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Leaked report into patient death exposes failings of private provider

By Lilian Anekwe

Exclusive: A Department of Health initiative to transfer care from hospital to privately run services in the community exposed patients to ‘significant clinical, managerial and administrative failings', a confidential report leaked to Pulse reveals.

An internal NHS investigation concludes a catalogue of blunders and system failures contributed to the death of an elderly patient, whose condition was allowed to deteriorate without her GP being alerted.

The 76-year-old woman, known as Patient X, died unexpectedly within 24 hours of being transferred against her family's wishes from hospital to the care of the company, according to the March 2010 report.

The investigation by NHS London in co-operation with Clinicenta, one of a number of companies signed up across the UK by the DH on fixed-term contracts to provide out-of-hospital care, lifts the lid on a series of safety incidents.

Its findings will prompt major questions over the previous government's decision to sign long-term deals with private firms to accelerate the shift of care from hospital.

They emerge the week after new health secretary Andrew Lansley halted all new NHS plans to move care into the community, pledging GPs and patients would be consulted first.

Clinicenta's contract was suspended in November, and Pulse revealed earlier this month that NHS London planned to set the company tough safety targets.

But a senior NHS source told Pulse managers were so concerned about the costs of cancelling the contract – estimated at about £10m – they intended to reinstate the company.

The leaked report lists 24 separate failings, including the fact a nurse registered as on duty was getting a car serviced on the morning of the patient's death, the lack of any urgent assessment despite the patient being classified as ‘higher risk' and a failure to alert the patient's GP about her deterioration. Staff were insufficiently experienced – ‘a key contribution to the service failing'.

The family of Patient X ‘would have preferred their mother to continue to be cared for in hospital'. She died within 24 hours of discharge from Barnet Hospital into Clinicenta's care.

The report also exposes problems at other Clinicenta sites. Among eight other incidents were confidentiality breaches, failure to deliver insulin at correct times and a two-day delay for a visit.

NHS London and PCTs had expressed concerns about the company. The report warns learning processes ‘critical in maximising patient safety' had failed and recommends ‘a review of referral processes by Clinicenta and PCTs'.

Pulse's source said a Care Quality Commission inspection – revealing staff often did not provide evidence of healthcare qualifications, criminal record checks or immigration status – had ‘barely scratched the surface': ‘The CQC was not thorough enough. It only looked at five or six reports but there are more than 100.

‘NHS London cannot terminate the contract unless a threshold of default is reached. Clinicenta has been issued a rectification plan with 15 [compulsory] topics. So far it has completed zero.'

Clinicenta said it would not comment. An NHS London spokesperson said: ‘A plan to rectify areas of concern identified has been finalised and we are in discussion with Clinicenta on these.'

The spokesperson said patient safety ‘will remain the key consideration' in any decision on reinstating services, but did not deny cost could be a factor.

NHS London said that even now only 53% of Clinicenta staff met compliance regulations, and services would not be reinstated until all staff were vetted.

Dr Michelle Drage, joint chief executive of Londonwide LMCs, said ‘the chickens were coming home to roost' on NHS private-provider contracts: ‘Clinicenta is but one example of what we see happening. It's clear the main driver of the tendering process was not quality.'

GPC negotiator Dr Chaand Nagpaul said the Government should heed the report, which he called ‘a warning of the dangers of allowing private firms into primary care without adequate clinical governance'.

Investigation into Patient X's death highlighted 24 separate failings in the standard of out-of-hospital care Patient X – what went wrong

• A ‘lack of nursing assessment', with three separate opportunities for an initial assessment missed – including one when the duty nurse was servicing a car
• Failure to act on referral information classifying Patient X as a ‘higher-risk discharge'
• ‘Limited appreciation of the deterioration of the patient's condition' and ‘no attempt to contact the patient's GP'
• Incomplete patient records that ‘do not meet Nursing and Midwifery Council [standards]'
• ‘Insufficient and inappropriate experience in staff responsible for a complex out-of-hospital service'

Source: NHS London and Clinicenta: Clinicenta out-of-hospital services

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