PATIENT safety concerns have been raised at a flagship Welsh hosptial by two separate reports.

Staff at the Accident and Emergency department at the Grange University Hospital, in Cwmbran, have said they are concerned the department cannot cope with the number of patients coming to hospital.

Meanwhile a report by the Royal College of Physicians said staff at the Aneurin Bevan University Health Board, which runs the Grange and three other hospitals in Gwent, faced "frightening experiences".

BBC Wales News said the Royal College found some trainee doctors and consultants were worried about working in case they lost their licence to practise citing understaffing and excessive workloads at the Grange causing "very serious patient safety concerns".

The £358m Grange Hospital, which opened last year, was intended to centralise critical care services but the Royal College has said staff are now being stretched across four hospital sites rather than three.

Patients are also having to move between hospitals and some are falling in "gaps" in care between the Grange and the existing hospitals at Newport, Abergavenny and Ysbyty Ystrad Fawr in Caerphilly.

It come on top of concerns revealed by a report into the emergency department at the Grange, published by the Aneurin Bevan Community Health Council – the independent watchdog for NHS services in the area.

It also reflected concerns by patients and staff over capacity at the new hospital and pressures placed on staff.

Concerns raised in July 2020

In response to the BBC’s publication of its report the Royal College, said it welcomed that the Aneurin Bevan board is responding to its concerns and said it will monitor the action plan drawn up by the board. 

The Royal College said it met with doctors, including a closed meeting with trainees, at the hospital in June and shared its report with regulatory and statutory bodies, including the Welsh Government and Healthcare Inspectorate Wales, in August but hadn’t made it publicly available. 

It said previously raised issues around operating four hospitals, general medicine provision at the Grange, staffing, transport, consultant wellbeing and a lack of consultation with NHS staff had been raised by the British Medical Association (BMA) with the health board in July last year, before the Grange opened in November 2020. 

“Not enough has been done in the past 16 months to address these concerns, and there is a huge amount of work to be done by Aneurin Bevan University Health Board to rebuild trust among clinicians,” said Dr Olwen Williams, the Royal College’s vice president for Wales. 

“As winter begins, the challenges that face the medical workforce are immense – there are simply not enough doctors and nurses in the system. The health board action plan is encouraging, but a great deal of work will be needed to repair damaged relationships.” 

She said the college recognised the pressures faced opening the hospital during a pandemic and said the report had been motivated by concerns for patient safety. 

“'This may be a tough set of findings, but the report should not reflect badly on the many senior clinicians at the health board who are doing their very best during an unprecedented global health crisis to keep patients and trainees safe.  

“Our intention is to support and listen to our colleagues. We want to work with senior management and our frontline clinicians across the health board to improve patient care and reduce the workload on NHS staff.” 

For its report the Aneurin Bevan Community Health Council visited the department over seven days in August between August 16 and 22, and spoke with patients waiting in the waiting room and NHS staff themselves.

They spoke to 84 people in face-to-face interviews and 24 more completed an online questionnaire.

Some of the issues the council found were people sitting on the floor due to a lack of waiting space, discomfort experienced when faced with long waits and poor communication about waiting times.

Staff revealed to the council that there were whole-system pressures, and the increased demand were impacting patient flow through hospitals and back into the community.

One of the received comments said: “Recent 10 hour wait in A&E. resulting in bowel infection becoming a perforation for which I had to be admitted.  Better and quicker triage would have prevented this. Too many folk with minor injuries clogging the system.’’

Another said: “Consider the stress on the SAU (Surgical Assessment Unit) and A&E departments at the Grange. From arrival to receiving pain relief is too long and having to sit on a chair for 36 hours because there was no bed available, is unacceptable. This situation makes it near impossible to adhere to strict Covid guidelines as patients' space is a chair in a waiting area and the turnover and number of patients in this area is greater than the facilities can cope with. 

“The ability of staff to have private conversations with patients is severely compromised by the limited space too. I heard conversations about quite personal diagnoses and how to take medication by suppository. Watching others in tremendous pain for hours on end is emotionally difficult to handle whilst I myself was also in pain. The toilet opens directly onto the seating area and offers no privacy to patients using this. The door to the SAU opens by pressing a button inside the unit. My chair was by this door, so I regularly got up to let people in.”

It wasn’t all negativity though, with people spoken to in the waiting area valuing and appreciating the hard work of the staff – who they understood were facing real pressure.

One of the comments received said: “All aspects of treatment from admission to discharge were excellent.  I was treated exceptionally well by all the staff I had contact with, professional and polite and kept me regularly informed as to what was happening with my treatment.’’

Another added: “The treatment I received was very thorough and waiting for test results was unavoidable, particularly as it was overnight.  I have only compliments for the treatment I received. The doctors and nurses are doing a brilliant job in difficult circumstances.’’

What did the Community Health Council find?

When speaking to staff, council members were told that there was around 30 per cent more people attending the Grange A&E than both Abergavenny's Nevill Hall and Newport's Royal Gwent hospitals, combined.

Members of staff said they felt the Emergency Department was not able to cope with the number of people attending. They felt that demand is no longer fully related to the pandemic, which is impacting on the level of care they can provide to patients.

It was reported that people were experiencing delays in receiving pain relief, which reflects some of the feedback comments. They were informed this is having an impact on staff wellbeing, with staff thinking of leaving their jobs, and some staff leaving.

Of the patients they spoke to in person, the council were told that 20 were brought to the department by ambulance, with three being transferred immediately, two waited up to 30 minutes, one waited up to an hour and 12 waited more than an hour to be transferred from the ambulance. Two were not sure how long they had waited.

Of those who were surveyed, 12 arrived in the department the day before they were spoken to, 59 were not told how long they would be waiting, and 71 of the 84 had access to refreshments while waiting, however, 11 did not. Two people didn’t answer the question.

The majority of people asked believed they had adequate privacy and that the toilet facilities were adequate to their needs, with 47 of the 84 saying they felt they were being kept informed about their wait/treatment, but 33 felt that they were not. Four didn’t answer the question.

In a positive finding, 71 people were happy that the doctors and nurses were discreet when discussing their treatment. However, seven did not and six did not answer.

Seventy-nine of the 84 felt they were able to communicate in their own language, with the remaining five not answering the question. Seventy-four also felt that they were listened to, with three feeling like they did not and seven not answering the question.

The council observed how many of the patients were full of praise for the staff and how their compassion and friendliness were highly rated.

They did also find that across the seven days, there were between five and 17 ambulances waiting in the emergency department bays. This raised a concern as some were waiting around eight hours and possibly at more risk because they could not be moved for treatment until those who had been treated were moved to a ward or discharged.

They also noted how there was regularly a high number of people in the waiting room – counting 97 on one visit and 85 on another – meaning people were unable to adhere to social distancing protocols and also had to sit on the floor as there were not enough chairs.

They also noted how if patients in the waiting area did not have money, they were not able to access the refreshments available and while they acknowledged that there were Red Cross volunteers in unit support, it was not clear if their refreshment support extended to those in the waiting room.

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What did the council recommend?

The council recommended the following:

  • The CHC would be pleased if the highly positive comments made by people regarding the care and approach from the staff could be shared with the department teams. It was evident from the feedback that people appreciated the hard work and efforts of staff during a visibly difficult time.
  • The CHC was concerned about the feedback regarding the physical capacity of the Emergency Department unit, including the waiting area, following the reports of people observed sitting on the floor and waiting for long periods outside in ambulances. The Health Board is asked to respond to the observations and share plans being considered to address the capacity issues and waiting time concerns.
  • The Health Board is asked to consider the feedback about communication. People told us that information about waiting times and waits for treatment would be helpful.
  • The Health Board is asked to respond to the feedback from staff about increased levels of demand, and the reported impact on staff wellbeing in such a high pressured environment.
  • The CHC would like to understand if refreshments are provided to people in the initial wait area in view of the length of waits reported
  • The CHC recognises the whole-system pressures in Health and Care services, which are affecting people’s care, experiences and the NHS’ ability to deliver timely care. In view of these concerns the Health Board is asked to share plans and developments being introduced or planned with Social Care colleagues and other partner organisations to address the pressures.
  • The CHC would like to understand how the  Health Board will address the feedback in relation to people’s comfort levels and pain management when experiencing long waits.

Aneurin Bevan Community Health Council’s chief officer, Jemma McHale, said: “There were very clear commendations from people who thought the staff and treatments received were excellent, despite the enormous pressures on the NHS and care system as a whole. Sadly, there are also experiences shared that were less positive, particularly around extended waiting times, inadequate waiting space and comfort issues.

“The CHC will continue to work with the NHS to share people’s experiences, and to press for a whole-system recovery approach, because we recognise the issues being seen at the Emergency Department are one part of the whole-system problem.”

What does the health board say about this?

The council have shared the issues with the health board and have received a management response.

The health board said in their response: “It is positive to note the feedback from the public and staff within the emergency department, who are working incredibly hard, will appreciate the comments. The CHC engagement report has been shared with the emergency department directorate leadership and management team for cascade.”

On the capacity issues at the Grange, they said: “ABUHB have reported the substantial increase in demand at the emergency department, Grange University Hospital which has been beyond predictions. This, coupled with the challenges of patient flow and Covid pathways, has resulted in long waiting times in the emergency department and, on occasion, over-crowding.

“There is work in-train to increase the footprint of the waiting area with a short-term solution and a longer term option being worked through. These plans will be shared with the CHC.”

On the communication feedback, the health board responded that effective communication about waiting times is important to manage people’s expectations and minimise anxiety and that work is already underway to introduce an electronic waiting time board in the waiting area.

On staff wellbeing, the clinical director for emergency department and the divisional director for urgent care escalated the concerns. The issues are being addressed through the urgent care transformation board with evidence based and data-driven streams focussing on patient streaming, admission avoidance, patient flow and length of stay.

They have also secured additional wellbeing support for staff in the emergency department and have organised wellbeing sessions and regular de-brief meetings. They have also conducted medical and nursing staff reviews and an increase in resource has been approved by the executive team – which will include recruiting additional staff in training.

They have also completed a review of nutrition and hydration to increase provision for the emergency department in light of the waiting times. They are providing refreshments for people in the waiting area.

A winter plan is being finalised for the hospital to manage pressures and improve the flow and patient experience.

They also said that there are regular dignity and essential care audits to ensure that there is essential care being provided for patients whether they are delayed in an ambulance, in the waiting area or in the Majors.

They also said that in light of the feedback, the senior nursing team will continue to assess experiences and ensure action to address deficits and a focus on comfort and pain.

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