‘Vivacious’ grandmother who was at risk of malnourishment died after NHS staff ‘forgot’ to insert feeding tube
Hospital staff have been accused of starving a grandmother to death after failing to feed her for four days.
Hildegard Mikalansky, 67, was admitted after a fall and designated as ‘nil by mouth’ by medics due to a risk of choking. However, it took four days before she was given a feeding tube to supply her with much-needed nutrients. By then, the mother of two’s condition had worsened and she died the following day.
Her son Mike Stringer, a company director, said: ‘I saw a vulnerable but vivacious and warm lady deteriorate rapidly and die in that hospital.’
At her inquest, the coroner criticised Stoke Mandeville Hospital in Buckinghamshire for the delay and for allowing her care to ‘drift’ after a bank holiday weekend.
Mr Stringer said: ‘Although my mother had some underlying problems such as multiple sclerosis, she was essentially starved to death. She just slipped through the cracks. Everyone kept saying she needed food and that she was malnourished but nothing was done.’
Mrs Mikalansky, who was divorced from her husband John, was admitted to hospital late on May 29 last year, a bank holiday weekend. Mr Stringer and his sister Kim, a philosophy academic, had gone to visit their mother and found her in a crumpled heap at the bottom of the stairs.
Doctors had initially focused on a head injury and fractured ribs, but Mr Stringer, 41, said he raised concerns about his mother’s nutrition from the outset.
‘She was naturally slim, and prior to her admission had not really been eating enough due to tiredness from her MS. We constantly prompted staff with regard to feeding and eating because mum was thin and ate little. We were concerned it may well get ignored as catering staff tend to just leave food and collect it later. ‘We could see the situation was getting more serious each day.’
The inquest heard Mrs Mikalansky ate some supper on May 30, the day after her admission, but was then sick several times. The following morning she had some breakfast, but was designated ‘nil by mouth’ due to a risk of choking on her food at some point on Tuesday, June 1.
By Thursday she had developed ketoacidosis – a serious condition caused through malnutrition when acid levels in the blood become dangerously high. When eventually a feeding tube was fitted on the Friday evening, it took a further 16 hours for it to be activated because an X-ray to check the position of the tube had not been done.
Mr Stringer said: ‘When I arrived on the Saturday morning and asked why it hadn’t been done, we were told the X-ray department was busy and didn’t deem her urgent. She was dead in 24 hours.’
Doctors at the inquest described Mrs Mikalansky, of Hazlemere, Buckinghamshire, as ‘gaunt’ and suggested she had a history of alcoholism and malnutrition – all of which Mr Stringer disputes.
Coroner Richard Hulett recorded a narrative verdict and raised concerns that it took four days for Mrs Mikalansky to receive food direct to her stomach through the tube.
Buckinghamshire Healthcare NHS Trust said in a statement: ‘Mrs Mikalansky was admitted to hospital with a head injury and chronic malnourishment. Staff were concerned about her very low weight and specialist feeding assessments were arranged. ‘However, Mrs Mikalansky quickly developed serious complications and sadly, despite treatment, she later died.’
Language test for all foreign doctors: Law will bar medics who can’t speak English
Foreign doctors will be barred from treating patients unless they have a good grasp of English under tough rules to be announced by Andrew Lansley today.
The Health Secretary will pledge to end the scandal which has seen 23,000 doctors from Europe registered to work in the NHS – despite never having been asked if they can speak the language properly.
A new law will give trusts the statutory duty to check the English language skills of all new overseas doctors before they are employed by the Health Service.
Failure to pass the language test will see them prevented from taking a job in an NHS hospital or a GP surgery – ensuring patients are treated by doctors they can understand, and who can understand them.
Last year, a report by the Commons Health Select Committee concluded that the failure to ensure GPs on out-of-hours shifts can speak English had cost lives.
Three years ago, pensioner David Gray died after being treated by out-of-hours locum Dr Daniel Ubani, who was exhausted after having flown in from Germany. He was allowed to treat patients despite having a poor grasp of English.
Doctors’ language skills are not yet routinely tested because Britain sticks rigidly to an EU directive which outlaws checks on overseas GPs’ language skills – while France flouts it. The ban is even enshrined in British law: The 1983 Medical Act, brought in by Margaret Thatcher. Mr Lansley will repeal the parts of the Act which stop trusts from testing foreign doctors’ English.
Under the new scheme, all trusts will have to appoint a ‘responsible officer’ whose job will be to test the language skills of all foreign doctors applying to work there. He or she must also ensure the applicant is trained to UK standards and understands how the NHS works.
Ministers are confident the new rules will be drawn up in such a way that Britain will be able to circumvent the EU directive – and protect the safety of patients.
Mr Lansley said: ‘There is considerable anxiety amongst the public about the ability of doctors to speak English properly. ‘After 13 years of inaction from Labour to tighten up language controls, we will amend the legislation to prevent all foreign doctors with a poor grasp of English from working in England. If you can’t speak adequate English, you can’t treat patients.’
Currently only doctors from outside Europe are routinely scrutinised for their language skills before being able to register with the General Medical Council, the doctors’ watchdog.
But European law prevents the GMC from vetting the language skills of doctors from within Europe, because it conflicts with the European ideal of the free movement of people. It has led to the farcical position where doctors from English-speaking countries such as Australia and Canada face tougher language tests than those from Italy and Lithuania.
Ministers plan to sidestep the directive by putting the onus on trusts – and not the GMC – to check language skills. The ‘responsible officers’ will also have to ensure that the doctor has the right qualifications to work in the NHS – and that appropriate references are obtained and checked.
There will also be a new power for trusts to refer a doctor to the GMC if they have concerns that their poor language skills could put patients at risk. Mr Lansley plans to legislate to give the GMC explicit new powers to take action against doctors when there are concerns about their ability to speak English.
In his speech, the Health Secretary will say: ‘We will amend the Medical Act to ensure that any doctor from overseas who can’t use a decent level of English is not able to treat NHS patients. ‘This is not about discriminating: We’ve always appreciated how much overseas doctors and nurses give to our NHS. ‘It is simply about our absolute commitment to put patients’ safety first.’
Currently 23,033 doctors from Europe – almost 10 per cent of the total – are registered to work in the NHS.
France has managed to get round the rules by not testing doctors’ language per se, but inviting applicants to interview. Those deemed not to have the requisite language skills will not get a job.
The Department of Health said it was in talks with the Nursing and Midwifery Council to consider testing the language skills of foreign nurses as well.
Is an obsession with natural birth putting mothers and babies in danger?
There is no doubt that for most women in this country, childbirth remains a safe and happy experience. But it is also true that for too many, it is a highly risky and frankly horrific experience.
Stories abound of mothers-to-be left alone in labour, sometimes refused pain relief or surgical intervention, putting their babies’ health or even lives in danger.
The statistics make grisly reading: an average of 11 babies are stillborn every day in NHS hospitals, according to research published recently in The Lancet.
Unlike other high-income countries, it’s a figure that has remained largely unchanged over the past ten years — putting Britain on a par with Belarus and Estonia.
More than £27 million in compensation was paid in 2008 by London hospitals alone for childbirth cases. Indeed, a shocking 60 per cent of all payments made by the NHS Litigation Authority relate to obstetrics.
In June this year, an unprecedented police investigation was launched into the deaths of five babies and two mothers at Furness General Hospital in Cumbria. And last weekend it was revealed another baby’s death at the hospital is also to be looked into. So what is going on?
Midwives point to an understaffed, overstretched system dealing with both a rising birth rate and a growing number of more complicated deliveries as a result of obesity, older mothers and multiple births.
The Royal College of Midwives warned last week that existing ‘massive midwife shortages’ will soon worsen as maternity hospitals face ‘falling budgets and pressure to cut staff further, despite a rapidly rising birth rate’.
Yet experts are far from convinced that falling budgets and staff shortages are the only reason for the obstetric scandals that have mired the reputation of UK maternity healthcare. Take the tragic case of 26-year-old health care assistant Liza Brady, whose son Alex was delivered in September 2008 stillborn at Furness General with the umbilical cord wrapped tightly around his neck.
At 11lb 13oz, Alex was exceptionally large, yet midwives refused her request for a Caesarean — despite this having been suggested by a consultant obstetrician whom she saw during her pregnancy. During a long and painful labour, the midwives persistently refused her plea to be seen by a doctor and delayed the delivery even though the machine monitoring the baby’s heart showed he was in distress. ‘A doctor offered to help as he came on duty, but he was shooed away by the midwives who said he wasn’t needed,’ recalls Liza.
Prabas Misra, an obstetrician and gynaecologist at the hospital, was so appalled by Liza’s care that he expressed ‘grave concerns’ about her case in a letter to hospital colleagues. He condemned as ‘indefensible’ the midwives’ claim that the foetal heart rate had been normal, since they’d admitted being unable to pick up the heart rate because of positioning of the monitor.
Summing up, Mr Misra wrote of ‘the risk of trying to make every labour and delivery normal and natural, and not thinking laterally (about) possible complications. I am all for having a natural childbirth — but not at any cost’.
Although talking about a specific case, Mr Misra has put his finger on an issue at the root of the problems in obstetrics today: the dangerous myth, promulgated by some midwives, that natural childbirth is not only the kindest form of delivery but also invariably the safest.
For years, the prevailing view among some leading figures in midwifery was that obstetricians were little better than trouble-makers. They were seen as over medicalising the natural process of childbirth, slowing down labour with their foetal heart rate monitors, and so increasing the risk of complications. It became something of a turf war.
‘These people need a job to do — and, too often, it’s taking over from the midwives and reducing their autonomy,’ said Professor Caroline Flint, a former president of the Royal College of Midwives as she opened a new midwife-led unit in 1997.
Yet while public attitudes might have changed — as seen in the rise in the numbers of women asking for Caesareans — this view that natural delivery is the only way is still influential in the midwifery world.
The NHS Institute for Innovation & Improvement’s guidance for midwives, for instance, instructs them to ‘focus on normal birth and reduce the Caesarean rate’. Doctors, it says, should ‘only enter the room of a labouring woman when asked to review (the patient) by a midwife’.
And despite objections from obstetricians, the RCM’s high-profile Campaign For Normal Birth has the slogan: ‘Intervention and Caesarean shouldn’t be the first choice — they should be the last.’
James Drife, a retired obstetrician and Professor of Obstetrics and Gynaecology at Leeds University, comments: ‘It’s difficult to see exactly who the RCM is campaigning against. Every woman would like a normal birth, but the real fear is of a bad outcome.
‘To prevent that happening, we need co-operation between all the professionals in the obstetric team, rather than campaigns about which treatment is best. Without such co-operation, there is a far greater risk of mistakes being made.’
Gill Edwards, a leading clinical negligence solicitor with the firm Pannone, is in no doubt why these fatal mistakes continue. ‘Too often, we see a desire for autonomy, sometimes verging on arrogance, on the part of some midwives,’ she says. ‘It leads them to ignore National Midwifery Council rules that require them to call on the skills of other health professionals whenever something happens which is outside their sphere of practice.’
Of course, the vast majority of midwives do a superb job and their professionalism is not comprised by rivalry with doctors or dogmatic views about natural birth. However, for a minority this is not always the case.
‘Some of our worst cases occur because the drive to achieve a “normal” delivery clouds the judgment of midwives about when to call in specialist help from an obstetrician, or for a paediatrician to be present at the birth to assist with resuscitation when there are signs of foetal distress during labour,’ says Ms Edwards.
Last month, NHS watchdog the Care Quality Commission highlighted the lack of ‘a joined-up approach to working together’ as a major risk factor at Furness General Hospital. The coroner who looked at Alex Brady’s death put it more simply: ‘I don’t believe the doctors integrated. The midwives ran the show.’
The criminal investigation into the hospital was launched after a coroner’s report on the death of ten-day-old Joshua Titcombe in July 2008 as a result of a serious lung infection.
The inquest had heard that his parents, Hoa and James, had urged midwives to treat their son for an infection for which Hoa had been given antibiotics — but were told there was no need for the baby to see a doctor.
The coroner’s report was damning, finding ‘no integration between the midwifery and paediatric teams’, alongside ‘a failure to record fully or at all many of the factors which, taken together, might have led to a greater degree of suspicion or a referral to a paediatrician’.
It wasn’t the first such case. In July 2008, Nittaya Henrickson and her newborn son, Chester, both died at the hospital after she suffered an amniotic fluid embolism, where fluid from the amniotic sac escapes into the mother’s bloodstream. It’s a leading cause of maternal death, but the baby normally survives provided it is delivered promptly by Caesarean.
At an inquest in July 2009, Chester’s father, Carl, described how he pleaded with the midwives to get a doctor after he felt his wife die in his arms — but was told she had only fainted and that no doctors were needed to deliver the baby.
But while the scale of the problems at Furness are unprecedented, the evidence suggests the nature of the problems is far from unique. Last month, Laura Newman, 21, told how her baby died, aged nine days, after being starved of oxygen during the birth at Sandwell Hospital in the West Midlands last December.
‘Not only was the midwife extremely rude and dismissive to Laura and her family, but when it was clear that something was wrong and the baby needed to be urgently delivered, the midwife ignored the warning signs,’ says Jenna Harris, of Irwin Mitchell solicitors, who is representing Laura.
Laura herself has urged ‘every expectant woman to make sure the midwife makes regular checks during labour. It doesn’t make any difference whether you had a healthy pregnancy or not; things can go wrong at the last minute.’
The failure by some midwives not to monitor the baby correctly is another major factor in baby injury and death. Some midwives are resistant to monitoring in the belief it is another step to over-medicalising birth.
Electronic foetal monitoring is designed to provide healthcare professionals with continuous information on the foetal heartbeat and uterine contractions. It is seen as a major defence against stillbirth or neurological damage.
Yet mistakes made in the use of the technology are a major contributing factor to babies being damaged during birth (leading to cerebral palsy and other problems) or dying, says Edwin Chandraharan, senior consultant obstetrician at St George’s Healthcare NHS Trust, London.
Mr Chandraharan recently pointed out: ‘A 1997 report highlighted that substandard care, especially with regard to CTG (cardiotocography or fetal monitoring) contributed to over 50 per cent of deaths during labour and birth. Unfortunately, more than decade later, (there is) a continuing problem of CTG misinterpretation.’
Last year, the Birth Trauma Association made a Freedom of Information request about obstetric cases going through the courts, and found that of 1,040 cases a large proportion related to failure to monitor the baby properly during labour.
‘While there are excellent maternity services, there are also some that are fragmented, dysfunctional and occasionally unsafe,’ says the association’s Maureen Treadwell. ‘For instance, despite evidence to the contrary, some midwives still believe using electronic monitoring on women considered to be at risk during childbirth is unhelpful because it makes medical intervention more likely. Simply having more midwives won’t change that.’
So what will? A start could be universal acknowledgement that no matter how much a woman longs for a normal delivery, ‘things can go wrong at the last minute’ — as Laura Newman put it.
And that recognition needs to start with antenatal information provided by midwives, which, according to Mrs Treadwell, is too often too rosy. ‘Women have the right to honest, objective information of what can go wrong, and what their choices are, and midwives have an ethical duty to provide that information,’ she says.
Such assessments have to be evidence-based. ‘Some midwives still suggest it’s equally safe to have a normal delivery with a breech baby, even though the evidence Caesareans are safest for breech births is overwhelming.’
Curb on immigrants’ rights to settle in Britain as rule that allows them to stay after working for five years set for axe
Tens of thousands of immigrants will be stripped of the right to settle in the UK permanently under Home Office proposals. Ministers are to crack down on a regime which allowed a record 241,000 foreigners to settle here last year – up from 51,000 when Labour came to power.
They plan to abolish a rule that gives those from abroad the right to live in Britain permanently if they work here for five years. The Government will also look at restricting the right of immigrants’ spouses to a British passport if they stay here long enough.
Ministers say it is vital if they are to hit David Cameron’s target of reducing net migration – the number of people entering the country, versus those leaving – to the ‘tens of thousands’.
Breaking the link between permanent settlement and the right to work in the UK temporarily has long been demanded by groups campaigning for a policy of ‘balanced migration’.
Under the plans, to be published before the end of this year, foreigners will still be able to gain a visa to work in Britain, but they will no longer be able to remain here permanently simply by virtue of staying in the country legally for five years.
A Whitehall source said: ‘We want to break the link between working and settling in Britain. It has become almost automatic for people who keep their noses clean and don’t get a criminal record.
‘The Government is not against people coming here to work, but that shouldn’t automatically mean they get to stay in Britain forever.’
Under the policy, a new ‘hurdle’ will be introduced for immigrants who wish to remain here permanently, based on their ability to support themselves and their families, their qualifications and whether they are working in professions where there are shortages of trained Britons.
Those on high incomes, businessmen and millionaire investors would be exempt because the Government believes they create jobs. EU nationals who have a right to live in the UK would not be affected.
The Home Office knows it needs to do more to cut immigration levels if the Prime Minister is to have any hope of meeting his election promises.
Crackdowns have already been announced on student visas and on the number of work permits given to non-EU nationals. But without reducing the number of people who can remain here permanently, the ‘tens of thousands’ target is highly unlikely to be hit. Last year net migration rose by 21 per cent – with 239,000 more people arriving in the UK than leaving.
British children should be able to leave school at 14 so they can learn a trade, says ex-Ofsted head
The school leaving age should be cut to 14 so that less academic teenagers can learn a trade, according to the former head of Ofsted. Sir Chris Woodhead said he believes that once a child has got the grasp of basic literacy and numeracy they should be given the chance to look at alternative career paths.
He added that it was a ‘recipe for disaster’ to make young people study English and maths up to the age of 18, and said it was a mistake to make vocational education ‘quasi-academic’.
‘If a child at 14 has mastered basic literacy and numeracy, I would be very happy for that child to leave school and to go into a combination of apprenticeship and further education training and a practical, hands-on, craft-based training that takes them through into a job,’ he told the Times.
Speaking about the riots across England he said: ‘Does anybody seriously think these kids who are truanting at 13, 14 are going to stay in school in a purposeful, meaningful way through to 18? ‘It just seems to me the triumph of ideological hope over reality.’
He backed Government plans to use synthetic phonics to boost reading in primary schools, saying 95 per cent of children should reach the literacy target at 11.
But Sir Chris, who is now chairman of not-for-profit schools company Cognita, criticised David Cameron’s call for independent schools to sponsor academies, calling it ‘morally wrong’. ‘The more that the science facilities or the playing fields are used by non fee-paying children, the less they are available for the parents of children who do pay the fees,’ he said.
Sir Chris was chief inspector of Ofsted from 1994 to 2000.
The need to engage youngsters with work that inspires them at an earlier age appears to be underlined by the experiences some bosses have of school leavers.
Last month, garden centre owner Richard Haddock, 54, said he despaired of the school leavers that he was sent. As a result he is now concentrating on recruiting older people and workers from abroad. He said: ‘I have had youngsters sent here from the Jobcentre and most aren’t interested in working at all. They just want their form signed to show they came for the interview.
‘When we have employed school leavers they have generally been unsuited for the world of work. They turn up late, half asleep or with hangovers and spend half their time checking their mobile phones.
‘They know they should not wear nail varnish because they are handling food but they turn up wearing it anyway. If you try to discipline them or help them, they throw it back in your face.’
British School bans children from putting up their hands in class – and tells pupils to do a ‘Fonz’ thumbs up instead
Schoolchildren have been banned from putting their hands up in class – and told to do a ‘Fonz’ thumbs up instead.
Parents blasted the rule as ‘daft’ and said the pupils at Burlington Junior School in East Yorkshire would look as though they were imitating Happy Days character The Fonz.
Helpful posters at the school show a raised arm with a thick red cross next to it and a picture of a child doing a thumbs up.
Father-of-three Dave Campleman, 44, who has two children at the Bridlington school, said: ‘I thought it was a joke at first. It’s daft. I can’t see the logic in it. ‘Fair enough if it was across the board, but I’ve not heard of any other schools doing it.’
The driving instructor added: ‘I think it’s a bit pointless, it’s not benefiting their education – they could focus on other things. ‘Kids are used to putting their hands up, it is natural for them. Being told to do something different just confuses them. ‘I am just bemused by it. I think they should go back to the old way of putting your hand up in class.’
Headteacher Cheryle Adams insisted that the more positive hand signal had a ‘calming’ effect on the eight- and nine-year-old children.
But another parent, who has a son in the class but did not want to be named, said: ‘It is going to make the class look like they are all imitating the Fonz from Happy Days. ‘On a serious note, when these kids go up to secondary school next year they could be a laughing stock because all the other children will be putting up their hands.
‘I think there should have been more consultation from the school with the parents over this and perhaps a trial first before an outright ban. ‘I can’t really see it making the classroom more relaxed – they are young, excitable kids and putting up your thumb instead of your arm isn’t going to change that.’
The school has previously tried out other ‘progressive’ teaching methods, including a lucky-dip lollipop-stick system to choose pupils to answer questions. It now plans to roll out the changes into its infant school – for children aged four and five.
Ms Adams said that the non-traditional teaching approach has worked since it was introduced at the start of this term at the 360-pupil school. She said: ‘It seems to be something all the children have accepted. It is to stop the pupils waving arms about, which can be distracting. It has calmed the pupils down.
‘Staff have noticed a positive difference in the amount of people answering questions.
‘I don’t think this approach to answering questions is a big deal. There is also no issue of children at the back of the classroom being missed or ignored.’
She added: ‘At a training day we discussed all sorts of ideas as we have found some children put their hands up, while others won’t, even if they know the answers.
‘We have looked at different options. This included a lollipop stick method in which children write their names on the sticks. We pick one out and the pupil whose stick is chosen answers the question. ‘With this technique we found everybody would listen in case their name was called out.
‘All these ideas help make the classroom environment calmer as well as encouraging the quieter pupils to share their ideas.’