Here’s the story:

Tetraplegic Man’s Life Support Turned off by Nurse

A couple of things spring to mind, the first being that they really should nail everyone involved in this to the wall. I mean for crying out loud the guy was worried enough to have someone set up a bloody webcam to keep an eye on him. Apparently his emails of concern to the authorities were ignored.

The other thing I can’t get my head around is how the hell the nurse concerned didn’t come right back to her employers and say, ‘hey you know what, this guy you asked me to care for is on a ventilator and I’ve not got the faintest idea how it works, so either train me on its use or get someone else’.

And that’s even before we think about simply putting Ambition24 out of business immediately and sending the directors to prison for culpable ABH or whatever the charge would be.

Yes, the world’s a simple place and a knee jerk reaction is clearly what is needed. best raise the mob 🙄

It did seem a member of his family was there as well.

I think if it was me and I was worried I’d have made sure there were ‘reboot’ instructions on a laminated card next to the ventilator.

This in no way excuses the actions of the nurse, the company employing her ort the nhs trust that contracted the work out – they are all to blame. She, as a professional, should never have touched a machien she couldn;t operate.

I haven’t read the story but I imagine it’s very much like the time my works IT dept put STW on the ‘banned’ list.

On a superficial basis this appears to me to be the old ” pay peanuts get monkeys”

Using agencies to provide complex care will almost always result in a reduction in standards. Staff are put under a lot more pressure and the agencies are under great commercial pressure – this results in this sort of situation.

Teh agenices have to provide the staff to do the care at a fixed cost. If they don’t provide the staff they lose the contract, if they overspend on staff they go bust. These contracts are often awarded on a chepest is best basis.

Teh answer is to keep it all in house – but that costs more. As an aside this chap would have been in institutional care if not dead 20 yrs ago.

Yes, the world’s a simple place and a knee jerk reaction is clearly what is needed.

Except it doesn’t seem like a knee jerk reaction. The facts as presented are that the guy was very concerned, wrote emails to that effect to the health authority and even had a friend set up a webcam next to his bed that then recorded the nurse turning off the machine by mistake, which has left him brain damaged.

It happened; the reaction isn’t knee jerk, this guy has gone from being a fully cognitive tetraplegic to a seriously cognitively impaired tetraplegic all because a whole bunch of people didn’t their job properly.

Oh ****. What an absolutely awful situation for him. ****. 🙁

A couple of things spring to mind, the first being that they really should nail everyone involved in this to the wall.

The nurse was involved. Should she be nailed to the wall?

The other thing I can’t get my head around is how the hell the nurse concerned didn’t come right back to her employers and say, ‘hey you know what, this guy you asked me to care for is on a ventilator and I’ve not got the faintest idea how it works, so either train me on its use or get someone else’.

Do you live in the real world? Fine, I’d have probably done exactly that because that’s what I’m like but plenty of people aren’t or don’t feel that they can and will simply try to do their jobs as best they can without complaining as they see it. It’s quite possible that the nurse didn’t think that the life support would be so simple to turn off as that and that it was a separate system – the fact is that there are plenty of people who think like that and have no real comprehension of anything technical

Geetee – but where does the buck stop?
With the nurse who was probably under pressure to work beyond her skills, with teh agencies cutting corners to make profits, with the service bosses who decided to use that agency, with the politicians who decided to contract out care like that, with teh politicians who decided cheapest = best, with the politicians who made home care for people in that position possible or with teh public who won’t pay the taxes for that service to be provided properly? ( he could be insurance funded -0 I don’t know)

Some nurses consider themselves to have skills way above their station & abilities – speaking as a nurse I’ve worked with enough of them over the years. She probably “thought” she could manage this patient without any idea of the training required.
Looks like there was some attempt at resuscitation using a bag & mask but as he had a trach in then that was useless too. Surprised the carer had not had some basics in using the bag & mask & wasn’t able to point out that Jamie needed venting via his trach not via a mask.

TJ (and others) I think you’re making a very important point.

Where does the buck stop? In my view anyone directly involved in the chain of events that led to the this situation should be held responsible. Nailed to the wall is an emotive response, but I think they should all be held accountable individually.

The nurse has no business being a nurse if she cannot handle the responsibility that comes with the job. This is a person’s life you’re caring for and sure many people can’t handle that pressure and that’s fine. The real world is a tough place to make a living, believe me I know, but it’s not that tough that you can hide behind it in the event you cause serious brain damage to someone. Maybe she shouldn’t be prosecuted (or maybe she should, that’s for the CPS to decide) but she sure has hell should be struck off from being a nurse.

The HA should be held responsibile for not having undertaken better due dilligence on the the services they were contracting and if it transpires that they did ignore the emails then someone should loose their job, if not be considered for ‘corporate manslaughter’.

The directors of Ambition24 should definitely be prosecuted for corporate manslaughter.

As for the politicians that make the policies etc, well you know who you’re not voting for next time.

GT, I agree fully, especially when it appears to be such an open & shut case with such a level of evidence.

As for politics, I’ve worked with such private agencies regularly over the last 10 years, they’ve been used increasingly as a source of costs savings. NHS cost cutting has not just occured since the last election, it has been ongoing for several years, well, in England at least.

The directors of Ambition24 should definitely be prosecuted for corporate manslaughter.

IIRC, no one died.

IIRC, no one died.

Never let a small detail like that get in the way of the rampaging mob!

What would be the equivalent charge in this case; is there such a thing as ‘corporate GBH’?

I am a firm believer in ” no fault” investigations into healthcare mishaps – on a similar basis to air travel accident investigations.

It is more important to understand why this happened and find out ways of preventing it rather than punishing people – and if people are at risk of prosecution the truth is harder to get to as it is only human for them to attempt to deflect attention from their own mistakes.

*watches thread with interest*

hmmmmm nearly joined up to Ambition 24 a while ago

Some one will be “nailed to the wall” – probably some scapegoat. Public opinion will demand it and after some expensive inquiry the boss of the agency will resign, the nurse will sue for not having the training and the gov will blame Labour for the mess.

Meanwhile some poor bloke is completely screwed for the rest of his life.

geetee1972 how much would they have to pay you to work in an environment where making a mistake can cost someone there life ? I bet its more than the nurse is being paid.

If I make a mistake at work, the worse thing to happen generally is some money is lost. Not sure I would want to work in a situation where it might cost a life.

Bottom line is we ALL make mistakes sometimes, something I think the STW collective forget sometimes.

It is more important to understand why this happened

I think that’s laudible, but don’t we already know why it happened? The nurse turned the machine off by mistake because she didn’t know how to operate it, thus not being in a position to know of her mistake.

Ultimately, while the truth may be harder to get to, it shouldn’t mean that people guilty of negligence should get away with it.

geetee1972 how much would they have to pay you to work in an environment where making a mistake can cost someone there life ?

Simple answer that – £35k a year. I went for just such a job where I would have had enormous responsibility for life.

Yes it’s a lot more than nurses get paid. Nurses should be paid better, trained better but also held to account if they are found lacking in their responsibilities.

Mistakes are one thing, but knowingly accepting a position of care that you know you’re not qualified for is not a mistake, it’s wilful negligence.

quick scan of the bbc piece…

A confidential report by Wiltshire social services into the incident – leaked to the BBC’s Inside Out programme – concluded the agency was fully aware it was required to supply a nurse with training in the use of a ventilator, but the company did not have adequate systems in place to check what training their staff had received.

the agency will learn a lesson from this, if not via the courts then via the amount of business it will loose when LA’s realise they’re not checking on staff properly. All it takes it one incident like this to destroy a business’ reputation.

His sister Karren Reynolds said he had become increasingly worried about serious errors involving nurses operating his ventilator, but claimed that health bosses did not act on e-mails of concern which he sent them.

i wonder if she got a “we have received your email, please expect a response within 28 days” type email back?

Ms Aylward has been suspended while the incident is investigated by the Nursing and Midwifery Council.

No surprises there…

all this happened in january 2009 though… ambition 24 is still going strong

pesky news only telling us half of it!

Geetee – nope – it will be a lot more complex and multifactorial than that. Did she have the training, did she have the proper info to assess if it was safe, was she put under pressure? from what source? did she ask for the training, did the agency provide training, did the HA properly monitor? Thats just a few questions to be answered.

If people are at risk of prosecution the truth becomes hard to get to. I would be prepared to bet there area multiple mistakes by multiple people which led to this situation. Teh key thing is to prevent it happening again. to do this you need to know everything that happened.

I recently read the report on this incident. No one mistake but multiple mistakes by multiple people

http://www.scotcourts.gov.uk/opinions/wightman.html have a read to see how complex these things can be.

Mistakes are one thing, but knowingly accepting a position of care that you know you’re not qualified for is not a mistake, it’s wilful negligence.

Is there evidence of the above ? This is a question not an argument as I have not read much about this, only heard it on the radio and I am genuinely interested.

Teh key thing is to prevent it happening again

I’d say it’s one of the key things. If I were the guy’s sister, I’d say that another key thing would be to have someone held to account for having caused my brother to become brain damaged.

Other than that I accept most of your other arguments. On the point about whether she had the correct training or not, isn’t it pretty clear that she didn’t? That’s where the whole problem has arisen in the first place.

Is there evidence of the above ?

I think it’s been inferred from the information that’s been made available. The issue is either that she knew what she was doing and made a mistake, which is something that can happen (and I think can in many instances be excused) or she didn’t know what she was doing and didn’t want to say anything about it for whatever reason (pressure from employers etc).

geetee – but why did she not have the skills and was doing the care. She might hvae been trained she might not.

Was there unfair pressure on her? Was the supervision there fromthe agency and from the HA?

Was the specifications from the HA correct?

Did the agency send someone they knew was not competent? did the nurse hide her lack of competence?

It really is much more complex and there are no simple answers.

On the point about whether she had the correct training or not, isn’t it pretty clear that she didn’t? That’s where the whole problem has arisen in the first place.

Is it clear she didn’t have the training though ? From what people have told me who have seen the video, its clear she didn’t know what to do. That is different from not having the training.

I was trained in first aid in an alpine environment two years ago, never used it or had a refresher since. So I am trained, but I am bright enough to realise I am not competent after that time.

Did the agency send someone they knew was not competent?

It seems that they didn’t have the systems in place to fully estabish this.

TJ, forgive me but I may well have misunderstood the story based on the way it’s been reported. I’ve read a few other reports and there is some contradiction in what’s been said (who’d have thought the media could get it wrong!)

The report this morning on Radio 4 said that the nurse categorically hadn’t been trained to use the ventilator, which is why she couldn’t get it restarted; she is reported to have said ‘what do I do with this’ when she realises her mistake.

Other reports however are not being clear about this and are not saying she 100% didn’t have the training.

Like you say, more complicated than it first appears. But, and i still stand by this, if there has been negligence (and by the nurse also) then people should be held to account.

Wheras I would rather prevent these incedents from happening again – and to do so you require com-plete certainlty in the information you collect which you cannot have if you pin blame on someone.

Now in this case I don’t know what happened but I bet its not a simple thjing to unpick

My experience is that multiple mistakes are made until you reach the situation where harm is done.

Rea the link to the FAI i put – it really is very interesting how many different mistakes are made in that case ( if tragic)

If you look at the wrightman case that I linked to and superficially it looks like the nurse made a serious mistake and it was her fault the woman died. However when you look deeper the mistakes run much deeprer and are made by multiple people both at the time and in the past

Is anyone else scared to click on the “testicle removed by mistake” link in the sidebar of that article.

Ofc it may be more complex than it sounds but it comes across to me as a company trying to maximise profits by minimising costs so they didn’t have the system in place (which cost money) to track their staff’s suitability for different engagements. Someone should definitely be held accountable and punished to fullest extent of the law when they put greed over someone’s well being.

What’s a no-fault air investigation anyway? Every time I watch air accident investigation stuff on the Discovery channel (I get bored sometimes :p ) they always seem to prosecute either pilots or maintenance companies if they’re found to be a major contributory factor.

Outsourcing fail.

I am I not right in thinking that a registered nurse is accountable for there action, and should not engage in actions or intervention that are beyond their knowledge and competence

Indeed that is true breakneckspeed

I merely was pointing out that in this situation there could be many reasons why this nurse ended up in this position. Multiple failures by multiple people

Multiple failures by multiple people

OK so we all agree that if nothing else then this represents a monufeckingmental FAIL somewhere along the line.

TJ I do appreciate where you’re coming from and respect your view, even if I don’t necessarily agree with your position.

I get what you are saying TJ and would agree that the system is far from fair or functional (having had a lot to do with continuing care packages and how they are funded and carried out) but the bottom line is that as a nurse we are, and should be held to account for our actions and indeed our admissions – which is why I have constantly refused to accept new referral on to my case load for the last 6 months as I do not have the capacity to manage them – I suspect in this case there are multiple failings

Its also worth noting that inside out & panorama do like these type of stories – failures in the care system – but fail to provide useful comment on the system failures or political meddling that is rampant – rather blaming indivduals

OK so we all agree that if nothing else then this represents a monufeckingmental FAIL somewhere along the line.

Certainly does. My experience of this sort of thing is that its multiple small failures leads to one almighty foul up.

How many people go through life can say they have never made a mistake or had poor judgement? Not many, and none that are honest.

It just so happens that people that work in healthcare situations are the goalkeepers of the world. I.e. when they make mistakes people tend to notice.

I wonder what “Turned off at mains by mistake” scored on the DFMEA ?

Do these things not have some kind of protection against this ?
Even Windows asks if your sure you want to shut-down.

Ms Aylward has been suspended while the incident is investigated by the Nursing and Midwifery Council.

No surprises there…

all this happened in january 2009 though… ambition 24 is still going strong

I think the NMC might have dealt with this nurse, as a quick search on http://www.nmc.org.uk doesn’t show anyone with her name on a nursing register in this country.

Corners get cut, people get slack, mistakes happen & people die.

I’m not making light of the situation, far from it, I spend a far too significant portion of my working time chasing medics who have prescribed drugs incorrectly and then the nurses who adminstered the drug of an incorrect prescription – neither medic or nurse sometimes understands what they have done wrong, and their re-education therefore falls to me.

I must say that this horrifies me.

A few of the nurses I work with do agency work, but I’m happy that they have the experience and insight to deal with that situation, as I would have had.

This is someone without the experience and/or knowledge and/or skill being sent to provide nursing care to someone whose LIFE depends on the ability to use a ventilator or to hand ventilate if that vent fails.

I have had occasion in the past to take a nurse off to one side and suggest that she didn’t have enough experience to go and do agency work of this kind; she didn’t like me for saying it, but she understood why I did and didn’t go ahead.

The agency should get hammered, the nurse should be struck off, the directors of the agency should not be allowed to work anywhere near healthcare ever again.

…and the NMC should have a word with themselves; they talk such bollocks about nurse registration and their role in patient safety; didn’t work, did it?