Sunday, 30 June 2013

Coding, once more.

This section of the Board meeting covering May is just a bit less reassuring than it should be:

“1 Executive Summary

The Trust is mindful of the need to increase its efforts to improve quality performance, in particular its in-hospital mortality and the experience of patients using its emergency services.

The Board’s attention is therefore drawn to three key issues discussed in the paper.

1. The challenge of reducing the amount of people who die in hospital;

Mortality reviews are being carried out at Divisional level but not on 100% of deaths as per the Trust’s aspiration. Therefore the performance of 97 deaths in hospital against a month’s target of 76 is disappointing. However, at a more Trust-wide level, the Clinical Outcomes Steering Group continues to provide in-depth analysis of the mortality data. There is more to be done to get all deaths reviewed in a standardised way and this is being tracked by the Integrated Governance and Assurance Committee.”

That’s 21 more deaths in one month than the target – how can we work to improve that figure, to improve patient outcomes?

I know, let’s have another look at the figures:

“The Medical Director and Chief Nurse introduced the Quality Report. This presented the quality dashboard with associated commentary on exceptions and the best care dashboard.

The following points in the report were highlighted:

The SHMI and RAMI target should be 73 which represented the proportion of in-hospital deaths. The RAMI had gone up to 83 in the month but on further investigation this was due to 30 patients who had not been coded appropriately;

Crude mortality for the month was 2.06% with a year to date figure of 1.66%. The increase towards the end of the year was a common seasonal peak with the year to date figure slightly above the planned 1.6%”

‘Coding’: I’ve had a bit to say about that in this Blog before – here’s an article I wrote which quotes from ‘Private Eye’ and The Daily Telegraph on this subject;


One section, ‘Change the diagnosis’, deals with how a hospital can change the cause of death from an illness which shows up in a category that rings alarm bells to one that doesn’t. You cook the books by altering cause of death so it doesn’t show up in the standardised mortality rates.

So, if someone comes in with a broken femur (that’s very treatable) but dies later of pneumonia (that’s not good) resulting from the break, you record it as caused by pneumonia and not the break. Then it doesn’t show up as a death that should have been prevented by better treatment.

So, the ‘Eye’ shows that in 2009 Mid Staffs Hospitals patients with hip fractures were 5 times less likely to die from that cause than the English average, even though the Hospital was losing far more patients with hip fractures than it should have done. It was credited as being one of the 5 ‘most improved’ trusts in 2009 as a result.

Well, they are all at it again!

Check out this Daily Telegraph report;

Wednesday 27 February

The head of an NHS trust has "stepped aside" amid fears that staff tried to mask high mortality rates by recording the wrong cause of death for patients. Dr Jackie Bene, medical director and acting chief executive of the trust, has 'stepped aside'

By Stephen Adams, Medical Correspondent6:30PM GMT 27 Feb 2013

2011, Bolton NHS Foundation Trust recorded a large spike in septicaemia deaths, which are not included in official mortality figures, at the Royal Bolton Hospital in Greater Manchester. During the same year, it also recorded a significant improvement in death rates and was given an award for the “most improved” trust.

But a recent audit demanded by local doctors has unearthed evidence that these improvements may have been fictional. On Monday staff were told that Dr Jackie Bene, medical director and acting chief executive of the trust, had “stepped aside” to “allow a fully independent view to be taken". The report is expected to be completed by March 6.

Professor Sir Bruce Keogh, medical director of the NHS, last night (Wed) said hospitals “must behave openly and honestly about their performance”, while campaigner Julie Bailey said: “It’s fraud in my mind.”

Until 2011 the Bolton trust had been one of the worst performing hospital trusts in England, with death rates well above the national average. But that year its mortality rate plummeted, leading to the award. Last December it was ranked as having death rates that were “better than expected”. Yet between April 2011 and March 2012 some 800 deaths from septicaemia were recorded at Bolton - four times the number one would expect in a trust of that size. A septicaemia coding also means the hospital would have received more money for that patient.

Dr Wirin Bhatiani, lead GP for the Bolton Clinical Commissioning Group, said he first became aware of the "unusually high" number of septicaemia cases in October. The group has commissioned the hospital rating firm Dr Foster to carry out an independent audit looking at 200 cases. Dr Bhatiani said interim findings based on 50 cases showed “cause for concern”. He said: “While we are keen to wait for the final report, we are sufficiently concerned by the interim findings to commence further investigations.”

David Wakefield, chairman of the trust, said it wanted to "rule out any serious issues as soon as possible" and make sure the way patients were coded met the"highest quality standards". He was brought in by Monitor, which regulates semi-autonomous foundation trusts, after it put Bolton in the highest risk rating for governance and finance.

A trust spokesman emphasised the issue was solely with the way “some causes of death were recorded”, and did not change the number of people who had died. Neither did it mean patients’ death certificates were inaccurate, she added. Julie Bailey, founder of the Stafford group Cure the NHS, said the Bolton situation showed “each and every hospital” should be vetted to find out “just how many unnecessary deaths there have been”. She said: “We are hearing more and more instances of people apparently ‘gaming’ the data to mask high death rates. If that’s what’s been going on here, it’s fraud in my mind.”

Professor Keogh said: "If we're to have an open and accountable NHS, where patients and the public know how NHS hospitals are doing, those hospitals must behave openly and honestly about their performance. "These allegations have been picked up by the local NHS working together and scrutinising what has been going on - with support from the Care Quality Commission and Monitor. As yet, there is no evidence that any patient has been harmed. But we will be monitoring the situation and learning any lessons." Bolton is not one of the 14 trusts currently being examined for apparent high death rates. However, a Department of Health spokesman said Prof Keogh “reserves the right” to call it in if he felt it necessary.


Why get told off for failing patients when you can just move a few figures around, get out of trouble and get paid more money as well?

How many more ‘trusts’ are doing this?

Probably all of them.


That’s how I ended the Blog back in February.

30 deaths re-coded – that really worries me.


Neil Harris

(a don’t stop till you drop production)

Saturday, 29 June 2013


Now, let’s have a look at some of the disturbing stuff:


“The Integrated Governance and Assurance Committee minutes

2013 Any Other Business

1. The Chief Nurse reported a Never Event, which was currently subject to investigations. The patient had since passed away, but IGAC was assured that the event did not contribute to the patient’s death.”


I should explain what a ‘Never Event’ is – it’s a mistake that NHS England has decided should never happen and hospitals are required to report on them.

These aren’t just everyday mistakes – those happen and can be very serious. These are mistakes that should ‘never’ happen like;

        Putting feeding tubes down into the lungs instead  of the stomach.

        Giving the wrong or no insulin.

        Operating on the wrong thing.

        Operating on the wrong person (no, really).

        Letting patients fall out of windows.

        Leaving foreign objects in peoples bodies after operations.

And so on – you get the idea. These mistakes usually mean a death which is completely avoidable and should ‘never happen’.

Mind you, one class of incident is where prisoners in custody escape from the hospital. Keeping people locked up is not a hospital’s responsibility, it’s not about treatment and really – as far as the patient is concerned - it is quite a good ‘outcome’.

The BBC recently published all the ‘Never Event’ statistics and I republished them so you could look up any Trust.

They are on my other Blog (the really serious one);

Here are the figures for 2009/12: 

Ashford & St Peter's Hospitals NHS FoundationTrust 5

             Retained foreign object post-operation 3

             Wrong site surgery 1

             Maladministration of Insulin 1

That’s 5 in 4 years, so another one is quite a serious matter, not just ‘any other business’.

Neil Harris

(a don’t stop till you drop production)

Friday, 28 June 2013

I think I've worked it out.

Right, I think I’ve worked it out.


This is from the Ashford and St. Peter’s Foundation Trust Board Meeting the documents are dated 30th May 2013. It’s not in the same form as in the report it’s in PDF form and won’t copy directly.


The ‘SITREP’ figures don’t include the Ashford figures – Ashford cases are much easier to deal with and would normally always be dealt with in less than 4 hours – they are patients who walk in and are sent home, whereas at St. Peter’s they usually arrive by Ambulance. After my operation it’s where I was told to go to get my dressing changes, which I did twice – hardly emergency treatment.

From the report;







As Figure 2 demonstrates, the Trust failed to meet the four hour standard for waiting times in A&E during April for the purpose of the Monitor Compliance Framework.


In addition to this, the standard was not met for St. Peter’s Hospital alone and the Trust will therefore incur a financial penalty under the terms of the contract with North-West Surrey CCG.



Period          SITREP Position                                                    MONITOR Position

                    (SPH, EPU & GUM)                                                (SPH, EPU, GUM, ASH)


Quarter 1             93.61%                                                                        95.63%


Quarter 2             95.80%                                                                        97.10%


Quarter 3             93.97%                                                                        95.88%


January                90.51%                                                                        93.30%

February              88.63%                                                                         92.00%

March                   88.70%                                                                        92.11%


Quarter 4            89.29%                                                                         92.47%



2012/13Total       93.18%                                                                        95.29%


April                     90.82%                                                                         93.56%


May to date          92.5%                                                                          94.7%


Whilst 4 hour performance for quarter 1 to date is currently below the Compliance Framework standard, it remains in line with the trajectory submitted to Monitor in March 2013, as shown in Figures 3 and 4.

At this stage the Trust is still endeavouring to meet the 95% standard for quarter one as a whole, although this is a significant risk.

Further detail about 4 hour compliance from a strategy perspective is included in a separate Board paper.




On the SITREP figures (the official NHS figures), they missed the 4 hour target in 3 of the four quarters last year, as well as every month this year, that’s far worse than last year.


‘Monitor’, is a fairly toothless state regulator for the Foundation Trusts, it seems to allow the Trust to water down the waiting times using Ashford’s ‘Walk-in’ waiting times, so those figures look better – how can they be?


Even on those dodgy figures they missed the target Quarter 4 and also missed the target in the first two months in the first quarter of this year.


That’s a foul in my book – Ref?


Neil Harris

(a don’t stop till you drop production)

Thursday, 27 June 2013

They all got in the act.

They all got in on the act – here’s the Deputy Chief Executives report:

The Deputy Chief Executive confirmed that the Trust did not meet the four hour waiting time target in quarter four. The Deputy Chief Executive expressed disappointment at this performance after the improvement noted in the previous three quarters of the year and highlighted to the Board the national context with severe pressures in meeting the A&E target at present.

That’s naughty, because I don’t think it did get better last year.

The Deputy Chief Executive assured the Board that the emergency department was a much improved working environment than in previous years with some strong appointments having been made to substantive positions with a new Associate Director of Nursing, Associate Director of Operations and Speciality Lead now in place and that these posts were starting to deliver real change.

This bit is interesting too – if they are getting fined for holding up the ambulances too long, that means the A and E waiting times are being flattered as patients clocks aren’t yet ticking, while they wait outside:

A priority for 2013/14 was the improvement of ambulance hand-over times with slow turnaround times leading to financial penalties in 2013/14. If 2012/13 performance was replicated in 2013/14 this would lead to fines of c£780k. However, current performance was positive with the Trust in the top two or three in the South East at present.

The Chairman sought assurance on the current position and the likelihood of achievement of the target. The Deputy Chief Executive confirmed that issues with the Patient Transport System and the new telephone 111 service had meant that achievement of the target in April was challenging however the complex discharges were reducing each day and were now down to 50-55.

The Board NOTED the report.

I’ve noted the report too, but I haven’t got to the bottom of it yet. Tomorrow I’ll take a close look at the Boards own figures.

Neil Harris

(a don’t stop till you drop production)

Wednesday, 26 June 2013

The May Board meeting at Ashford.

Here’s a bit of a mystery – I’ve been holding a magnifying glass over the documents from Ashford and St. Peter’s May Board meeting and there are a few things that don’t add up, and a few disturbing things too.

I’ll start with the Chair’s opening remarks, (highlighted and edited by me);


30th May 2013

Chairman’s Report

Accident and Emergency Target

Our performance in this area remains the primary concern of the Trust Board. We continue to experience many days of very tight capacity with high numbers of patients, with complex needs, needing to be admitted at the same time as we are seeing delays in the discharge of patients.

This pattern appears to be prevalent throughout the country and the issue is being debated in both the national and local media. Whilst our performance is better than a year ago, helped by all the changes we made in the organisation and delivery of our emergency care, we clearly need to do more to get our performance back in line within target. This matter will be discussed elsewhere on the agenda.”

Actually, I don’t think their performance is better than a year ago, even though last year was a pretty bad year by any standards – take a look at this article from the Health Service Journal last year dated 24th August 2012.


PERFORMANCE: Ashford and St Peter’s Hospital NHS Foundation Trust breached the four-hour target for accident and emergency waits more often than it met it during the first quarter of 2012-13, according to board papers.

NHS Surrey has published data on the performance of the county’s acute trusts against the 95 per cent target for A&E patients dealt with inside four hours, from the start of April to the end of June.

Ashford and St Peter’s was the joint worst performer – along with Royal Surrey County – of the county’s four main acutes, missing the target in seven weeks out of 13. The trust missed the target on three weeks out of five in April, achieving an average of 91.20 per cent.

It subsequently also failed to meet the target over four consecutive weeks across May and June. These were the week beginning 21 May, when it achieved 91.67 per cent, and that beginning 28 May, when it achieved 93.36 per cent.

It missed the target again in the week starting 4 June, when it achieved 93.13 per cent, and in the week starting 11 June, when it achieved 93.89 per cent.

An NHS Surrey performance report stated: “Quality performance issues remain of concern across the main trusts; most significantly acute provider attainment of the four-hour A&E wait, which three of Surrey’s Providers were unable to meet during April 2012.

“Contract queries were issued to Ashford St Peters and Royal Surrey County in April, although the Ashford St Peters notice has since been revoked following improved performance in the beginning of May.”


“In overall terms however there is cause for concern about the levels of attendances and the volatility of A&E performance.”

NHS Surrey board papers                                

Source Date: 20 July 2012


I’m puzzled, I need to check this years A and E waiting time figures using the Boards own figures.

We’ll see who got it right – hope I’m wrong.

Neil Harris

(a don’t stop until you drop production)

Tuesday, 25 June 2013

Tak, Tak, Tak.


I took the motorway up to town instead of the normal route – looking for route one, maybe. What I got was a long traffic jam and no exit. Gulp.

When I got to my Jazz club at The Red Lion, Isleworth, I found that the grapevine had told everyone it was going to be a quiet night – the last few weeks were packed. They were right.

Trevor Tomkins took the chance to push his drums out to the front for a change. There was a lot of Wayne Shorter and a couple of Dick Pearce (Trumpet) compositions;‘Fast track’ and ‘Airships in a cloud’.

For me the highlight was ‘my one and only love’ and Pearce was left at the bar for this one. There were some long solo’s from Pete Hurt on Sax but the stars were the trio of John Donaldson on keyboards, Steve Watts Bass and TT on the brushes and split sticks. Very sparse, very precise. Tak, Tak, Tak.

Otherwise, there was an encore ‘a short blues’, which sounded like Monk to me, and that was pretty good.

Neil Harris

(a don’t stop till you drop production)

Sunday, 23 June 2013

It looks better when it's full!

I’ve failed so far in my search for some ‘Kwak’.

a) It’s not a sound effect for a Manga movie.

b) It’s not what ducks do.

c) It’s not an unqualified Doctor.

Kwak (pronounced Kvack) is a Belgian beer, and a very special experience it is too.

There are about 800 different Belgian beers, each has their own unique glass, many of them have two – different ones for bottled and for draft beer.

With Kwak, I think the bottled glass is fairly ordinary, but the draft glass is special.

Apart from anything else it costs about £28 – luckily I found one in a charity shop for a pound! Here it is;


  It looks better when it’s full!

Legend has it the beer was made for coaching Inns in the 18th century, the problem being that the coachmen didn’t have anywhere to put their glass on a horse drawn coach without it falling over. So the Brewery commissioned one like a small yard of ale – basically a tube with a sphere on the bottom – it was intended that it would hook on a bracket at the driver’s side.

When you order a Kwak, it wouldn’t stand up on its own (unless you have a horse drawn carriage to hang it on) so the glass comes on a little wooden frame. You can either hold the wood or take out the glass and drink from it.

In the old days, if you ordered one, the barman would make you hand over a shoe as a hostage for giving the glass back when you had finished.

On the top of the wood it says;

                       “Op uw gezondheid”

                               Pawel Kwak

                            “A voire santé”

Of course, it may all just be marketing but the beer? It’s really special.

Quite strong, brown colour.

When you first taste it there is a definite hint of what I could only describe as a vomit flavour, then a really nice taste sets in.

Then you want another one.

And another.

Now, where on earth can I find one? And don’t say Belgium because, due to family problems, I can’t go.

Neil Harris

(a don’t stop till you drop production)

Saturday, 22 June 2013

Light touch regulation.

Now we got hold of the names, I’ve put together some biographical notes about Cynthia Bower, the former Chief Executive of the Care Quality Commission.

It turns out she started work in the NHS in the West Midlands, where her boss was Sir David Nicholson, who has been in this Blog quite a lot this year.

At that time, he had responsibility for Mid Staffordshire Hospitals – where between 600 and 1200 unnecessary deaths occurred.

When he was promoted, she became Chief Executive of NHS West Midlands Strategic health Authority.

In 2008 she was appointed Chief Executive of the Care Quality commission.

In 2011 the BBC exposed abuse at Winterbourne view Care home – at that time the CQC had only ordered one enquiry, Bower indicated the CQC was operating a ‘light touch’ regulation policy.

At about the same time, the report raising concerns about Furness General Hospital maternity unit got buried because it showed that the CQC had failed to act on concerns.

‘Read my lips’. 

Coming up…

Next week – Tuesday onwards, I’m going to take a sharp knife to the May Board meeting of Ashford and St. Peter’s NHS Foundation Trust. It’s time someone independent (that’s me folks) took a close, hard look at the figures to work out what’s going on.

It won’t be dull.

It won’t be boring.

It won’t be… well, I’ll try my best but there may be some statistics.


Neil Harris
(a don’t stop till you drop production)   


Friday, 21 June 2013


I’ve been celebrating the longest day of the year – the summer solstice and this is how, my first ever fruit beer;

This is ‘Tesco’s Finest Belgian Kriek Bier’ which is described as;

 ‘Cherry bomb of a fruit beer pours a frothy light pink with a complex almond aroma and a rich cherry finish. A classic lambic style produced by the Van Honsebrouck brewery in Ingelmunster, Belgium’.

A bit sweet for my taste – I notice they use a sweetener which is probably not a great idea, with a very powerful cherry flavour I hadn’t expected, as a result it was a bit like an alcopop.

But I have to admit it was a sparkling, refreshing glassful of happiness at the end of a difficult and tough day. And it was only £1.

I wouldn’t want more than one at a time, whereas whenever I’ve been in Belgium drinking beer that was never a problem. Mind you I never tried a fruit beer before and I’d been expecting something more like a wheat beer.

Next time a ‘Kwak’, I think, if I can find one. That really is paradise.

I’ve even got the proper glass for that – ever seen one? You are in for a surprise.
Happy solstice.

Neil Harris

(a don’t stop till you drop production) 
Contact:   neilwithpromisesto

'false, uncorroborated and has since been retracted'

We got there, this is from the ‘Mail online’, 20/6/13, heavily edited by me;

The toxic order telling a CQC official to suppress his critical internal review was issued at a meeting on March 12 last year at the regulator’s London office.

Present with the official – named only as Mr J – in the Finsbury Tower building were chief executive Cynthia Bower, her deputy Jill Finney and a third senior official, whose identity is not known.

In the redacted report, commissioned by the CQC from consultants Grant Thornton, the three officials are identified as Mr E, Mr F and Mr G.

Grant Thornton does not say which letter relates to which individual, although it has confirmed that genders have been changed.

Mr J said Mr G ‘gave him an instruction to delete his report and that Mr E supported him in this, as did Mr F’.

The report continues: ‘According to Mr J, the reason for Mr G giving this instruction was that the report was damaging for the CQC and posed a “FOI” [freedom of information] risk.

‘Mr J claimed that Mr G said to him “Read my lips” when he gave him the instruction.’

Mr J produced a handwritten contemporaneous note of the meeting to support his allegations.

When Grant Thornton spoke to Mr G he was ‘somewhat equivocal’ about what had occurred.

At an initial interview he said ‘he was not sure’ whether there had been an instruction to destroy the report. Questioned a second time, he claimed he could not remember as far back as March 2012.

When asked if he had instructed Mr J to delete the report , Mr G replied that he did not as ‘he would not have been authorised to do so’, which, says Grant Thornton, ‘was somewhat ambiguous, although preceded by a denial’.

Grant Thornton concluded that when given the chance to explain himself at two interviews Mr G ‘did not unequivocally deny’ giving the instruction. Mr F was also ‘somewhat equivocal’. When asked if he recalled anyone giving an instruction to delete Mr J’s report his first answer was that he did not. When asked a second time, he replied that he could not say whether the instruction was given but if it had been he could not think why he had not acted upon it, ‘which is not a denial that the instruction was given’.

Mr E’s answer was much more clear-cut. ‘He “had no recollection of the meeting but said that an instruction of that sort” would have stuck in his mind.’ None of the three produced notes of the meeting.

The report concluded: ‘Of the four accounts we were given during the course of the of our enquiries, we find Mr J’s version the most reliable.’

After all this nonsense of ‘Mr J, Mr E and Mr G’, a few hours later Channel 4 news revealed everything, although for legal reasons, they and I are publishing ‘denials’ as well.

These are extracts from their website, heavily edited by me;

Former CQC boss Cynthia Bower, her former deputy Jill Finney and current CQC media manager Anna Jefferson are named as the officials accused of covering up inspection failures at a Cumbrian hospital.

The Care Quality Commission (CQC) had redacted the senior managers' names from a damning report which detailed the alleged cover-up of an internal review highlighting a failure of inspections of Morecambe Bay NHS Trust.

The report described how "Mr G", who we now know was Jill Finney, uttered the ominous words "read my lips" when telling the author of the report to get rid of it.

Current CQC media manager Anna Jefferson was quoted in the report as saying "are you kidding me? This can never be in a public domain, nor subject to FoI (Freedom of Information request)".

Louise Dineley, the author of the damning internal report, told independent investigators that Ms Finney had ordered the deletion of the report and that Ms Bower and Ms Jefferson had "verbally agreed".

Cynthia Bower, former chief executive of the CQC, and her deputy, Ms Finney, have since left the CQC, but Ms Jefferson is still in post.


Denials of deletion

Cynthia Bower, 57, became CQC chief executive in 2008 but left the organisation last year after the publication of a report, critical of the CQC, with a pension pot of over £1.3m. In a statement, she said she regretted any regulation failings, but denied ordering that the critical report be deleted.

"I gave no instruction to delete any such report; I have no note or recollection of such instruction being given. Had I heard any such instruction, I would have countermanded it.

"The report was, in fact, never deleted and indeed a copy was provided to Grant Thornton," she said in a statement.

Ms Finney was behind the CQC's response to the Francis report into the Mid Staffs scandal. She was on a salary of up to £145,000 after being appointed Ms Bower's deputy and director of communications and marketing in 2009, but left the CQC in February and now works for the internet company Nominet.

According to her LinkedIn profile, Ms Jefferson has been at the CQC since February 2003. She also denied the allegations, and said the quote attributed to her was "false, uncorroborated and has since been retracted, I am appalled that it appears in the report".

Nominet has now fired Ms Finney. What a shame.

Neil Harris

(a don’t stop till you drop production)