A PATIENT at Princess Alexandra Hospital has testified to senior management regarding her treatment at the Harlow hospital. Treatment that hospital bosses have described as “shocking” and say they were “shaken” hearing about it.

Anne Weersing (AW) spoke at a recent public meeting of the Board of Directors held at their Kao Park offices in Harlow.

Her testimony was documented in the minutes of the meeting.

The minutes stated:

“THE key issues for her that day were the hospital’s response/approach when things didn’t go right for patients and the support provided following that. She would also be keen to hear from the teams involved as to what had been learned from the complaint.

The Associate Director of Patient Engagement added that the story raised for him, questions as to how respected the patient voice was in the organisation and the potential issue of over-reliance on technology.

AW informed members she was a long-standing sufferer of urethral stenosis and bladder
under-activity which led to chronic urine retention.

On 29.05.21 she had attended the Trust for a routine elective day surgery procedure. She had met the treating consultant for the first time in the pre-operative consultation on the day and he had declared that the diagnosis of urethral stenosis was incorrect.

Previous procedures and diagnoses had been made at a different hospital and the consultant that day did not have access to her notes.

Her request to be allowed home with a catheter in place (following previous complications with dilatations) was refused.

It was later discovered that discharging her home without a catheter was against Trust policy.

The procedure went well and AW had been discharged to the day stay recovery unit later that
afternoon. Over the next few hours AW drank about 2.8 litres of fluid but was unable to pass
urine. She knew then (from previous experience) that she was going into urinary retention
and she let the nurses know. As a nurse herself she suggested a fluid balance chart be
started but was told those had been replaced by bladder scanners. She also asked for some
pain relief but was told pain was to be expected after the procedure and she should try to
walk around to relieve that.

Two bladder scans were then performed over the next few hours which showed low amounts
of urine in the bladder. She was then told she was ready for discharge and her husband
arrived around 17:30 to find her crying in pain and in distress.

Various attempts were made to bleep the medical team, on-call urology registrar and on-call surgical team to catheterise her.

The latter responded but were in the ED.

The on-call matron was also bleeped for approval for the nursing staff to perform the catheterisation but that was denied due to nature of the procedure and she was catheterised by a doctor later that evening.

AW confirmed she was then transferred to a ward overnight where her catheter drained over
three litres of water. This had caused AW significant pain and the bladder had in fact
ruptured.

The following morning she had been visited by the same consultant who had been
surprised to see her and to learn that she had gone into acute urinary retention. Her request
to go home with a catheter was refused on the grounds that it was not safe for AW to remove
the catheter herself.

Later that day the catheter was removed by a nurse and AW managed to pass urine but with intense pain. She was discharged home later that day.

Over the next 14 hours AW became aware something was not right which resulted in her
then being admitted to Addenbrooke’s hospital for three nights where a scan revealed a 7mm
tear in her bladder.

Three further weeks of conservative treatment then followed.

Following this her confidence in the NHS was shattered, her mental health poor and she had shown
signs of PTSD.

She had found the PAHT complaints process frustratingly slow to the extent
she had ended up contacting the Ombudsman eight months after first submitting her
complaint to the Trust.

Just prior to Easter 2022 she had been offered a resolution meeting with Trust colleagues which both she and her husband had found wholly cathartic and she had then received a final response letter from the Lead Urology Consultant confirming that the care she had received which had resulted in the bladder rupture was far below the standard expected by the organisation.

The DoN&M thanked AW for sharing what was a harrowing story and she asked for some
reflection from surgical colleagues.

In response the Surgical Matron (SM) updated that the Lead Urology Consultant had spoken with the consultant in question.

The nurses involved had undertaken a reflective piece and the bleep system involved at the time had recently been updated to a new more efficient one.

Continence nurses had since changed processes around use of the bladder scanner and fluid charts were now recorded on a recently introduced electronic system in ED known as Nerve Centre.

AW commented that it meant a lot to her to hear that changes had taken place, particularly the process around the use of the bladder scanner and not forgetting basic training skills for example in terms of basic patient examination.

In response to the above the TC requested that a report on lessons learned and the embedding of those be fed back through the Quality & Safety Committee (QSC) in October.
The DoN&M agreed.

A number of the board members made the following responses after hearing of Mrs Weersing’s experience:

Non-Executive Director (NED) Rob Gerlis highlighted that for him the lack of physical patient
examination was worrying along with the high handed approach of staff.

NED George Wood commented that he had been shaken by what he had heard.

The time taken to address the complaint troubled him and he requested a review of that
process be included in the paper to QSC.

He thanked AW for bringing her story and confirmed the organisation would now put things right to ensure mistakes were not repeated.

In response AW reiterated how cathartic she had found the resolution meeting. It was very
important for patients to be listened to.

NED Helen Glenister commented there was much wider learning for the organisation and she agreed there also needed to be further consideration of the complaints process. As Chair of QSC she would very much welcome the report described above to ensure this experience was not repeated.

NED Helen Howe agreed about the wider learning. Listening and respect for the
patient were key and if a shift in culture was required then then that was what should happen.
She noted that patient stories should be shared across the organisation particularly amongst
juniors.

ANED John Keddie stated he had found the story hard to listen to. ‘Patient at
heart’ was the Trust’s first, of three, values and the hospital had not got that right. He would
follow up tirelessly now how people lived the Trust values and treated patients.

In response AW commented that she had been pleased to hear the nurses involved had been asked to
write a reflective piece. She questioned whether the consultant involved in her care would
also write a reflective piece.

At this point in the meeting the Medical Director (MD) Fay Gilder confirmed the story had shocked her
and the Board.

The incident would be recorded on internal systems (Datix) and declared as
a serious incident (SI).

There had been a series of failings in the case starting with the assessment.

The consultant would be scrutinised following the ‘Just Culture’ approach and she was deeply sorry for AW’s experience.

The consultant would now be required to write a reflection and it would be included in their appraisal.

The Surgical Matron confirmed that AW’s experience had been recorded on Datix and presented to the Trust’s Incident Management Group.

ANED Anne Wafula-Strike commented she was truly sorry to hear about the experience and she thanked AW for articulating what had happened so that the Board was aware.

The CEO Lance McCarthy then also reiterated his thanks to AW for articulating a poor set of experiences in
the hospital.

It showed the power of a story when things didn’t go well and he had been pleased to hear of the positive response from the surgical team.

The key piece now would be to take all the actions away to prevent a similar experience for others and also to take the broader learning around communication and behaviour generally and for that to be followed through and articulated to colleagues.

He noted that Patient Stories were shared at divisional level. He was pleased to update that the previous week had seen the start of a programme of work to address culture and behaviours in theatres of which communication, speaking up and common sense were key elements.

He would also now be looking to the Patient Experience team to understand how the complaints process (responsiveness) could be improved.

“He thanked AW for her time and apologised again on behalf of the organisation for her experience”.