The Walton Centre NHS Foundation Trust, Liverpool.
In May 2013 I walked in to the Walton Centre NHS Foundation Trust (the Trust) for a routine operation. I left as a person with a disability, who among other issues, now uses a wheelchair.
I never intended to go public about my experience in Walton. After my legal case was settled, I offered to meet, at my own expense, with the Chief Executive of the Trust and senior management, to discuss what went wrong and how they could learn from their mistakes.
They declined to meet me.
This may be an unusual blog entry. It is certainly a long one and for the casual reader, perhaps not very interesting. It is not intended to raise fear in anyone who requires care at The Walton Centre in Liverpool, but serve as a warning. My sincere hope is that Senior Management with the power and will to make changes, read this and give serious consideration to the points raised.
Having refused to meet with me, the Trust did suggest that I wrote a report for them. Given my obvious lack of trust in the Trust, I didn’t see any point, as I don’t believe they would look at any report or more pertinently, act upon it. I had said that I was prepared to submit a report to a particular clinical manager who I had met when I was an in-patient. I had trusted this senior nurse and believe they would have been keen to act upon it. Unfortunately she has since moved on to work for a different hospital so that was not an option.
This is written mainly as a last chance to feedback to the Trust and so that I can feel that I tried everything reasonable to offer them ‘lessons.’ It is also ‘closure‘ for me. I need to know that if I heard of someone experiencing adverse outcomes at this hospital in the future, I had at least tried to act in a professional manner to alert the Trust. If (as I sadly expect) they choose to ignore this statement, then that is out of my hands.
In May 2013 I walked in to The Walton Centre for what should have been a routine operation. I expected to be there for four nights. Instead, I became a disabled person who now uses a wheelchair and has other neurological problems related to a spinal injury.
In May 2019 Walton Centre NHS Foundation Trust & I reached a significant out of court settlement.
It is important to state here very clearly that the Trust deny any liability in my case.
However, without going in to details of the final agreement, it was ‘substantial’, to the point where I am now paying cash for a large bungalow that will meet my future needs & still have a seven figure sum left for loss of earnings, future care needs etcetera. My wife has now retired from work and we are confident about our future. To me, it is disingenuous at best to agree to such a settlement out of court while still maintaining that they acted entirely appropriately and have nothing to learn from my case.
I am a Registered Mental Nurse. In my previous role, I was a Service Manager responsible for approximately fifty staff & volunteers. Ironically, we supported people who had physical disabilities. As part of my job, I was an investigating officer, examining serious complaints in other services. These investigations were often complex. I would in effect, carry out Root Cause Analysis (‘RCA’) when serious adverse outcomes were experienced. I had offered the Trust to feedback to them in an RCA style or to cooperate in their own RCA. Sadly, it would appear that rather than examine what went wrong and why, the Trust have not made any effort to carry out an RCA and have no intention of doing so in the future.
Due to the legal proceedings I have had access to my medical notes. I will refer to nursing notes & observation charts and medical entries. Due to the length of time elapsed, I will not refer to any staff personally, as they would not have recourse to deny or challenge my comments, however, some actions were significantly unprofessional and in my opinion, could be construed as being in breach of the Nursing & Midwifery Council (‘NMC’) Code of Professional Standards.
Root Cause Analysis.
This is a system that is recognised world-wide. It should be a ‘team’ approach. Ideally it is carried out as soon as possible after an adverse outcome is recorded. Many proactive environments will also use Root Cause Analysis to examine ‘near misses’, where harm did not occur but could have done if the situation reoccured or simply, they weren’t so lucky in future.
Obviously, this is my reflection, not a collaborative approach and it is more than six years since the index event. Sadly, in my opinion, the fact that Walton Centre management did not carry out RCA at the time and have no desire to learn from the event now, even when offered to them, suggests to me that there has not been a significant culture change since May 2013. If circumstances are repeated, then debilitating outcomes are likely to reoccur.
I would point out that I am not trained in Root Cause Analysis but I am using a method of reviewing my own care in the style of RCA and also a reflection on the standards & approach to ‘care‘ that I experienced while a patient at The Walton Centre, coupled with my own knowledge as a Registered Nurse and a manager in the field of supporting people who have physical disabilities.
This will be a narrative, rather than an actual RCA. For example, I will not be using tools, such as flow charts. It is important to reflect that I am largely carrying this out for my own professionalism and as a last opportunity to communicate my concerns with Walton Centre management, if they ever read it.
I intend to reflect openly & honestly and as far as possible without ’emotion’. I will endeavour to make it clear where a statement is my ‘opinion’, ‘factual’ as I recall it, or quoting written entries by nursing or medical professionals.
Once published on my blog, I will indicate its existence to the Care Quality Commission (CQC) and if I can find a contact, to Walton Centre management. I also intend to copy it to the Isle of Man Minister for Health & Social Care who purchased the care at The Walton Centre and who may wish to raise concerns on behalf of Isle of Man patients.
If a Root Cause Analysis is carried out by a team in an open & honest manner, where learning is the priority then it is not unusual to identify a variety of system errors or failings. Often, if one or two small failures occur in isolation, then no significant harm is experienced. This is one of the key reasons for being able to identify the RCA behind near misses. In my case, I will identify multiple issues that unfortunately for me, all came together in a ‘perfect storm‘. Some of these errors are human, some are system.
I have no doubt that in the vast majority of cases, patients do not experience the multiple failures that I did and would therefore pass through the Walton Centre having experienced only positive outcomes. Equally, I have no doubt that I am not alone in having entirely avoidable complications that were not appropriately investigated.
My biggest concern is that the over-arching failure is ‘cultural’, which in itself leads back to the Trusts unwillingness to be self-reflective or welcoming of critical feedback.
I was born with spina bifida occulta. This is a ‘closed’ form of spina bifida and often does not result in significant issues. In fact, in my case, I did not find out about it until I was 19 years old and went for my nurse training medical, where they found an absence of reflexes in my lower left leg & foot. Other than the reflexes, the only other indication was a smaller left foot and no pain responses in that foot. With hindsight, I always walked with a slightly ‘rolling’ gait, where I ‘flicked’ my foot out, but it didn’t impact upon my life. Many years later, following an MRI, I was found to have a ‘tethered spinal chord’. This is also something that I was born with. In normal development, as a person grows, the chord moves freely up in to the spinal column. In my case, it was caught in some fatty tissue, so it became stretched. In younger life, this also did not cause any issues and I was unaware of it. Again, with hindsight, I had some relevant symptoms but I was unaware that they weren’t ‘normal’ and they did not impact upon my life. I was fit & healthy and able to walk for many miles and was obviously, passed fit to complete my nurse training, starting in 1985.
In my late thirties, in to my forties, I began to notice a wasting of my left calf and some other symptoms. These were caused by the tethered chord. As time progressed I developed other mild symptoms, one of which was that when lifting my feet upwards, my left foot rotated slightly.
Untethering of the chord is a relatively routine operation. Once freed, deterioration of the symptoms stops, but the condition does not improve. Therefore the plan is to leave the operation as late as possible, due to direct risks, while still carrying it out prior to the associated symptoms interfering with the patient’s quality of life. With this consideration, there was initially a ‘wait & see’ approach.
Eventually, the time came to consider the untethering. At this time, I was still physically fit with no significant issues. My right leg was entirely normal, with good strength.
Within my family, there is a history of severe bleeding post operatively. Although I had not been diagnosed with this at that time, it was mentioned pre-operatively and recorded.
I was admitted to the Walton Centre for an operation on the 3rdMay 2013.
I was Admitted to the Ward where People Undergo Brain Surgery.
Due to the spinal ward being full, I was admitted to the ward that supported people who had brain surgery. For ease of writing, I will refer to ‘head injury‘ & ‘spine injury‘ to reflect the different wards.
I believe this is significant. Throughout my time on this ward, nursing staff regularly carried out Glasgow Coma Scale (GCS) assessments. This is relevant to someone with head injury but not relevant to a person with a spine injury. I actually joked with a nurse who woke me up in order to carry out a GCS (shining a light in to the eyes and noting if the pupils react). I said, “I don’t know why you are doing this, if my pupils aren’t equal and reacting to light, we have a real problem as you didn’t operate up there [pointing to head] you operated down there [pointing to back]”. She replied with a laugh “yes, but we have to do this”. Although assessment of my lower limbs was carried out, I don’t believe the staff recognised the importance of these assessments.
Having undergone the operation I returned to the ward. It appeared to have gone well with no unexpected complications. There was some contention between me and the nursing staff. I had been told by the Consultant prior to the operation that I would be required to remain “flat on my back in the bed” for 48 hours. The nursing staff wanted to turn me to avoid pressure damage and to mobilise as soon as possible. I refused to be turned as I did not believe that met with the Consultant’s instructions. They also wanted me to sit upright in bed. Again, I refused.
Either I misunderstood the instruction from the Consultant or the staff on the brain injury ward were trying to treat me in a different manner than they would on the spinal injury ward?
On the evening of Friday 3rd May, my legs & feet were moving normally for me, that is to say, my left foot rotated as before, my right foot moved freely.
This was the May Bank Holiday Weekend.
When I awoke on the Saturday morning, I had a burning sensation in my right foot and it was rotating in the same way as the left. I recognised this as being neurological for this reason. There was a Ward Round. They did not stop at my bed, walking straight past to exit. My Consultant was not on that weekend and the Ward Round was being led by another specialist who I had not met. However, I recognised one of the doctors in the team and called him over. I uncovered my feet and told him I had a burning sensation and showed him the inward rotation of the foot. He did not ask any questions or examine me further. He simply said “don’t worry, that is just bruised nerves, it will settle down” and left. My wife, who is also a Registered Mental Nurse said “well he couldn’t have cared less”. I replied “no, he’s probably got a game of golf to go to”. However, I thought that being on a specialist neurological unit, they must see this all the time. Although not overly happy with the manner of the response I trusted it. I also had ‘saddle anaesthesia‘, where the inner muscles of the buttocks become numb. I didn’t realise there was any significance to this, I simply assumed it was from lying flat on the bed. I now realise that on the Saturday morning, I had three out of the four ‘red flags’ for Cauda Equina Syndrome (CES). Loss of or changed sensation in lower limbs, saddle anaesthesia, loss of movement in lower limbs. The only one I was missing was pain.
Cauda Equina Syndrome is a medical emergency that requires swift intervention in order to avoid permanent nerve damage.
Missed Ward Round.
According to the Trust’s evidence, I would have routinely been seen at Ward Round on the Saturday. I wasn’t. The specialist on that day submitted evidence that they would have seen me but only carried out an examination if a problem was raised by staff or patient. There is no documentation of me having being seen at Ward Round. Walton claim that the lack of documentation indicated that no issues were raised. However, I contend that it was not documented because they missed me out and the review never happened. My experience as a Registered Nurse who has been involved in hundreds of Ward Rounds during my career, is that even if there were no problems, as an absolute minimum, “seen at Ward Round, no change” or something similar would still be documented.
A nurse that morning wrote “patient complaining of pins and needles. Medics aware”.
The Trust are therefore suggesting that I reported the change in sensation to a doctor (who didn’t document it) and a nurse (who did document it) but didn’t mention it at the non-documented Ward Round when I had the opportunity?
I cannot prove that I was forgotten, but I know that I wasn’t seen at a Ward Round on Saturday or Sunday.
It is my belief that the likely reason for this was because I was under a different specialist and would ordinarily have been on the spinal injury ward. I strongly suspect that I was missed for this reason. Had I been on the correct ward, I would have been on the list, or if my own Consultant had been on duty, he would have known to review me as he’d operated on me the day before.
I believe the Trust should at least examine if my assumption is correct and make system changes to ensure that a patient can not be ‘forgotten‘ in future.
Some time later, while on the rehab unit, I met my Consultant surgeon. In conversation, I said to him “I’m not going to ask you a question, because it would be unfair to expect a response, so I will simply make a statement. I believe that if I’d been operated on, on Monday, Tuesday, Wednesday or Thursday, you would have seen me the following morning. You would have taken one look at me and thought, ‘that’s not right’ and ordered further investigations”. He didn’t respond. The reasoning behind the statement though was that if he believed everyone acted appropriately, he would have jumped to their defence, he would have made a comment along the lines of ‘well, that’s not really fair because…‘ but he did not.
In my opinion, not responding spoke volumes.
At the time of that conversation with my Consultant, I was unaware that I was supposed to have been seen by someone else on the Saturday morning. Had the Trust carried out an RCA at that time, they would have been able to identify exactly what actually happened, how and why?
Assessment by Rote.
As well as the Glasgow Coma Scale, which was not relevant, I’d suggest that the staff were carrying out relevant assessments without understanding the outcome. The deteriorating strength of my right leg was recorded on my observation chart but that information wasn’t acted upon or raised as a concern, it was simply documented then left.
Reviews from the Nurses’ Station.
On the Sunday, I had experienced further deterioration and could hardly move my feet. I complained to the nursing staff but received the same response as the day before, that this was ‘normal’, ‘bruised nerves’.
I was shocked during the legal case to discover that I had apparently been seen by a doctor. At no point did the doctor visit me at my bedside. Obviously, the Trust would dispute that this.
On the Bank Holiday Monday, there are further records from doctors in my notes that morning. I state unequivocally that these reviews did not take place at my bedside and I did not have an opportunity to raise my concerns with any medical staff. By the Monday, I could not move my legs at all. When I raised my concerns, I was told by a nurse “don’t worry, you’ll see your Consultant in the morning”. I was not prepared to accept this and insisted upon seeing a doctor. She responded that because this was a Bank Holiday, “there’s only one SHO on for the whole hospital”. Reluctantly, but because I was insisting, they called the on-call Senior House Officer (SHO). This doctor reviewed me fully and sent me for an MRI scan. The scan showed that I had internal bleeding which was compressing nerves.
If we accept the Trust’s position, that my records were accurate and that I had been reviewed properly at my bedside, then they have to explain why, so soon after allegedly being seen on the Monday, the on-call SHO had to attend to me on the ward and found me in need of a scan? If they conclude that the deterioration was extremely rapid and must have occurred after the first doctor reviewed me, in the space of an hour or so, which may be possible, if unlikely, then they also need to explain the documented increased weakness in my right leg and the “pins and needles” sensation, both recorded two days earlier but not referred to by any doctor[s] over the weekend?
In short, the Trust is claiming that I had “pins and needles” on the Saturday morning recorded by a nurse, a weakness in my right leg on the Saturday evening which was also recorded, then no symptoms reported or assessed by the doctors on Sunday or Monday morning, until the Senior House Officer was summoned (for an unknown & unrecorded reason) also on the Monday morning, where she found symptoms sufficient to warrant an MRI scan.
They also would have to believe that even though I was experiencing the symptoms that they documented (even though it was a burning sensation, not “pins and needles”) and the weakness in my right leg, I, as a Registered Nurse, chose not to tell the doctors on the numerous occasions when they apparently examined me? Not only that, but that the doctors’ examinations did not observe the weakness in the leg that the nursing observations did?
Alternatively, as I claim, I wasn’t seen by a doctor at all through the Bank Holiday weekend until the SHO on Monday and that this was only because I was insistent. The doctor’s records over that weekend were completed from the nurses’ station without ever talking to or assessing me.
It would be up to the Trust to decide which of those two scenarios was the most likely and of course, people reading this can draw their own conclusions.
Unfortunately, if the Trust are not interesting in reviewing what happened, then they will never know.
Following the MRI scan, it was found that I had internal bleeding. As I understand it, I have an extremely rare “Uncharacterised Severe Bleeding Disorder”. If I cut myself, I stop bleeding very quickly but following the operation, my organs began to ooze blood. This could not have been reasonably predicted. However, my family history of bleeding was raised at the pre-operative assessment and documented. While I accept that this information would not have stopped the operation from going ahead, it could/should have raised a flag for further observation once things began to go wrong. If not, then this is yet another ‘assessment’ of the patient that is promptly ignored. Simply recording: “Family history of post operative bleeding, please observe” would have perhaps been enough to alert staff quicker when I began to experience unusual symptoms?
If not… why bother asking?
Following the MRI, I was reviewed by the on-call Radiologist and as a result, required an emergency operation that evening to remove the blood clot. Had I had the MRI & operation on the Saturday morning when I first raised concerns and had observable, recorded symptoms, on the balance of probability I would have made a full recovery.
Lying by Omission.
There are different ways to tell an untruth. One is to deliberately omit salient information. This is known as ‘lying by omission‘.
Two staff came to reposition me up the bed. They moved in to a position as if to manually lift/drag me up. With my background, I was fully aware that a manoeuvrer of that type was illegal and had been against all reasonable moving & handling techniques for a decade or more. Also, I had a wound on my spine from the operation, so was concerned about the integrity of the dressing. I rhetorically asked “don’t you use slide sheets?” The Registered Nurse confirmed that they do and one of them went off to get one. A slide sheet requires hardly any effort from the staff, protecting them from injury and it avoids ‘sheering’ of the patient, maintaining the skin integrity. But it takes more time.
If you view this video on Youtube, at 4 minutes 26 seconds in you can see how easily a correctly positioned patient can be repositioned up the bed, with barely any effort.
The staff were clearly not familiar with using slide sheets. Once positioned, they then counted to three and pulled on the sheet with a similar level of force as they would have needed to manually lift me. I shot rapidly up the bed and smacked the top of my head on to the headboard with considerable force. I had pain in my head, neck & shoulders. Fortunately, this was transient and there wasn’t any lasting damage. But considering I was on the ‘head injury’ unit, it could have been catastrophic. I was in pain and annoyed. The staff were observably embarrassed and apologetic. I stated that I expected an accident record to be made regarding this incident. Obviously, the staff didn’t anticipate this ever coming to light as there wasn’t any lasting injury or loss of consciousness. However, as part of the legal process, my team, at my request, ensured that we received a copy.
Following this incident the nurse wrote in my notes:
“When moving up bed head touched head board slightly pt [patient] it hurt his back incident form done SHO & pt came to no harm” (sic)
No explanation of how this occurred and the term “slightly” inserted.
The SHO stated;
“Informed that Keith hit his head on side of bed. No LOC [Loss of Consciousness] No bleeding from orifice”
At least the SHO did not claim to have seen me. However, the SHO was informed that I had somehow hit the side of the bed?
In the ‘Datix Incident Form’ (DIF2) which appears to be the electronic reporting form used by the Trust, it states;
“when moving patient up bed head slightly touched head board”
In this instance, no mention of how and no mention of pain. Again “slightly”.
As a Registered Mental Nurse, part of my wife’s role is reviewing incidents. She is also Institution of Occupational Safety and Health (‘IOSH’) qualified. She observed this incident and in her professional judgment, it was anything but “slightly”.
Under ‘Action taken‘
“observations recorded, nurse in charge and SHO informed no harm to patient”
There is a ‘Message’ from a senior manager (the same one I mentioned earlier, that I trusted to investigate issues correctly, but has now left the Trust) on 10/05/13;
“[Identifying marker removed]. Please review and add comment regarding manual handling technique used and whether staff competent or need additional training?”
The response is under Comments and Lessons Learned‘ Comments by DIF2 Manager‘ states;
“Approriaye (sic) action taken. No injury to patient. Incident can be closed [identifying marker removed] 13.5.13”
How do you carry out a review as to what happened if you don’t talk to the patient? This is basic. I was not spoken to. If the Trust tries to claim that I was, then why wasn’t that documented? In my opinion, this was quite simply lying by not explaining what actually happened and covering up for staff incompetence. The actual accident was not the problem in my opinion, it was not being open and honest about it. Clearly, there were learning opportunities and training issues that led to this incident. It may have been down to pressure of work that led to trying to take a short cut? It may simply have been the culture on the ward? Regardless, it was clear that slide sheets were not routinely used on the ward, the staff did not know how to use them appropriately and having made an error, it was downplayed and not explained openly.
This incident could have required an RCA in itself as a ‘near miss‘. As stated earlier, I was on a ward where patients have brain injury and/or brain surgery. Such an accident to a patient in that situation could have resulted in a catastrophic, irrevocable injury. The NMC Code of Conduct demands that Registered Nurses maintain a higher standard of truth and openness.
It may sound bizarre but this incident annoyed and frustrated me more than anything else. This incident did not result in any lasting damage, while the other failings resulted in me acquiring a life changing disability and becoming a wheelchair user. However in this case, it demonstrated to me a culture of cover-up and an unprofessional approach to taking responsibility. That the Trust did not want to meet with me to discuss my case suggests an unwillingness to take responsibility at a management level that spreads right through to the wards. This is cultural.
I wanted to offer my feedback directly to senior managers in the hope that they would investigate and review their position, so that lessons could genuinely be learned. Had they done so, my intention was to speak openly, candidly but in confidence. I never wanted to make public my concerns. But I need to know that I have not kept my concerns to myself, in a manner that could result in other patients potentially being put at risk.
For obvious reasons, I do not trust the Walton Centre and I do not want to be a patient there again. I believe that my case was due to a number of circumstances and failures all occurring together. Had any of these errors been picked up and acted upon appropriately, the outcome for me would in all probability been different. The Walton Centre Foundation Trust could & should listen to feedback and review each and every occurrence where the actual outcomes for a patient fall so dramatically short of those that were anticipated.
The CQC report from 2016 rated the Trust as ‘Outstanding‘ overall.
I would like to make it clear that my experience within the Walton Neurological Rehabilitation unit was positive. In particular, the physiotherapy & occupational therapy were excellent. The Consultant there, along with the psychological support were all first class. They deserve their ‘Outstanding’ rating as far as I’m concerned. Since I was there, they have moved to the Sid Watkins Building, where the physical environment is much improved. I’m sure this will have led to a continuation of their great work.
I don’t write this with the intention of causing fear among potential patients or their relatives. As I said earlier, my disability came about largely due to a few issues all coming together. Had any one of them been picked up appropriately, then the final outcome would have been avoided. To become as disabled as I did took a significant amount of bad luck, by experiencing multiple system & human failures all at the same time.
That said, I would recommend that any patient or their relatives who are treated within this Trust, keep their own clear, in-depth notes about their own care. Document what happened and by whom. Be an ‘informed patient’, actively involved in your own care. Ask questions and record answers. And if things appear to be going wrong or you have concerns, be assertive and demand responses.
In my experience, had I not insisted on being seen by the SHO on the Bank Holiday Monday, I would have been far more disabled than I actually am. That my disability is as limited as it is, is due to my assertiveness, rather than Walton staff who wanted me to wait until my Consultant returned on the Tuesday morning.
I would like to thank Stephen Jones and his team at Leigh Day for their hard work & support in securing the substantial compensation payment. While money doesn’t really compensate for not being able to take the dogs for a walk in the forest or on the beach, it certainly means that I can look forwards to the rest of my life without financial worries and can live in an environment that meets my physical needs, both now and in the future.
In summary, points for Walton Centre NHS Foundation Trust to consider:
When patients with spinal injury are occupying a bed on the head injury ward, or visa-versa, are adequate measure in place to ensure that they are not ‘forgotten’ or missed off ward rounds?
When patients are on ‘the wrong ward’, are staff adequately trained to meet their different needs?
Are staff competent to understand why they are carrying out observations, for example, is a Glasgow Coma Scale appropriate for a patient who has had surgery on their spine?
Are staff competent to understand the outcome of observations and confident enough to escalate those outcomes when they are not as should be expected? For example, observing and recording a weakness in the leg where normal power was there previously, but not informing medical staff.
Are adequate procedures in place to ‘hand over’ patients from one Consultant to another at weekends or annual leave?
Is there a culture of ‘blame’ that stops ownership of errors at ward level which would encourage cover-up?
Do staff still take ‘short cuts’ rather than carrying out safe moving and handling or other such procedures?
Is there a culture at senior management level that prevents ‘learning’ opportunities?
When an outcome is so far away from what was expected, why isn’t a Root Cause Analysis carried out?
Are ‘errors’ masked in order to chase an ‘Outstanding’ CQC rating? Are the ratings more important than the actual outcomes for patients?
Given that the case had been settled out of court, and the Trust were now free to talk openly, what justification did they have for not wanting to actively pursue an opportunity to learn when it was offered to them? Despite a significant compensation payment, and legal fees that were probably in excess of £400,000 (both sides) do they still genuinely believe it when they ‘deny liability’ or are they simply in denial?
I have no confidence that the Trust will have any interest in answering these points unless the CQC force them to. I sincerely hope they do not severely injure or even kill any patients through their unwillingness to learn from their mistakes.
Finally, since 2013, I have also been an inpatient and outpatient at the Royal Liverpool Hospital and had both outpatient and A&E care at Aintree Hospital. I found that the quality of medical & nursing staff in both these hospitals to be excellent. You can imagine, having experienced Walton, I took an even closer eye on my care on later hospital admissions. The Royal Liverpool in particular was a dreadful building (the new Royal Hospital was being built at the time) but with great staff. This demonstrates clearly that the culture within the environment is far more important than the building itself. Talking to a Registered Nurse at Aintree, they made it clear that the Aintree Trust take reviewing of untoward incidents very seriously and she gave examples of process changes that were introduced swiftly after an unexpected incident, to reduce the likelihood of similar occurring in the future. I suspect that Aintree Trust actually follow a Root Cause Analysis format when appropriate or required.
If the Walton Centre NHS Foundation Trust really deserve their CQC ‘Outstanding’ rating, they need to be more proactive when it comes to learning from their errors.
If they were ever to regain my trust, they would have had some listening & responding to do.
Sadly, they refuse to do so and I fear, they are destined to make the same mistakes again.
While there is probably very little more to add, I’m happy to be contacted at email@example.com should either Walton or CQC etcetera wish to do so.