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Libby, left, and her sister Lottie |
Parents: our shock at hospital failings
Inquiry urges staff retraining after girl with cystic fibrosis was wrongly given all-clear – twice
AN investigation – launched after tests to detect life-threatening illness in children wrongly gave a three-year-old girl the all-clear – has exposed serious failings at the Royal Free Hospital.
The investigation report follows a “critical incident” at the Hampstead hospital after two separate tests for cystic fibrosis (CF) on Libby Pitman found her in good health.
In fact, Libby, now four years old, did have the condition and was diagnosed with CF nine months later after the same test was performed at Great Ormond Street Hospital (GOSH) in March this year.
Her parents, Katie Fletcher and Peter Pitman, who live in Fairhazel Gardens, West Hampstead, believe Libby’s health deteriorated as a result of the nine-month delay in diagnosis.
They are also coming to terms with the fact that their daughter is unlikely to live into her 40s – having been twice told there was nothing wrong with her. Ms Fletcher said they were “shocked” by the series of failings highlighted by a panel of hospital directors, managers and a leading biochemist from GOSH in the strongly-worded, 21-page report.
The findings, sent to the family and seen by the New Journal on Friday, revealed:
• There was no record of Libby’s tests in the hospital.
• There was a “lack of training and competency assessment” and there were “weaknesses in the way testing had been performed”.
• There was no evidence of maintenance of the trust’s “dated” equipment and a need to replace “missing parts”.
Cystic fibrosis – which affects the digestive system and lungs by clogging them with thick, sticky mucus – is the most common life-threatening, inherited disease in this country. It is diagnosed by the analysis of salt levels in children’s sweat. Sweat testing has been suspended at the hospital and 63 children recalled for new tests – none was found to have CF.
But while Libby’s was an isolated incident, the report found widespread problems in the department. Sweat collection techniques by nurses were “inappropriate” and “could have increased the likelihood of false negative results”. They should be “abandoned”, the report concluded.
Staff “had not received sufficient training in sample collection” and biochemists in the hospital’s laboratory “had no involvement in the way samples were collected”.
There was also “no evidence” the fridge used to store diagnostic samples was kept at the necessary 8 degrees temperature.
The review recommended an immediate review of “quality controls for other diagnostic tests undertaken elsewhere in the trust”. It added that all staff in the paediatrics department should be retrained for “competency”.
Ms Fletcher said: “Pete and I are shocked by the report. It worries me because these are basic things – they should already have been in place. There is a lack of competence and these things may be affecting other areas of the hospital.
“Libby now has physio, vitamins, antibiotics and four nebulisers. Seeing how she has blossomed since treatment has made us wish that it could have happened sooner.”
The review admitted that early diagnosis “was known to improve clinical outcomes”, adding that, “had the patient’s initial results been positive, the panel felt it is likely that she may have started treatment/physiotherapy sooner”.
A hospital spokeswoman said: “The trust will be implementing all the recommendations of the report into the quality and effectiveness of sweat tests at the Royal Free.
“We are putting into place procedures to ensure that staff carrying out the tests are fully trained and meet a range of competencies, and we have identified a key member of staff to lead on sweat testing in the future.
“The trust took immediate action to suspend sweat tests at the end of March and tests will not be resumed until all the report’s recommendations are implemented.” |
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