Saving Lives in Seconds

Hospital actuality

Waite
Every adult hospital inpatient should go through this procedure when they're admitted.

Hunt
So here we have the checklist for the medical patients, so do we have active cancer or cancer treatment; are they over 60; personal or a family history of blood clots; have they been on HRT or the oestrogen containing pill and do they have varicose veins with inflammation.

Waite
So how long would that take?

Hunt
Well if you have done this a couple of times you'll know how to do it so it should take probably 15 seconds.

Waite
Despite the short time it takes, despite the fact that any problems it may reveal are easily solved and despite a government target which requires all hospitals in England to carry out this procedure, Face the Facts can reveal that it often isn't done. And as a consequence thousands of people, according to the government's own estimate, 25,000 people, die needlessly every year. Having been admitted to hospital, often for routine medical treatment, they die of deep vein thrombosis - a condition which can almost always be prevented.

Dye
I didn't realise until my mother died and I started looking into this that DVT is the single biggest cause of preventable deaths in hospitals. So I cannot understand a. why it's taken them years and years to introduce these procedures and secondly, why there are so few hospitals that are hitting the targets that have been set for them.

Waite
The risk of getting a blood clot or deep vein thrombosis increases with long periods of immobility. So hospital patients who spend a long time in bed or sitting in a chair are obviously prone to the condition. Professor Beverley Hunt is a consultant haematologist.

Hunt
Actually just sitting for an hour and a half in a chair the blood flow drops by about 50%. So you develop a clot in the veins and that's a deep vein thrombosis. The problem with the deep vein thrombosis is that that clot can break off, travel round the body, go through the heart and then block the blood supply to the lungs. If it's a really big one you'd actually drop dead.

Bugden
She went to take some rubbish out one night and she misfooted and went across and banged her leg against a brick wall for a hard standing, the other side of the steps.

Waite
That's Ian Bugden talking about his wife Pauline, who, in 2006, broke her arm and leg in that fall he described. Mrs Bugden was admitted to Medway Maritime hospital in Gillingham in Kent. And, after an overnight stay, and with her broken limbs in plaster, was discharged.

Bugden
Everything seemed okay and then after a few days she actually was having breathing troubles and we got her up to the hospital, the hospital diagnosed an infection on both lungs and decided to give her a double antibiotic.

Waite
But it seemed to have no effect. And 10 days later Pauline was back in hospital with chest pains.

Bugden
She died four and a half hours after going to the hospital. For her to go like she did was a great shock. The doctor thought she was severely dehydrated through not keeping fluids down and that. But again he knew she'd not been mobile and everything else and the breathing trouble and he still decided not to consider a blood clot.

Waite
Had Medway Maritime Hospital followed best procedure at the time, and what is mandatory now, Pauline Bugden would have been risk assessed on arrival. Overweight and facing an extended period of immobility due to her broken leg, she would have been considered at risk of deep vein thrombosis. Doctors may have prescribed a blood thinning drug such as Heparin which prevents clots developing. But she wasn't risk assessed. She died. And at her inquest the coroner confirmed she died of a pulmonary embolism caused by deep vein thrombosis and he criticised the hospital which treated her.

Bugden
The findings were that basically the signs were there and missed on all occasions. The day she first went there with the breathing trouble then she is most liable to have been here - was over a 99% chance of her survival. And the day she died, very remotely, but if they'd have been aware, responded quickly, gave her the new drugs she still had a few per cent chance.

Waite
So in a sense really she died for nothing?

Bugden
She did, she died needlessly.

Waite
Needlessly, not least because the risk of deep vein thrombosis to hospital patients was established 60 years ago, and three decades later a successful treatment was confirmed. As John Black, the outgoing President of the Royal College of Surgeons told me.

Black
The first place where it was really looked at was at Birmingham Accident Hospital in the late 1940s and 1950s when it was realised that patients with hip fractures, who were immobilised, were at a particularly high risk of this and some pioneering work was done there to use anticoagulants which stop the blood clotting. So once we knew how common the problem was people were able to look at ways of stopping it. And the first treatment that was used was a very low dose of stuff called heparin, which is an anticoagulant, but if you give a very small dose it stops the early stages of thrombosis but it doesn't interfere with wholesale blood clotting.

Waite
And you yourself were a young surgeon weren't you in the '60s, '70s?

Black
Yes I was - in the '70s I was a trainee in Birmingham but the penny dropped with a very large multi-centre trial organised by Professor Vijay Kakkar at King's College and there was something like 18,000 patients in this group, it was an absolutely massive trial. And it showed quite clearly that the people who'd had the low dose heparin they didn't get pulmonary emboli at all whereas in the control group, who didn't have the treatment, there were quite a few deaths. And I think that established - and there were many other trials as well - but that established beyond any reasonable doubt - as the judge would say - that preventive treatment does reduce almost to zero the incidence of pulmonary emboli. So the research question that treatment could and should be given was answered over 30 years ago.

Waite
Yet it wasn't until 1986, that guidelines were commonly adopted in hospitals to prevent DVT. And these were drawn up by doctors in America. Scotland introduced its own set of guidelines in 1995 but it took until 2005 before the Department of Health recommended guidelines for England and they would only be published two years later, and would only apply to surgical patients. The Commons health select committee, which investigated the problem in 2005, was scathingly.

Commons Health Select Committee (reading)
This is a remarkable tardy response to a serious situation and, moreover, the scope of the guidelines, commissioned by the department, is limited to a subset of surgical patients, while the majority of sufferers are non-surgical patients.

Not only that but the true scale of this "serious situation" is not easy to judge. The best, agreed estimate is 25,000 deaths per year from hospital acquired DVTs, but doctors in the field tell us that many more deaths may go unidentified - especially as post mortem examinations are no longer automatically held after a patient dies in hospital. Consultant Beverley Hunt, who we heard from earlier, is also medical director of the charity Lifeblood which campaigns for recognition of the DVT problem.

Hunt
We are talking about a potential number of deaths in this country of about 60,000, of which - and it's an astonishing figure - two thirds are due to hospital admissions. That's so much bigger than hospital acquired infection which at their peak caused 10,000 deaths. So we've got another two and a half times the number of deaths due to hospital acquired clots.

Waite
Because when people think of deep vein thrombosis they'll think of long haul plane flights won't they?

Hunt
They do but the risk of just going to hospital is a thousand times greater than getting a clot from a long haul flight.

BA Film
Your wellbeing is part of the greater service that you can expect to receive from British Airways...

Waite
In the 1990s passengers who developed deep vein thrombosis after a long haul flight began to sue airlines for failing to warn them of the risk. A House of Lords report in 2000 said airlines should do more and since then short films like this, advising passengers to exercise on board and to wear compression stockings, have become commonplace at the start of a long flight.

BA Film
The body control Pilates group have developed a series of exercises exclusively for us. These are easy stretches you can perform while seated which can help with posture, comfort and circulation and in particular help to reduce the risk of travellers' thrombosis.

Waite
Despite the tiny risk of long haul passengers developing deep vein thrombosis in comparison to that for immobile hospital patients and despite a compensation bill amounting to £110 million in the past six years all paid out of NHS funds, it was only in January 2010 that the English NHS introduced a guideline for all hospital inpatients, including non-surgical cases. Long awaited and campaigned for it required patients to have a risk assessment for DVT. Those found to be at risk should be given appropriate measures including blood-thinning drugs and compression stockings. And a mandatory target of risk assessing 90% of all adult inpatients was set and backed up with financial penalties for failure to comply. Consultant haematologist, Professor Beverley Hunt was delighted.

Hunt
It was a bit of a triumph really, I actually sat on the guidelines committee and it was - I've got emotion in my voice - it was a wonderful to have a national guideline out there, having worked so hard to get it there. So we really felt we'd made a major step forward.

Waite
But guidelines can be ignored and targets can be missed. And indeed that is what happened. Figures produced by the Department of Health show that many hospitals are failing to reach that target of risk assessing 90% of all adult inpatients. In the second quarter of 2010-11 only 11 out of 154 hospital trusts succeeded - just 7%, by the third quarter it was 16% and for latest quarter the compliance rate is up to 43%.

Hunt
It's incredibly frustrating. It's taken many years to get to this point and we were absolutely thrilled that the Department of Health in England - not in Northern Ireland or Wales or Scotland - went ahead with this method whereby if hospitals do not risk assess the patients they pay a financial penalty. It's great the system's in place but it still hasn't been taken up fully. So it seems amazing in this day and age where trusts are short of money that they aren't taking time and effort to deliver risk assessment.

Waite
Earlier you may recall I was speaking to Ian Bugden whose wife Pauline died of a deep vein thrombosis in 2006. After going to hospital with a broken arm and leg, doctors at Medway Maritime Hospital in Gillingham failed to identify her as a patient likely to suffer a DVT. Medway Maritime's medical director is DrGray Smith Laing.

Smith Laing
The trust has paid a sum of money to the Bugden family and has admitted liability and from that point of view the trust is no longer dealing with this patient or the family.

Waite
When this guideline was introduced last year your hospital here did badly, didn't it, in reaching the target?

Smith Laing
It did and there are a number of reasons for that.

Waite
Because the first audit for July you didn't return any data at all.

Smith Laing
In common with many places we have had problems collecting the data. It's actually a very time consuming business, we're talking about several thousand patients a month who need to be assessed and their notes have to be checked, we have to verify that they've had the assessment form done and received the prophylaxis, so this is not a small task.

Waite
Medway Maritime returned no figures at all to the Department of Health last August and for September just 14% of patients received a risk assessment. And even for the last quarter for which figures are available the hospital only reached two thirds. Remember the target is 90% which means the hospital will lose money for not meeting that target. This a hospital which has already had the chastening experience of having to pay out for the death of Pauline Bugden- caused by a hospital acquired deep vein thrombosis. But Dr Smith Laing says patients there have been receiving the treatment or "prophylaxis" to prevent DVT even if the paperwork isn't always complete.

You can't be proud of your record.

Smith Laing
No I'm not proud of our record. I think my job and the trust's role is to make sure that we are now making very large strides and we should be achieving the 90% very shortly.

Waite
You can see what I'm getting at here - that you've had a preventable death at this hospital, not good, that it's cost you a lot of money in compensation, not good, you have a guideline to stop that happening again introduced yet first of all you don't supply any data at all about what you're doing here and then, until recently, you do pretty woefully.

Smith Laing
The problem here is that you have to supply data on the assessment form plus the giving of the prophylaxis. We have been much better at giving prophylaxis than we have been at completing the paperwork and so there has been a mismatch there so the patients by and large have received the appropriate treatment but unless we complete the paperwork that is not recognised as doing the job properly. So in that sense we have fallen down.

Waite
And indeed the latest news from Medway Maritime is that they are now assessing 81% of patients. But elsewhere patients continue to die from a deep vein thrombosis caused by immobility in hospital and nothing to do with the original medical condition which led to them being admitted to hospital.

Dye
She died extremely suddenly. When the coroner told us what the cause of death was I must say there was something inside that just thought well really this can't be right.

Waite
Giselle Dye's mother Giska was admitted to Worthing Hospital in Sussex in January - more than a year after those long-awaited guidelines were introduced - yet she was not assessed for the DVT which killed her.

Dye
I obviously had heard about people developing DVTs on long plane journeys but probably, like a lot of people, I didn't know really that hospital acquired DVT was such a big killer.

Waite
Giska was admitted to hospital after a fall at her home. She seemed confused, and had suspected internal bleeding. She died in hospital 18 days later of deep vein thrombosis. The hospital failed to carry out a risk assessment for the condition.

Dye
To my mind it's such a simple procedure, it's such a short form, it should be such a simple thing for them to get right.

Waite
Should the Department of Health be doing more?

Dye
Well I think there's absolutely no room for complacency. They have to make sure, in my view, that hospitals across the UK are hitting these targets. What we're talking about here is fundamentally about saving people's lives, preventing people from dying unnecessarily.

Waite
Western Sussex Hospitals Trust, which runs Worthing Hospital, has apologised for not assessing Mrs Dye and for other shortcomings in the care provided. But, the trust says, it is important to remember that treatment is not always appropriate, in fact it can be extremely dangerous. The trust told us it's currently assessing 93% of patients for the risk of DVT and is aiming higher. Giselle Dye again.

Dye
If they had done the risk assessments there might have been some other steps that they could have taken - making sure my mum's legs were raised - and I think the worst and most painful thing of all was that the day before she died the carer took a photograph of my mum sitting in a chair with her legs on the ground and her legs from the knee down were dark purple. Well your legs don't go dark purple unless you've been sitting for a very long time not moving. And again the hospital apologised and said no her legs should have been elevated.

Waite
Throughout making this programme there's a sense of the National Health Service in England only now waking up to a problem that has been known about for over 60 years and readily treatable for over 30. Thousands of people die of a deep vein thrombosis which developed whilst they were in hospital. We were constantly told these are needless deaths. Their prevention would take up precious little time or money. And the deaths are costing the NHS tens of millions of pounds in compensation. They cost hospitals, which are strapped for cash, money for failing to meet that government target of a 90% risk assessment rate. And in Scotland, Wales and Northern Ireland there isn't even a mandatory target. Jo Webber is deputy policy director at the NHS Confederation which represents all 160 English hospital trusts, how does she explain that less than half of her members comply with this life-saving policy.

Webber
The numbers that are assessing patients are going up and the numbers of patients assessed are going up within those hospitals, so it is an improving picture but we've still got some way to go.

Waite
Indeed and it has taken 18 months and thousands of people have died.

Webber
I - I think that the issue now is how we take this forward. Yes I would absolutely agree that...

Waite
Well how you take it forward is getting every hospital to realise that - not to be overdramatic - this is literally a matter of life and death. How is it then that so - that so many hospitals aren't anywhere near their target?

Webber
I think this is a matter of making sure that everybody and every place in every hospital is seeing this as their responsibility and it is everybody's responsibility. The hospitals really do need to step their game up.

Waite
Well you sound, I have to say, pretty frustrated about this, is there more that the NHS Confederation could or indeed should be doing?

Webber
Well we've been talking about this for the past two years.

Waite
To talk about it for two years has seen, surely, more people die who didn't need to?

Webber
No we put a briefing out about two years ago again making the point about how vital the early assessment of this was. It's making sure that every frontline clinician is seeing this as the first thing they do when somebody comes through the door.

Waite
But we have heard on the programme from relatives of people who've died after not being risk assessed and of course one can't be absolutely sure the outcome would have been any different had the guidelines been followed but you can understand, surely, how distressing it is for relatives to know that their loved ones fell through the net?

Webber
I can absolutely understand that. I would pick up your point though - you can't always be sure that somebody dying of a DVT was as a result of not being assessed. We will never get rid of this risk completely, we just need to make sure that it's at an absolute minimum level.

Waite
Hospitals may say they're on the case as far as deep vein thrombosis is concerned but if the tone of our final interview today is anything to go by they'll be receiving some pretty harsh encouragement to do better. Sir Bruce Keogh is medical director of the NHS in charge of clinical leadership and he introduced the 90% target. How does he regard a compliance rate of 43%, indeed one hospital providing a risk assessment for barely one in 10 of its patients?

Keogh
Those figures you've quoted to me I regard as absolutely disgraceful and I think the trust boards, who are responsible for those organisations, need to take a very serious look at those figures and get a grip of it because I don't think in the sort of NHS that I want to work in and be treated in I don't think that level of practice is acceptable at any level.

Waite
Because I think we are talking here - and you use the word "disgraceful" - some would say it's a scandal, they should be ashamed.

Keogh
I think those that reach the very low levels I think you're right, of course this is fairly early on in this initiative, we're only 18 months in from having started it and we're now well ahead of most other countries in the Western world, so I'm pleased with it from that perspective. What I think we need to be firm about is those that are failing to improve and that's the area that I'll be taking a particular interest in.

Waite
And when you talk about the performance of some hospitals still being, in your words, "disgraceful", what are you going to do about that?

Keogh
Well I have a network of regional medical directors and we will be turning our attention to those hospitals. Tackling this problem is actually a professional, moral and social responsibility for the professionals.

Waite
Is there a stick you can use here, since the carrot doesn't seem to have worked?

Keogh
I think the immediate and obvious stick is to simply expose the figures of and identify those hospitals that aren't performing. I'm a great believer that quality is driven by public awareness and programmes such as this.

Waite
So will you be naming and shaming the hospitals that are...?

Keogh
Yes once we're satisfied that we've got good data we'll be - this is part of a much bigger drive on transparency of performance that I'm keen on at the moment.

Waite
So it sounds like you are determined that everybody is going to come up to the assessment levels you've laid down?

Keogh
This is the number one clinical priority for me, as NHS medical director, and for my colleagues on the NHS management board, we are absolutely clear that we're going to pursue this with vigour. You know 25,000 people a year dying from something that is preventable is the same sort of number of people that die from stroke and other major conditions which are far less preventable. This is something where we can make a very, very significant gain, if you like, in terms of the quality of care in the NHS.