Consultant anaesthetist links two patient deaths to unsafe staffing at Woolwich Hospital Intensive Care Unit – Chris Day tribunal hearing

Dr Sebastian Hormaeche Pic credit: Linked In

” Troubling” trust commissioned report ignoring patient deaths

A second consultant anaesthetist was highly critical of safety standards at Woolwich Hospital Intensive Care Unit (ICU) in 2013 and 2014 linking the lack of night time trained doctors working there to the deaths of two patients.

Dr Sebastian Hormaeche, an elected member of the British Medical Association Council, provided evidence to the tribunal on expected staffing levels and qualifications of doctors working at the ICU.

His evidence followed a devastating critique last week by Dr Megan Smith on the staffing levels at the ICU run by the Lewisham and Greenwich NHS Trust.

She had told the hearing : “You would not find an anaesthetist or ICU doctor in the country who would accept those ratios. There was a clear and present danger to patient safety – no question about that.”

Dr Hormaeche said that the trust did not follow national standards for doc to patient ratios there but went on to criticise the lack of supervised training for doctors handling emergencies and the way the trust’ called external investigators who presented a false picture of what was happening there. He said:

“The Core Standards state that exceeding this staffing ratio is deleterious to patient care. The ICU cares for the sickest patients in the hospital requiring the most intense level of care and attention and when staffing levels are stretched patients may be exposed to higher degree of risk of harm. This is also impacted by the number and experience of trainees- doctors below the consultant grade, as well as the turnover of patients and the case-mix.”

“Airway skills- the skills required to secure and maintain the airway (intubation) in critically ill patients- are the core element of the anaesthetist’s training and are their fundamental skillset. The sickest ICU patients (Level 3 patients) are those requiring ventilatory support in the form of a breathing tube being inserted into the airway (trachea, or windpipe) in order to help maintain their life support. Situations requiring airway intervention in the ICU typically require the presence of a practitioner with advanced airway skills.

Dr Chris Day

“This is important because an emergency involving an airway issue can be immediately life-threatening, therefore it is a requirement that there be immediate access to a practitioner with advanced airway skills, and in practice this is usually provided by the resident anaesthetists. It should be noted that novice anaesthetists who have not yet completed their lnitial Assessment of Competency do not yet possess advanced airway skills”.

.”I have seen evidence that on 15 October 2014, Health Education England carried out a quality visit at the Trust which recorded concerns from other junior doctors about staff patient ratios and the lack of ready availability of airway support. ln my view, the findings of this quality visit by the HEE and the ICU Core Standards are clearly relevant to Dr Day’s protected disclosures.”

He contrasted this with an external report by M J Roddis Associates, a clinical management consultancy, commissioned by the trust, which said: “The core standards say that the ICU resident / patient ration should not exceed 1:8. These ratios are therefore not absolute.”

Dr Hormaeche said: “…this doesn’t meet safety standards in terms of staffing levels either for doctor to patient numbers or for Dr Day’s level of training at that time. ln my experience this level of cover requires a senior trainee (a Registrar) with advanced airway skills and a higher level of ICU training to be resident in addition to an SHO, who is still undergoing their Core Training, as a minimum.”

M J Roddis Associates said: “Dr Day has immediate access of the resident anaesthetic registrar for airway management “while Dr Day. said the opposite and also warned of serious threat to very sick patients and added of ” I have observed a number of hypoxic cardiac arrests from tubes getting displaced. The unit’s self-extubation rate was high when I was there.”

This is an alarming paragraph – Dr Hormaeche

Dr Hormaeche said: ” This is an alarming paragraph for me to come across lt suggests an unsafe ICU
environment in terms of patient safety, by way of staffing levels and access to advanced airway skills. The term intubation refers to the insertion of a breathing tube, which is a crucial element of life support for the sickest ICU patients. The term extubation refers to the removal of a breathing tube from a patient’s airway.”

” …Self-extubation, however, refers to an unplanned and serious event where a breathing tube has unexpectedly become dislodged or displaced from the airway. This can become a life threatening event.”

He added: “The term hypoxic refers to a low level of oxygen circulating in the blood. This will be expected to occur if a breathing tube becomes accidentally displaced. Severe hypoxia can lead to cardiac arrest and death. To prevent this outcome, immediate access to advanced ainruay skills is essential.”

He then quotes from Dr Day’s evidence about two deaths that followed and linked to staff shortages

“On 7 November and 5 December 2013, two patient deaths occurred at night under the care of lntensive Care. These deaths involved two different non-anaesthetic trained doctors and were declared as Serious Untoward lncidents (‘SUl) and subject to Coroner inquests .The SUI’s involved just the kind of circumstances that I had been concerned to avoid when I raised concerns about patients safety in
August and September 2013.”

Neither deaths were investigated or mentioned by M J Roddis Associates in their report.

Deaths findings fully support Dr Day’s warning

Dr Hormaeche said: “”lt seems to me that the findings of both these Sls fully support Dr Day’s warning in his August 2013 protected disclosures about the training and experience of the grade of doctors used by the Trust to cover the night shift in the lntensive Care Unit under distant supervision.”

The December 5 case involved insertion of a chest drain which was incorrectly sited and pierced the liver. The patient died from haemorrhage according to the coroner.

Dr Hormaeche said: “I cannot understand why Roddis Associates were to exclude these two highly relevant SIs from their investigation.”

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6 thoughts on “Consultant anaesthetist links two patient deaths to unsafe staffing at Woolwich Hospital Intensive Care Unit – Chris Day tribunal hearing

  1. “involved insertion of a chest drain which was incorrectly sited and pierced the liver. The patient died from haemorrhage according to the coroner.”

    I have very limited knowledge of anatomy or medical procedures but aren’t the liver and the chest about a foot and a half apart on the average person?

    This still makes no sense to my mind, as to why they spending so much to cover this up…it’s not as if these people are ever prosecuted for their crimes! Unless there really is a group of Shipmans or Beverley Allitts working in tandem here…..

    I believe several of my elderly relatives were also murdered, effectively, at Pilgrim…but that’s all covered up to. Threat of sectioned for life if I talk about these things….but hey it looks like some very powerful people with lots of money are on the other side of this one for once. That’s how it works, but still the tip of the proverbial iceberg in my view….


    • The liver is much higher up than one might think and also moves with respiration. If trying to insert a chest drain to drain blood or fluid on the right side, it is typically wanted to be put lower in the chest to avoid damage to the underlying lung but to insert it into the fluid.

      A doctor not sufficiently trained in, say, ultrasound scanning to identify the point where the drain can be inserted safely, is at much higher risk of causing damage to liver. It’s therefore a recognised serious risk of unguided right-sided chest drain insertion.

      Still doesn’t mean it should happen and I agree that they are spending vast sums to cover this up in a way that benefits no patients whereas money spent on training and hiring at the correct level would have had a much more positive effect.


  2. I am so encouraged by those supporting Chris and telling the truth; I hope ir brings about the right outcome. It is a sad reflection of our times that organizations seem to be prepared to go to great lengths and pay more to cover their backs than it would have cost to do the job properly in the first place. I have to question whether the involvement of lawyers has prompted this basic dishonesty.


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