Patient Starved to Death in Hospital.
Discussion
No words can suitably describe my feelings of anger for those involved in the death of this patient.
Yourlocalguardian said:
A Kingston Hospital patient starved to death after being left for 26 days without a feeding tube, a damning report has revealed.
Down’s syndrome sufferer Martin Ryan, 43, was said to be the victim of a “communication failure” between doctors and nurses and died in hospital.
Mr Ryan’s case is due to be ruled on by a health watchdog later this month, along with five others highlighted by charity Mencap in its 2007 report Death by Indifference.
Mr Ryan, who had severe learning difficulties and could not speak, was admitted to Kingston Hospital after suffering a stroke. While in hospital he also contracted pneumonia, the report said.
An internal investigation by the hospital found there had been a “multidisciplinary communication failure”, which resulted in the doctor being “under the impression” that the nurses had been feeding Martin through a naso-gastric tube.
By the time doctors decided after 21 days that Mr Ryan was malnourished and needed a feeding tube directly into his stomach, his body was in no state to handle the operation. He died five days later on December 21, 2005.
His family, from Richmond, complained to the hospital and reported his case to the Healthcare Commission.
A relative described him as “the light of my life” with a “quirky sense of humour and oodles of charm”.
In a statement, Kingston Hospital’s chief executive Kate Grimes accepted that the hospital’s failure to provide nutrition was “inexcusable” and said staff had been deeply affected by the tragedy.
She added: “Since Mr Ryan’s death in 2005, we have opened a dedicated stroke unit to provide specialist care to patients.
“We have also introduced a care “passport” for patients with learning disabilities. This makes staff aware of patients’ specific care needs on admission to hospital, and ensures that care is tailored to individual needs. Training has been given to key staff and nutrition policies have been strengthened.”
David Congdon, head of campaigns and policy at Mencap said: “We find it incredible that anyone could spend 26 days in hospital and not be fed. That was clearly what killed him.
“When you have got someone with a severe learning difficulty who cannot communicate verbally they get ignored and staff in their subconscious do not value them, so they don’t get the care or attention they deserve.”
Ann Abraham, the Parliamentary and Health Service Ombudsman, is expected to publish her report later this month. If she finds the hospital to have been negligent it will be given a strict list of recommendations to improve future care.
Down’s syndrome sufferer Martin Ryan, 43, was said to be the victim of a “communication failure” between doctors and nurses and died in hospital.
Mr Ryan’s case is due to be ruled on by a health watchdog later this month, along with five others highlighted by charity Mencap in its 2007 report Death by Indifference.
Mr Ryan, who had severe learning difficulties and could not speak, was admitted to Kingston Hospital after suffering a stroke. While in hospital he also contracted pneumonia, the report said.
An internal investigation by the hospital found there had been a “multidisciplinary communication failure”, which resulted in the doctor being “under the impression” that the nurses had been feeding Martin through a naso-gastric tube.
By the time doctors decided after 21 days that Mr Ryan was malnourished and needed a feeding tube directly into his stomach, his body was in no state to handle the operation. He died five days later on December 21, 2005.
His family, from Richmond, complained to the hospital and reported his case to the Healthcare Commission.
A relative described him as “the light of my life” with a “quirky sense of humour and oodles of charm”.
In a statement, Kingston Hospital’s chief executive Kate Grimes accepted that the hospital’s failure to provide nutrition was “inexcusable” and said staff had been deeply affected by the tragedy.
She added: “Since Mr Ryan’s death in 2005, we have opened a dedicated stroke unit to provide specialist care to patients.
“We have also introduced a care “passport” for patients with learning disabilities. This makes staff aware of patients’ specific care needs on admission to hospital, and ensures that care is tailored to individual needs. Training has been given to key staff and nutrition policies have been strengthened.”
David Congdon, head of campaigns and policy at Mencap said: “We find it incredible that anyone could spend 26 days in hospital and not be fed. That was clearly what killed him.
“When you have got someone with a severe learning difficulty who cannot communicate verbally they get ignored and staff in their subconscious do not value them, so they don’t get the care or attention they deserve.”
Ann Abraham, the Parliamentary and Health Service Ombudsman, is expected to publish her report later this month. If she finds the hospital to have been negligent it will be given a strict list of recommendations to improve future care.
This doesn't surprise me at all. The care you can receive varies dramatically from one hospital to the next.
After the Summer last year my father was admitted to Solihull hospital following a stroke. The level of attention he received there was pitiful. At a time when he needed help and reassurance from the medical profession, they just about managed to bring him food 3 times a day and water whenever his visitors asked for it (when the jug was empty).
Later, he was transferred to the QE in Birmingham. Now this is an old bulding (due to be replaced in a couple of years when they finish the new one) yet the staff are kind, patient and have time for everyone under their care. My Dad was a virtual mental wreck in Solihull and actually had a nervous breakdown whilst in there. Within a day of being in the QE he was showing improvements in all respects (physical and mental).
It's the management of hospitals that needs changing. Solihull has a culture of just "getting by" whereas the QE has a culture of listening to, and acting in the best interests of its patients.
After the Summer last year my father was admitted to Solihull hospital following a stroke. The level of attention he received there was pitiful. At a time when he needed help and reassurance from the medical profession, they just about managed to bring him food 3 times a day and water whenever his visitors asked for it (when the jug was empty).
Later, he was transferred to the QE in Birmingham. Now this is an old bulding (due to be replaced in a couple of years when they finish the new one) yet the staff are kind, patient and have time for everyone under their care. My Dad was a virtual mental wreck in Solihull and actually had a nervous breakdown whilst in there. Within a day of being in the QE he was showing improvements in all respects (physical and mental).
It's the management of hospitals that needs changing. Solihull has a culture of just "getting by" whereas the QE has a culture of listening to, and acting in the best interests of its patients.
I and my wife have needed treatment from the NHS from time to time. Each time we have needed it the treatment has been forthcoming, prompt and well delivered.
I can understand how the case referred to arose, (apart from the family, what the f
k were they doing) and it seems like steps have been taken to reduce the chance of something like that happening again. I'm sorry to hear about the OP's anger, and hope it gets better soon.
I can understand how the case referred to arose, (apart from the family, what the f
k were they doing) and it seems like steps have been taken to reduce the chance of something like that happening again. I'm sorry to hear about the OP's anger, and hope it gets better soon.Ordinary Bloke said:
Mobile Chicane said:
Where were the family in all of this? Surely they'd have noticed 'something'... 
Obviously not, in this case...NHS employee here.
Unfortunately these things do happen. Working with learning disabilities is a skill and hospitals (often GPs too) tend not to be very good at working with people who don't fit into the 'normal' categories. I was once an LD nurse and anyone under my care had me as an advocate with a clinical background to help them. Individuals cared for by families who don't question the status quo don't get that luxury.
Learning Disability training for hospital staff is available but mandatory courses such as box lifting etc tend to queue jump the audit appeasing priority list. 'Health and safety' rules. Plus, any preaching for minorities is often seen as overly PC. Thankfully you don't see any of that attitude on Pistonheads.
This isn't just an NHS problem. -Try to approach any large organisation with an unusual problem which doesn't fit the script.
However, it is unacceptable and thankfully very rare. The rest of the time we tend to get satisfied customers. On the whole...
Unfortunately these things do happen. Working with learning disabilities is a skill and hospitals (often GPs too) tend not to be very good at working with people who don't fit into the 'normal' categories. I was once an LD nurse and anyone under my care had me as an advocate with a clinical background to help them. Individuals cared for by families who don't question the status quo don't get that luxury.
Learning Disability training for hospital staff is available but mandatory courses such as box lifting etc tend to queue jump the audit appeasing priority list. 'Health and safety' rules. Plus, any preaching for minorities is often seen as overly PC. Thankfully you don't see any of that attitude on Pistonheads.
This isn't just an NHS problem. -Try to approach any large organisation with an unusual problem which doesn't fit the script.
However, it is unacceptable and thankfully very rare. The rest of the time we tend to get satisfied customers. On the whole...
captainzep said:
NHS employee here.
Unfortunately these things do happen. Working with learning disabilities is a skill and hospitals (often GPs too) tend not to be very good at working with people who don't fit into the 'normal' categories. I was once an LD nurse and anyone under my care had me as an advocate with a clinical background to help them. Individuals cared for by families who don't question the status quo don't get that luxury.
Learning Disability training for hospital staff is available but mandatory courses such as box lifting etc tend to queue jump the audit appeasing priority list. 'Health and safety' rules. Plus, any preaching for minorities is often seen as overly PC. Thankfully you don't see any of that attitude on Pistonheads.
This isn't just an NHS problem. -Try to approach any large organisation with an unusual problem which doesn't fit the script.
However, it is unacceptable and thankfully very rare. The rest of the time we tend to get satisfied customers. On the whole...
Regardless of disabilities, you'd think they would feed the poor bUnfortunately these things do happen. Working with learning disabilities is a skill and hospitals (often GPs too) tend not to be very good at working with people who don't fit into the 'normal' categories. I was once an LD nurse and anyone under my care had me as an advocate with a clinical background to help them. Individuals cared for by families who don't question the status quo don't get that luxury.
Learning Disability training for hospital staff is available but mandatory courses such as box lifting etc tend to queue jump the audit appeasing priority list. 'Health and safety' rules. Plus, any preaching for minorities is often seen as overly PC. Thankfully you don't see any of that attitude on Pistonheads.
This isn't just an NHS problem. -Try to approach any large organisation with an unusual problem which doesn't fit the script.
However, it is unacceptable and thankfully very rare. The rest of the time we tend to get satisfied customers. On the whole...
d. What if the poor sod was in a coma? It's basic care, regardless of their impediments, and they failed completely.Badgerboy said:
captainzep said:
NHS employee here.
Unfortunately these things do happen. Working with learning disabilities is a skill and hospitals (often GPs too) tend not to be very good at working with people who don't fit into the 'normal' categories. I was once an LD nurse and anyone under my care had me as an advocate with a clinical background to help them. Individuals cared for by families who don't question the status quo don't get that luxury.
Learning Disability training for hospital staff is available but mandatory courses such as box lifting etc tend to queue jump the audit appeasing priority list. 'Health and safety' rules. Plus, any preaching for minorities is often seen as overly PC. Thankfully you don't see any of that attitude on Pistonheads.
This isn't just an NHS problem. -Try to approach any large organisation with an unusual problem which doesn't fit the script.
However, it is unacceptable and thankfully very rare. The rest of the time we tend to get satisfied customers. On the whole...
Regardless of disabilities, you'd think they would feed the poor bUnfortunately these things do happen. Working with learning disabilities is a skill and hospitals (often GPs too) tend not to be very good at working with people who don't fit into the 'normal' categories. I was once an LD nurse and anyone under my care had me as an advocate with a clinical background to help them. Individuals cared for by families who don't question the status quo don't get that luxury.
Learning Disability training for hospital staff is available but mandatory courses such as box lifting etc tend to queue jump the audit appeasing priority list. 'Health and safety' rules. Plus, any preaching for minorities is often seen as overly PC. Thankfully you don't see any of that attitude on Pistonheads.
This isn't just an NHS problem. -Try to approach any large organisation with an unusual problem which doesn't fit the script.
However, it is unacceptable and thankfully very rare. The rest of the time we tend to get satisfied customers. On the whole...
d. What if the poor sod was in a coma? It's basic care, regardless of their impediments, and they failed completely.But it is all about the disability.
http://news.bbc.co.uk/1/hi/health/7530624.stm
Find a recent case of coma patient dying in the same way...
A coma patient is unconscious. Fits into a nice normal procedural box. I don't think this Martin fella was unconscious probably grunted and groaned whether happy or sad and the staff didn't see through it because he couldn't say 'I'm f
king starving' or point at food, or rub his stomach or whatever.Edited by captainzep on Friday 9th January 22:38
King Herald said:
But they never noticed him wasting away, with no food for three weeks......
Maybe not but I'd be a damn site more worried that people who have supposedly received years and thousands/tens of thousands of training via our pockets couldn't manage that simple little taskette either.Then think about all of the cases that don't get reported or get called something else, of course somewhat common on the old death certificate.
f
k a duck the NHS scares me stless a lot of the time and I say a little prayer every time I remember that I haven't had anything of note to worry about. Yet 
Do they have witch doctors in Yellow Pages
captainzep said:
Of course they failed.
But it is all about the disability.
http://news.bbc.co.uk/1/hi/health/7530624.stm
Find a recent case of coma patient dying in the same way...
A coma patient is unconscious. Fits into a nice normal procedural box. I don't think this Martin fella was unconscious probably grunted and groaned whether happy or sad and the staff didn't see through it because he couldn't say 'I'm fking starving' or point at food, or rub his stomach or whatever.
[Devils Advocate]But it is all about the disability.
http://news.bbc.co.uk/1/hi/health/7530624.stm
Find a recent case of coma patient dying in the same way...
A coma patient is unconscious. Fits into a nice normal procedural box. I don't think this Martin fella was unconscious probably grunted and groaned whether happy or sad and the staff didn't see through it because he couldn't say 'I'm f
king starving' or point at food, or rub his stomach or whatever.Edited by captainzep on Friday 9th January 22:38
If this person had extremely severe disabilities, plus extensive damage due to the stroke, is it possible that the hospital staff may have thought it better that he die?
I'm not saying it's right or wrong, but there must be cases where it's decided it's fairer for someone to die than for everyone's quality of life to be reduced as a result of illness? The fact that it took nearly a month for him to die may not have been intentional.
[/Devils Advocate]
It can happen anywhere. I wouldn't be so quick to rush to judgment, but I would want to know what changes have been made to prevent it happening again.
Here in the US, many of the better hospitals have specific procedures to ensure that patient's conditions and treatments are communicated across shifts and staff levels. Simple, but effective solutios. For instance, some facilities have a board with hanging cards for each item like "x-ray", "lunch", "cleaning", etc. Across the top are details like patient name, room number, doctor's name, in and expected out dates, etc. As each item is taken care of, the card is turned over, initialed, and hung back on, facing backwards and now showing the completed status. Simple, cheap, and highly effective, but it is not obvious.
There are tons of things to tend to in each shift, for each patient, and staff sometimes are too busy to hand over properly, or communicate problems and issues up and down the chain of command. Without big visual checklists, things can easily be missed.
Whilst inexcusable, I can understand how this can happen. It's not a matter of common sense. Rather, it's a case of bureaucracy, where everybody does their bit and assumes everybody else is doing their bit. If there is no established procedure to catch a mistake or omission, it can easily lead to disaster.
Here in the US, many of the better hospitals have specific procedures to ensure that patient's conditions and treatments are communicated across shifts and staff levels. Simple, but effective solutios. For instance, some facilities have a board with hanging cards for each item like "x-ray", "lunch", "cleaning", etc. Across the top are details like patient name, room number, doctor's name, in and expected out dates, etc. As each item is taken care of, the card is turned over, initialed, and hung back on, facing backwards and now showing the completed status. Simple, cheap, and highly effective, but it is not obvious.
There are tons of things to tend to in each shift, for each patient, and staff sometimes are too busy to hand over properly, or communicate problems and issues up and down the chain of command. Without big visual checklists, things can easily be missed.
Whilst inexcusable, I can understand how this can happen. It's not a matter of common sense. Rather, it's a case of bureaucracy, where everybody does their bit and assumes everybody else is doing their bit. If there is no established procedure to catch a mistake or omission, it can easily lead to disaster.
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