IS WESTMEAD HOSPITAL SHAPING UP TO BE ANOTHER KING/DREW?

The management at this big NSW government hospital seems to be nearly as hands-off it was at the disgraced and now-closed King/Drew hospital in Los Angeles. Two brand new reports below plus re-runs of two previous reports -- one from yesterday and another from March 8th:

Amazing bungle at Westmead leaves family seething

"He was in agony"... a feeding tube was wrongly inserted into the lungs of Francis Wilks-Tansley, 7. The bastards should be sued for millions for what they did to the boy

THE family of a boy who almost died after a ''breathtakingly basic'' hospital bungle nine months ago is still waiting for a written apology and a change in policy to prevent other children suffering the same fate. Francis Wilks-Tansley will be fed through a hole in his stomach for the rest of his life and is unable to breathe properly after a feeding tube was inserted into his lungs - and not detected for 36 hours.


During that time the seven-year-old, admitted to The Children's Hospital at Westmead for seizures, was given water and six medications through the tube, causing him to develop a life-threatening pneumothorax, where air gets trapped in the cavity around the lungs, and his right lung to collapse. One of the drugs, sodium valproate, causes severe chemical burns to lung tissue.

Up to six staff tended to Francis, who was born partially blind, deaf and with limited voluntary movement, over several shifts before the error was discovered, despite repeated calls from his mother, Sarah Wilks, that he was in respiratory distress. A chest drain was then inserted for 17 days to remove the fluid in his lungs. ''He was in agony, in extreme pain,'' she said yesterday.

One staff member, who did not want to be named, described the mistake as ''breathtakingly basic''. Staff must draw out some contents of feeding tubes as soon as they are inserted to test for the presence of stomach acid. A drop is placed on litmus paper, which turns a vivid pink if stomach acid is present. A chest X-ray can also be used to confirm the tube's placement, particularly in heavily sedated or unconscious children.

But Dr Wilks, who has a PhD in biology, said the lamp next to Francis's bed, used to check the colour on the litmus paper, was not working, making the room dim and difficult for staff to determine if the tube had touched stomach acid or lung secretions.

A case review carried out by the hospital found there had been three attempts to insert the tube, and its blood-stained contents had turned the litmus paper pink, leading staff to believe it had been placed correctly. But it also said difficult or repeated attempts should alert staff to the need for an X-ray to check position. After the incident, staff were sent a short email reminding them of the importance of correct tube placement.

''They almost killed my son and yet haven't changed their culture,'' Dr Wilks said. ''This is not an error made by one person. It was a group of people, which means there must be a systemic or cultural problem, and I want to make sure they can't do it again. I don't want them punished; I want them educated.''

Dr Wilks, who also has three teenagers, had bought a house in Hobart the day Francis was admitted to hospital and has been commuting twice a week to be with him. Yesterday the hospital offered to reimburse her air fares and promised a new policy would be in place by the end of the month.

But she is adamant the offers were made only because she contacted the NSW Health Minister, Carmel Tebbutt, last week. ''It's been an unconscionable length of time. An apology now is worse than no apology at all. There is nothing I can do to reverse the damage done to Francis but, at the very least, the hospital needs to ensure this doesn't happen to other children.''

A spokeswoman for the hospital yesterday said staff had verbally apologised to Francis's family. She said a statewide safety notice had been issued in February and a compulsory education program was being developed for all staff inserting feeding tubes, but it was not known when it would begin. ''The hospital sincerely regrets this incident and how it has affected Francis and his family. We are not denying we made a mistake, and we are sorry about it.''

SOURCE

Patients catching lethal bugs at Westmead

FOUR patients a week admitted to Sydney's biggest hospital, Westmead, are being infected with potentially lethal golden staph and MRSA infections picked up while in the wards, hospital documents show. An investigation into where every one of the reported 2392 hospital-acquired infections, some known as "superbugs", occurred in 2008 in public hospitals showed Westmead topped the list, but other big hospitals including John Hunter, Liverpool, Blacktown and Royal North Shore were not far behind.

Experts believe the spread of infection is largely due to poor handwashing and other hygiene controls by nurses and doctors, The Daily Telegraph reports.

Official NSW Health records, obtained by Channel 9 under Freedom of Information laws, reveal the numbers of infected patients at public hospitals for central line associated bacteremia, surgical site infection, staphyloccus aureus (golden staph), multi-resistant staphyloccus aureus (MRSA) and acinetobacter baumanni.

A report on golden staph and MRSA, published in the Medical Journal Of Australia this week, reported golden staph infections can prove fatal for up 21 per cent of those infected within a month. Survivors can face having treatment sometimes over years to beat the illness.

The documents show Westmead recorded 243 infections in 2008, including 201 cases of golden staph and its antibiotic-resistant variant, MRSA.

Newcastle's John Hunter Hospital came in second with 150 infection cases, including 126 golden staph and MRSA incidents. The third highest hospital was Liverpool, which had 144 cases including 100 golden staph and MRSA cases. Children's hospitals also reported potentially life-threatening infections.

The Children's Hospital at Westmead had 31 cases of hospital acquired infection while its sister facility at Randwick, Sydney Children's Hospital, recorded 28 cases.

NSW Health Deputy Director General Tim Smyth said the likelihood of getting an infection in a public hospital was very small. The Department reported in 2008 an average of just 3.8 cases of MRSA infection for every 1000 intensive care days in public hospitals and 2.5 infections for every 10,000 bed days for golden staph bloodstream infections.

SOURCE

Unmonitored patient left to die at Westmead

Staff switch off "annoying" monitors that are there to save lives

A YOUNG mother at risk of sudden death from a brain cyst was left without a heart monitor for 20 hours before going into cardiac arrest at Westmead Hospital. Monitoring systems in the hospital's high-dependency unit were ''less than perfect'' when Rashpal Hayer died in July 2007, the NSW Coroner Mary Jerram said yesterday.

She was delivering findings after an inquest into Ms Hayer's death, which examined the failure to reattach the monitor and heard evidence of ''a 'culture' of silencing irritating alarms in that ward''.

Ms Hayer, 36, went to hospital with a severe headache. A CT scan revealed she had a colloid cyst, ''a very dangerous condition in which sudden death is known to be a possibility'', Ms Jerram said. A neurosurgeon instructed staff to monitor her closely, but a cardiac monitor was removed before a scan on July 2 and was not replaced when she returned to the ward. Ms Hayer was found in cardiac arrest at 6am on July 3. She never recovered brain function and died four days later.

Ms Jerram said nurses on the night shift and three doctors - including neurosurgical registrars - either failed to notice or saw no problem with the fact that she was without a cardiac monitor. Ms Hayer could possibly have been treated if a monitor had been fitted and sounded when she went into arrest, she said.

The inquest also heard that a finger probe monitoring Ms Hayer's pulse and oxygen levels had detached half an hour before her cardiac arrest. It should have sounded warnings.

Ms Jerram said it was possible the alarm connection to the nurses' station was not working, or that ''the alarms were deliberately silenced at some stage … not necessarily from any malice''. She accepted evidence from a nurse that the ward had a culture of ''silencing irritating alarms''.

Ms Jerram made no formal recommendations, noting that the hospital conducted three investigations into the death and had policies to remedy some of the problems highlighted.

SOURCE

Westmead public hospital bankrupt and partly closed down

Bed numbers have been slashed this week at Sydney's biggest hospital, in a round of ward closures aimed at reining in a $70 million blow-out in the region's health spending. Ten of 16 operating suites have been closed and elective surgery has been cancelled, with staff forced to take leave, sources said. Forty-three cardiology and heart surgery beds have shut since late last year, said medical and nursing staff, culminating last week in the closure without notice of the heart surgery ward - which staff found empty and locked when they arrived for work.

The unprecedented axing of about 70 beds comes after the Herald revealed in late January that Sydney West Area Health Service, which oversees Westmead, owed $26 million to creditors - more than any other region and almost a quarter of NSW Health's outstanding debt to suppliers at that time.

Neurosurgery and general surgery beds have also closed, said the sources, while casual nursing shifts have been curtailed across the entire hospital, as displaced permanent staff are redeployed into vacancies on the roster. The closures represent about 9 per cent of Westmead's total capacity, and are the biggest round of cuts at a single hospital to strike the beleaguered state health system. The chairman of the hospital's Medical Staff Council, Andrew Pesce, said the closures were by far the most severe the flagship teaching hospital had seen. "It's a quantum leap [compared with] the modest bed closures usually built around [public] holidays," Dr Pesce said.

Coming a month before Easter and without any promise that beds would reopen or surgery resume, the closures were the equivalent of an extra Christmas closedown, said Dr Pesce - referring to the practice of selectively suspending services during the holiday period to save money. "If things continue the way they are going, the morale of the place will become so low that doctors and nurses will start leaving," he said. Hospital managers were not solely to blame because NSW Health gave them "unrealistic budgets".

Public hospitals had traditionally been insulated from state spending cuts, Dr Pesce said, but NSW's wider financial crisis meant they were no longer receiving favourable treatment. Health accounts for about one-third of the state's spending, and had blown out by about $300 million at the time of November's mini-budget. Area health services were ordered to save $943 million over four years.

A spokesman for the Health Minister, John Della Bosca, declined to address the Herald's specific questions about closures, offering instead in a written statement: "There have been adjustments to bed platforms and relocations of some services within Westmead's overall funding base . Westmead has further capacity to improve bed utilisation and this is a priority for management attention in the relevant services as part of the operational strategy." He also did not answer a question about the number of patients whose elective operations were cancelled, instead insisting elective surgery was still available but saying the hospital was "under resource pressure and needs to ensure that its priorities are met but not exceeded and that all opportunities to ensure it operates efficiently are explored".

The president of the NSW branch of the Australian Medical Association, Brian Morton, said he understood patients would be moved to general wards under the care of "staff who don't have the same skills". Patients would be at risk if already overcrowded hospitals were further stressed. .. That's when mistakes happen."

The Opposition's health spokeswoman, Jillian Skinner, said the closures would endanger patients. "The evidence is quite clear that delayed treatment makes conditions worse and makes the hospital stay longer - and therefore more expensive."

SOURCE

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2 comments:

  1. The management and Governance at Westmead Hospital has been suspect for many years. The William Tarnow Mordi scandal dating from 2001 and over twenty letters written to the authorities over the years exposing other deficiencies have been covered up. None of these serious issues were addressed by Westmead Hospital. The Human Resources department and management preferred to take reprisals against those who cared enough to improve things for patients. Click here www.westmeadhospitalwhistleblowers.com to read more and to find out how to write to your Member of Parliament asking for an external review of Westmead Hospitals management and Governance.

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  2. The problem is that Dr Pesce is management. He was a management player in the Tarnow Mordi scandal. http://www.westmeadhospitalwhistleblowers.com/dr-andrew-pesce-and-belinda-nicholson-the-third-reprisal.html

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