Analysis

Overlong waiting times are ‘inhuman and degrading’

A landmark inquiry into emergency health care in Northern Ireland (NI) has found individual human rights violations that amount to inhuman and degrading treatment

A landmark inquiry into emergency health care in Northern Ireland (NI) has found individual human rights violations that amount to inhuman and degrading treatment

The inquiry team identified cases in emergency departments (EDs) where patients were made to wait unnecessarily long for pain relief, food or fluids, or were left unsupported and unable to use toilets.

Increase

The findings were published at the same time as the latest government figures on waiting times for NI’s major acute hospitals. These reveal that the number of patients waiting more than 12 hours for treatment increased by one third, from 408 to 611, between March 2014 and March 2015. This represents a decline in performance from 70.5% to 69.7%.

The inquiry, the first of its kind, was conducted by the NI Human Rights Commission (NIHRC) last year amid concerns that EDs were struggling to cope with demand following several incidents at hospitals across NI.

The NIHRC team found instances in which staff did not respect patients’ dignity or privacy, and showed a lack of kindness. However, the team found no evidence of a ‘systemic violations of human rights’.

Lasting impression

A report of the inquiry’s findings published last month states: ‘No evidence emerged to suggest that human rights violations were systemic in emergency departments. Where they did occur, however, they left a deep and lasting impression on the individuals and families affected.’

The NIHRC team heard from patients, relatives, staff, trade unions and members of the public, all of whom gave evidence in public sessions across NI.

It found that some groups of patients, including older people, blind people and those with mental health issues, were more vulnerable than others.

Dignity

The team also raised concerns over patient dignity, including a lack of privacy for people experiencing mental health crises, such as those involving self-harm and attempted suicide.

The report makes 26 recommendations for trusts, the Department of Health, Social Services and Public Safety (DHSSPS), and the Health and Social Care Board.

It recommends, for example, that the DHSSPS develops dedicated ED minimum care standards that are rooted in human rights and that can provide benchmarks for patient experience. These standards should include criteria on the promotion of dignity, measures covering staff behaviour and attitude, and adequate facilities. The report also recommends a review of the four-hour ED waiting time target and the development of other quality measures of care.

Good practices

NIHRC chief commissioner Les Allamby, who led the inquiry, says that cases involving older and vulnerable people, such as those with mental health problems, dementia or disabilities, are the biggest causes of concern. However, he also says that the inquiry team heard of good practices and experiences, and that the rights of patients were often improved significantly by the introduction of ‘relatively simple measures’ (above right).

Chief commissioner at the Northern Ireland Human Rights Commission Les Allamby says: ‘The commission considered quality, accountability and governance of the service. We visited emergency departments throughout Northern Ireland during the day and night, and we heard from dedicated staff striving to maintain patient dignity in what can be a challenging and crowded environment.

‘There were reportedly instances where patients did not receive assistance with personal care needs, no pain relief, and no access to food and fluids.

Concerns

‘Of particular concern were cases involving end of life care, the inappropriate transfer of older patients from nursing homes and the experiences of those presenting in mental health crisis, or with dementia or disabilities.

‘The commission heard individual cases that amount to inhuman and degrading treatment but did not discover evidence of systemic violations of human rights.

‘The inquiry also heard of good practices and experiences. Often the introduction of relatively simple measures significantly improved the human rights of patients.

‘The report’s aim is to be constructive and show that a human rights-based approach can improve emergency care department services for patients and staff.’

Saddened

Chair of RCN Northern Ireland’s Emergency Care Association Roisin Devlin says that she is saddened by the need for an inquiry into emergency care but that she expected its findings.

‘Nurses working in EDs are frustrated because the report reiterates what they have been saying for a long time: that patients are not always getting the care or being treated with the dignity they deserve,’ Ms Devlin says.

‘It is reassuring that human rights violations are not systemic, but there is no excuse for poor communication and undignified care.’

Action needed

Ms Devlin believes that action is needed to improve the healthcare system and alleviate pressure on staff.

‘We should look at the usefulness of the four-hour target and focus more on nurse key performance indicators to ensure patients receive good care,’ she says. ‘The health board and trusts need to address the way the healthcare system works, and to improve the link between the front door of the hospital and the back door as people are discharged into the community.’

The DHSSPS says it is not complacent about the issues raised in the report but point out that the NIHRC is not the statutory authority responsible for inspecting health and social care services in Northern Ireland. This responsibility lies with the Regulation and Quality Improvement Authority (RQIA).

Significant improvements

A DHSSPS spokesperson says the RQIA highlighted similar issues in an inspection of Belfast Health and Social Care Trust in 2014, but that a follow-up inspection late last year found significant improvements had been made. According to the spokesperson, the DHSSPS will begin consulting on ‘a values and principles statement for emergency care in NI’ soon.

Ms Devlin says she fears that, because the NIHRC has no political clout, its recommendations will be ignored. She says: ‘How many of these reports do we need before action is taken and something changes?’

Recommendations
  • Staff strive to maintain patient dignity in challenging and crowded environments.
  • While interactions with staff were often reported to have been positive, person-centred care was sometimes undermined by health professionals’ perceived lack of attention or kindness.
  • Unnecessarily prolonged waits for pain relief, food, fluids and use of toilets. Treatment and care failed to respect dignity or privacy.
  • Good end of life care for patients and their families is not always prioritised.
  • Concerns about the care of older people, particularly those with dementia, who were being transferred alone at night in taxis.
  • The police identified that 21% of people reported missing were from hospitals, predominantly emergency departments (see case study opposite).
  • No consensus on how to meet waiting time targets.
  • Patients with mental health problems reported a lack of compassion from staff.
  • A dismissive attitudes towards, and deliberate de-prioritisation of, older people.
  • £25 million of funding for the Transforming Your Care programme was diverted into other areas of care.
  • Improved recruitment of advanced nurse practitioners, development of the emergency nurse practitioner role and the emergency care framework.
Case study from the NIHRC report. The names of the people concerned have been changed to preserve their anonymity.

One morning John was reported missing by his sister, Julie. The police found him later that day, at 6pm. He had ‘slit his wrists’ and was taken to Belfast City Hospital emergency department (ED).

Due to John’s ‘habit of walking out’, Julie said she telephoned the ED reception asking them not to let him leave before members of his family had arrived. Julie stated that despite ‘the hospital classifying Johnny as high risk they let him go out for a smoke and get food while unsupervised’.

Julie said: ‘The hospital stitched John’s wrists up but I don’t think they looked after his mental health. He was there until 1am and he should have been sectioned under the Mental Health (NI) Order 1986, but this never happened. They couldn’t section him until another doctor signed him off. The doctor never arrived to do this and John left without receiving the help he needed.’

Julie described how John had subsequently gone to another hospital to seek help but that ‘they didn’t help him either and have since told me that they don’t have any records of him ever being there’.

Julie told the inquiry team that ‘despite all his attempts for help and all the time he spent in A&E,’ John took his own life later that day.

More information

The Human Rights Inquiry Report into Emergency Health Care

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