Woman suffers serious injuries at care home as watchdog issues warning to private NHS provider

Posted 03/12/2013

A private healthcare provider which runs community health services in Suffolk allowed a patient to fall out of bed, sustaining serious injuries, yet didn’t notice.  The news comes just days after the company was criticized for failing to ensure patient safety from just this kind of occurrence.

In September 2012 Serco won the contract to deliver community health services in Suffolk on behalf of the NHS. Two months later the elderly patient in its care was allowed to fall out of bed, sustaining life-threatening injuries. Yet nurses didn’t even realize the fall had occurred and failed to notice the extensive bruising on her face.Only last week the East and West Suffolk Clinical Commissioning Groups (CCGs), who awarded Serco the contract on behalf of the NHS, criticized the company for a string of failures, including missing targets on assessing the risk of falls.Mrs Joy Saunders, aged 76 of Ipswich, had been admitted to the physiotherapy care unit at Bluebird Lodge in Ipswich on 27 November 2012, following a stroke whilst on holiday in Spain. Her husband, David Saunders, was particularly concerned about his wife’s obvious distress. When he left her on that first evening he specifically asked nursing staff to make sure they erected the bed rails, to prevent his wife from falling out of bed and causing herself damage.But early the next morning Mr Saunders received a call to tell him that his wife had fallen out of bed, only two hours after he had left the previous evening. When he visited her that same day he was shocked by the bruising on her face. He was also concerned that she was uncommunicative, unaware of her surroundings and generally dazed.By the next day her speech had deteriorated and, according to her husband, she was talking nonsense and her conversation made no sense. Mr Saunders was extremely distressed and the next day asked to speak to the matron. But neither she nor any other member of staff was available.A short time later however, he received a call saying that nurses had become concerned at his wife’s deteriorating condition. She was moved to Heath Road Hospital for a scan but by that time she was barely conscious. A scan showed Mrs Saunders to be suffering a major brain haemorrhage as a result of her fall. Her husband was told that she could deteriorate further at any time and, if that happened, she wouldn’t be resuscitated.Since then Joy has been confined to her bed requiring 24 hour care. Understandably her husband does not like to leave her side. She is uncommunicative, has little or no quality of life and is in a terminal phase.Following his wife’s injuries Mr Saunders wrote a letter of complaint to Suffolk Community Healthcare in February this year, but it was ignored. After sending a chasing letter in May he eventually received a response. He also received his first telephone call from Bluebird Lodge since his wife was discharged. Surprisingly it was not to ask how his wife was recovering but, instead, to ask why he wanted to receive a copy of his wife’s medical records.The letter of response to his complaint claimed that a proper risk assessment had been carried out following Joy’s admission but admitted there was no written record of it. Staff had however recognised that Mrs Saunders was at high risk of suffering falls. So her bed was fitted with a pressure sensor which rings an alarm if the patient moves. However, staff claim that it didn’t work and they heard no alarm at the time of the fall. They say the alarm sounded on a number of occasions, but each time they attended to Mrs Saunders she had not moved.As a result they claim they increased the number of times they checked Mrs Saunders. These additional checks are not documented in the records. The letter claims that, following the fall, it was noted that that Mrs Saunders had suffered extensive bruising. However, no further examinations were initially requested.Suffolk Community Healthcare was contracted out to Serco, a huge American multi-national company, as part of the Government’s bid to bring private competition into the NHS. Serco won the £190 million contract to provide care for Suffolk’s elderly whilst reassuring the public that care services would remain unaffected. But within a month they revealed plans to axe 137 healthcare jobs.Since then they have been the subject of a damning investigation by BBC Radio 4’s File on 4 and heavy criticism by MPs. They have also admitted misrepresenting data 252 times in another NHS contract they run in Cornwall. The chair of the House of Commons health select committee has suggested this amounts to fraud, and the company is under investigation by the Serious Fraud Office for other non-health related fraud allegations.Mr Saunders is now taking legal action on his wife Joy’s behalf against Suffolk Community Healthcare. His lawyer is medical negligence specialist Ben Ward of Ashtons Legal.“This is not the first time that my firm have pursued a claim against Suffolk Community Health on behalf of a patient who has suffered an avoidable fall,” Ben explains. “What is particularly concerning here is that, in breach of their own policy, no formal written risk assessment was undertaken. And we see from the criticisms of the CCGs that this is precisely one of the areas in which they feel Serco are failing NHS patients.If private companies are to be trusted with our NHS, these basis steps cannot be ignored. Standards must improve. It looks rather like staff are under pressure, an issue which if true Serco must address.We hear so many terrible stories of elderly care provision. On this occasion, what has frustrated Mr Saunders as well as the injury is the lack of compassion and care shown towards Joy following her discharge from Bluebird Lodge. Not once did anyone pick up the phone to see how she was recovering. Not once did anybody apologize until the complaint was eventually dealt with. This really isn’t the way that patients’ families should be treated following an incident like this.”