack of compassion to an impassive QC, her words discreetly transcribed by a stenographer tucked away in the corner, immortalising yet another piece of damning testimony. I could blame my inaction on my lowly status at the bottom of the food chain – the most junior, and thus least powerful member of the team of doctors – but the fact remained that I’d known it was wrong and done nothing about it. All of us were complicit, including me. So were we really any different from, any better than, the staff who had allowed, even if they not actively participated in, the horrors of Mid Staffs? Like frogs who accept being boiled alive without a croak of complaint, provided they are heated sufficiently gradually, were the newest recruits to the wards of NHS hospitals being stealthily inured to unacceptable levels of brutality?

  The trouble with trying to answer these questions was, I didn’t have a clear grip on ‘normal’ any more. The moment I’d first pressed a scalpel into a human corpse, normality had ceased to mean the same for me as for my non-medic friends. And, once you start breaking taboos, perhaps you need external guidance about when to stop. You can no longer rely upon the churning in your stomach or the tingle down your spine because you’ve developed an abnormal steeliness that enables you to act in defiance of your basic instincts or – worse – cease to feel them at all.

  My SEU was not Mid Staffs. Of that I was certain. The majority of the nurses and doctors were kind and professional. Patients were not routinely being starved or soiled. But, in one fundamental respect, my place of work felt uneasily similar. There were, from my frontline perspective, insufficient doctors and nurses. Francis had identified the root cause of the horrors of Mid Staffs as being the severely depleted numbers of frontline staff. The Trust board, determined to win from the government the coveted ‘foundation Trust’ status, had sought to demonstrate their fiscal prudence by saving £10 million. This would be largely achieved through draconian staffing cuts, in spite of warnings from both doctors and nurses:

  I have no doubt that the economies imposed by the Trust Board, year after year, had a profound effect on the organisation’s ability to deliver a safe and effective service. With hindsight it is possible to discern an ever more desperate situation,’ stated Francis. ‘A chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care.’1

  In some ways, the testimony from overstretched individual members of staff working at Mid Staffs mirrored the anguish of patients and relatives. One nurse from the hospital’s emergency assessment unit told Francis:

  I remember at the time when our staffing levels were cut and we were just literally running around. Our ward was known as Beirut from several other wards. I heard it nicknamed that. ITU used to call us Beirut … I remember saying: this will have repercussions, this can’t go on like this. Because relatives were regularly coming up to us and saying: my Mum has been buzzing for this long, there has been a buzzer going there for that long.9

  Another nurse recalled her distress and guilt at being too overstretched to provide humane care for her patients:

  In some ways I feel ashamed because I have worked there and I can tell you that I have done my best, and sometimes you go home and you are really upset because you can’t say that you have done anything to help. You feel like you have not – although you have answered buzzers, you have provided the medical care but it never seemed to be enough. There was not enough staff to deal with the type of patient that you needed to deal with, to provide everything that a patient would need. You were doing – you were just skimming the surface and that is not how I was trained.9

  The junior doctor from the Mid Staffs Emergency Department who had speculated about incremental brutality building up over time was adamant that the fundamental problem in the hospital was not the quality of its staff, but their shortage and the overstretched system within which they were being obliged to work, forcing them to keep their heads down and muddle through the best they could:

  There just were not enough staff … Very few people come to work to do a bad job and I have never met a nurse who comes to work to do a bad job. The nurses were so under-resourced they were working extra hours, they were desperately moving from place to place to try to give adequate care to patients. If you are in that environment for long enough, what happens is you become immune to the sound of pain. You either become immune to the sound of pain or you walk away. You cannot feel people’s pain, you cannot continue to want to do the best you possibly can when the system says no to you, you can’t do the best you can. And the system in the hospital said no to the nursing staff doing the best they could and to the doctors.9

  This struck a disconcerting chord. Only a few months into my life as a doctor, immunity to the sound of pain was something with which I was already familiar. In some ways, it was a prerequisite for doing my job. Every time I assessed a patient’s level of consciousness, for example, and they failed to open their eyes in response to my voice, I would grind my knuckles into their breastbone with such force that all but the most deeply unconscious of patients would flinch, groan or cry out loudly with pain. Those cries caused me not a moment’s guilt. In provoking pain, I felt the opposite sensation – a wave of relief – since I now knew that the patient’s brain injury was not as severe as I had feared. Without first causing the pain to which I graded their response, I had no way of objectively quantifying their conscious level.

  More prosaically, I’d moved on from my early days of struggling ineptly to site cannulas in my patients’ veins, their grimaces at my clumsy efforts making me hot and sweaty with guilt. I’d learned that treating the task as a purely technical challenge, rather than a human encounter, gave the patient the best chance of a pain-free cannula. Paradoxically, being cruel was the best way to be kind. I would talk gently and soothingly as I decisively stabbed them, but, inside, I was ruthlessly focused, feeling nothing at all. It worked. I became cold but proficient – a proficiency that spared my patients the bumbling misery of an incompetent, if kindly, practitioner. Notably, only children in our hospital had the automatic right to a dollop of anaesthetic cream that would numb the site of their cannula. And even then, this was probably more for the sake of expediency, not kindness, with distraught tots being some of the most challenging and time-consuming patients to manage. Everyone else was expected to bear the few seconds of pain, even though, for an unlucky minority with ‘difficult’ veins, those seconds could drag out into half an hour or more of increasingly painful attempts at cannulation. It had never occurred to me to question why, if we knew a patient had ‘bad’ veins, we didn’t pre-empt our efforts with the kindness of a squirt of local anaesthetic.

  In fact, no one at medical school had ever discussed with us the idea that inflicting a minimal degree of pain might be a necessary component of providing exemplary medical care. Nor challenged us to question when its infliction was justifiable, and when it was simply abuse. I thought back to one of my surgical inpatients who had recently become dangerously septic, his body overwhelmed with bacterial infection. The source of the bugs was unclear, so I was asked to perform a rectal examination, exploring the rectum with my gloved finger to see if his prostate gland was inflamed. Based on my examination technique, it was not. But when my consultant repeated my pitifully gentle examination, causing the patient to leap off the bed with a howl of pain, the prostate was clearly exquisitely tender. My feeble, minimalist technique – the product of not wanting to cause my patient discomfort – had wholly failed to elicit the diagnosis. In attempting to be kind, I had merely let my patient down.

  While effective medicine undoubtedly entails a degree of detachment, I had a sneaking fear that, on my SEU, our patients’ distress might be turning into white noise, a persistent but necessarily surmountable distractio
n. The fact was, there were simply insufficient doctors to manage the ward. As house officers, we barely had time to think straight. Four of us should have been looking after the hundred or so surgical inpatients, but sickness, night shifts and annual leave meant that rarely were there more than three of us, and frequently we were down to two.

  As for our immediate seniors, the surgical trainees, they too were desperately short-staffed, struggling to balance on call admissions, which they were usually left to deal with on their own, along with supporting their juniors and getting into theatre for their actual training. Above them, the surgical registrars and consultants on call were often unable to get up to the wards not because they were loathe to leave clinic or theatre, but because they physically could not. The consultant in charge might appear frustrated and rushed since he or she was the sole individual in charge of over one hundred acutely unwell patients, trying to see all of them in the time it took to anaesthetise their first patient in theatre. If they were late for theatre, they would cause a whole team of often over ten staff, as well as the anaesthetised patient, to be kept waiting. In short, at every level of seniority, the system – the sheer lack of capacity for surgical beds and theatre time – was pushing all of us away from kindness and further towards callousness. It felt like a Mid Staffs in the making.

  For we house officers, the sheer volume and complexity of patients daily outstripped our ability to keep then safe unless we toiled without a break from the moment we arrived at work until several hours after we were meant to have gone home. Often, this meant starting work at 7 a.m. and not stopping until 10 or 11 p.m. Not infrequently, I was filled with dread at the thought of the effort required to get through another day.

  ‘Hey ho,’ my friend would say as we changed into our scrubs each morning. ‘Fancy being assaulted for the next sixteen hours?’