Francis Report

Ann Clwyd Excerpts

Wednesday 5th March 2014 Commons Chamber

[Ann Clwyd (Cynon Valley) (Lab)]

I congratulate the hon. Member for Stafford (Jeremy Lefroy) on his eloquent presentation. The Francis report carries lessons for everyone involved in health care—whether it be hospitals and their boards, regulators, professionals or Governments. However, those lessons need to be learned all over Britain. It is a matter not just for England, but for Scotland, Northern Ireland and Wales.

The letters keep coming. When I gave evidence to the Health Committee the other week, I was asked what had changed. I said that I did not know and could not honestly answer the question. Perhaps I will know when the letters stop coming. Every time I open my mouth, I am punished by yet more letters. I have had hundreds of letters from Wales; and hundreds too from England, Scotland and Northern Ireland. When I was carrying out my review, I received 3,000-plus letters and e-mails, and they still keep coming.

My concern today is for my constituents in the Cynon Valley and those elsewhere in Wales where health is a devolved function. I will not be popular for saying this, but when this House is asked to give yet more powers to Wales, I will ask many questions, because the main things for which the Welsh Assembly is responsible are health and education. I was a keen pro-devolutionist in two campaigns, but in future I will think very carefully before giving any more powers to the devolved Administrations.

Many people were to blame for what happened at Mid Staffs, just as there were many people to blame for the worrying situation that was revealed at several other English hospitals in subsequent investigations by Professor Sir Bruce Keogh. There is nothing to be gained by politicising such catastrophic situations and everything to be gained from being honest about the problem and seeking appropriate solutions. After all, we are talking here about sick and vulnerable people who are often afraid and in pain. Political bun fights here or in the Welsh Assembly are of little interest to them; they just want something to change for the better.

What was so shocking in Mid Staffs of course was that no one spoke out and the warning signs of a trust in meltdown were ignored. Robert Francis has listed some of those warning signs and they read directly across to many of my concerns about the NHS in Wales.

The first warning sign is an accumulation of patient stories that detail adverse incidents, bad practice or neglect. As I have said, I have had literally thousands of those, and they continue to arrive in my office every day from all over Wales and from England.

The second warning sign, said Francis, is the level of mortality statistics. In fact, they appear to be dangerously high in many hospitals in Wales. Confusion remains on how accurate the data are. The system by which they are collected is questionable, to say the least, and there is a backlog in the coding of cases for inclusion in the risk-adjusted mortality index—RAMI—so we are now seeing retrospective alterations in the figures in at least one hospital, thus making it difficult to compare hospitals in Wales, or to compare England and Wales.

[Alun Cairns]

I pay tribute to the right hon. Lady for her work in championing patients and in drawing attention to some very unpleasant outcomes in many hospitals across the whole United Kingdom. In relation to the higher mortality rates that she refers to, does she share my concern about the political rebuttal to an e-mail from one clinician in England to another clinician in Wales simply asking for further investigations?

[Ann Clwyd]

I am grateful to Professor Sir Bruce Keogh for offering to assist. Given his vast experience, the people whom he offered to assist would be sensible to take the offer very seriously indeed.

The Transparency and Mortality Taskforce, which was set up by the Welsh Assembly a year ago, has today announced recommendations on a measure of mortality for Wales. Although I welcome its finally releasing the recommendations, I will await details on their implementation, which is unlikely to start until the autumn of this year. On mortality statistics, the taskforce provides an interesting academic discussion of the pros and cons of using mortality statistics as a measure of service quality and a means to compare hospitals and countries. Of course, none of that is new, but neither approach is impossible.

After almost a year, it is disappointing that a taskforce of 31 members has failed to arrive at the benchmarks on mortality that are urgently needed, so that fair international comparisons can be made between Wales, England and other countries. That was the taskforce’s job. The promise of a further statement in September 2014 appears to put the resolution of this matter even further away; one can only speculate on the reasons for that. Some good intentions may be expressed, but that is not enough, given the high level of public concern.

We continue to have only the published RAMI figures to go on. Six Welsh hospitals have RAMI figures of between 105 and 115, with 100 showing cause for concern, as we all know by now. A figure of more than 100 was described as a smoke signal. If the figure is way over 100, there is a big fire. It is not surprising that people are worried about what is actually going on. This is horribly similar to the murkiness that surrounded the mortality statistics for Mid Staffs.

We now know for certain, however, the position as reported by the Royal College of Surgeons after visiting the University hospital of Wales at Cardiff in April 2013 to investigate poor standards of care. It describes certain parts of the hospital as dangerous. It was worried about people dying on hospital waiting lists while waiting for heart surgery. Even those who got their surgery had deteriorated on the waiting lists. When they got their surgery, they were much more ill than they would have been.

Last week, the Royal College of Surgeons wrote to Healthcare Inspectorate Wales to ask what action has been taken about concerns raised last July in a report about patients dying while waiting for heart surgery. Following its initial report, the Royal College of Surgeons wrote to Healthcare Inspectorate Wales in August to claim that 152 patients had died in the past five years while waiting for heart surgery at the University hospital of Wales and Swansea’s Morriston hospital. I put on record my alarm about the lengthy delay in the promised revisit of the Royal College of Surgeons to those hospitals. It was promised in September, but it still has not taken place.

Other warnings to be heeded, said Francis, should come from complaints made by patients. Well, what do we know about this in Wales? Complaints trebled last year, according to the Welsh ombudsman, but the system for dealing with complaints, let alone learning from them, is highly unsatisfactory, so much so that an inquiry is under way after several high-profile cases. Obviously, we look forward to seeing the outcome of that, mindful that the retiring Welsh ombudsman said in November last year that accountability in NHS Wales has “broken down” and that there is a “lack of challenge” in the system. He asked:

“Where is the voice of the patient in the NHS in Wales?”

The fourth warning sign that Francis mentioned was signals from staff and whistleblowers. Many of them have reached me, too. Some people have told me that they are no longer able to do their jobs properly. I have had several phone calls from consultants who will not even give their names and who say that, if they gave their names, they would be sacked from their jobs.

More people are speaking out openly, and this week a letter appeared in the Western Mail from a consultant paediatrician, who said:

“The intervention of Sir Bruce Keogh, Medical Director of NHS England, expressing concern regarding high mortality rates in several Welsh Hospitals may not be welcome… It deserves to be taken seriously.

Mortality rates are ‘risk adjusted’, which means that the mortality rate is ‘adjusted’ for hospitals that deal with a disproportionate number of seriously ill patients, some of whom, sadly, but inevitably may not survive their treatment. It’s therefore appropriate to review clinical practice in all hospitals whose mortality rates are above 100. The recent publicity relating to high death rates at the University of Wales following liver surgery, where an independent Royal College of Surgeons’ report identified 10 deaths that were deemed ‘avoidable’ highlights the sluggish response of the hospital’s own management to information that should have been spotted far earlier.

A ‘Wales-wide’ investigation...or indeed a ‘health board-wide’ investigation would be too general, and would probably fail to identify clinical practice where there is a need for improvement.

Any review needs to be ‘department-wide’. All health boards have sufficient information available to them that allows identification of individual departments, possibly individual practitioners, where clinical outcome falls below the norm”—

the outliers.

[George Freeman]

The right hon. Lady is a doughty campaigner and commands the respect of the whole House for her work in bravely highlighting the issue. Does she agree from her experience and the correspondence that she has received that there is a lesson about the need for a different culture in the NHS of respecting the views of patients and whistleblowers, not treating them with contempt as though expressing such views is disloyal? Does she also agree that this saga highlights the importance of integrating data and having a statutory requirement to use the data to highlight the best and worst practices in the interests of patients?

--- Later in debate ---

[Ann Clwyd]

I am grateful to the hon. Gentleman for making that point. In the report that I wrote with Tricia Hart on complaints, we made several suggestions and recommendations, which the Government have accepted. I hope that we have a debate similar to today’s on progress in that area in a few months’ time. Professor Sir Mike Richards has promised to campaign on the issue when he goes round the many hospitals that he visits, but it is not possible to say whether complaints will head his list and whether the way in which they are dealt with will be picked up.

The letter that appeared in the Western Mail went on to say:

“A review should look not only at mortality rates. Complication rates, a high number of complaints from patients and their families, or frequent falling out between consultants within the department, all offer useful markers for identifying potential problem areas.

Careful analysis of departmental practice could lead to a prompt and effective change in practice. The Welsh public should be in receipt of all clinical outcome measurements, department by department.

Hysterical responses, such as BMA Cymru’s description of the perceived criticism as ‘wicked slander’…are unhelpful. Our health boards’ first duty of care is to their patients. Our political leaders and BMA Cymru (my own union by the way) should also be reminded that their first duty of care is to the patients and not to our established and very powerful institutions.

I hope that we have no ‘Mid Staffordshire’ in Wales. Our leaders’ current reaction is worryingly similar to the reaction of NHS management in the North of England, where a refusal to listen to constructive concern delayed essential change for many years, with tragic consequences for many families.”

The letter is signed by Dr Dewi Evans, former consultant paediatrician, Swansea Hospitals, who sent it to the Western Mail before he sent it to me.

Warning lights should flash when the governance of a hospital fails to function or to question quality and performance, and boards are in denial about poor standards, possibly because of political pressures. We have already had examples of this in Wales at Betsi Cadwaladr, and the Welsh Assembly’s Public Accounts Committee has called for a strengthening of performance and accountability procedures across all NHS organisations in Wales. That needs to happen urgently—our boards must raise their game.

Finally, perhaps the greatest step forward in England following the Francis report was the reform of the key regulator, the Care Quality Commission, and the appointment of Professor Sir Mike Richards to the newly established post of chief inspector of hospitals. Sadly, again in Wales, the regulatory system is a shambles. The evidence to the Assembly’s inquiry on Health Inspectorate Wales was shocking. It revealed that the inspectorate was under-resourced, under-skilled, and unable to carry out the annual inspections required, or to follow up its own recommendations. It was unable to hold boards to account. It is startling that its chief executive told the inquiry in November that she was unable to guarantee that there would not be another Mid Staffs in Wales.

I am concerned, too, about the delay in the publication of the report on the inquiry, which was promised in mid-February and should provide the building blocks for the reform of the NHS in Wales. I am sure that it is inconvenient to many for me to speak out in this way about my concerns, but what we all have to learn from the Francis report and indeed from the brave Julie Bailey of Cure the NHS is that we must not stay quiet, however difficult that might be, when we know that there is a risk to patients.

Mid Staffordshire NHS Foundation Trust

Ann Clwyd Excerpts

Tuesday 19th November 2013 Commons Chamber

[Mr Hunt]

That is the central change in culture that we need throughout the NHS. I pay tribute to my hon. Friend in particular, because he has had a more difficult challenge with respect to his local hospital than any hon. Member. He has campaigned for the people who use that hospital and for the staff there with great integrity and courage, which I commend.

I have never believed that there is a conflict or a choice between putting NHS staff first and putting the patient first. I have never met a doctor or nurse who does not want to put the patient first. The trouble is that we have created structures and incentives that make it difficult for front-line staff to do what they joined the NHS to do, which is to care for patients with dignity, compassion and respect. That is what we are trying to do in the changes today.

[Ann Clwyd (Cynon Valley) (Lab)]

I am grateful for the kind words about the report from the Secretary of State and from my right hon. Friend the shadow Secretary of State. If I may plug our report for a moment, “A Review of the NHS Hospitals Complaints System: Putting Patients Back in the Picture” is available. I have not yet gone through the tick-list of all the things that we asked for, but I shall be doing that. The Secretary of State has agreed that we can monitor the progress that Sir Mike Richards makes in putting complaints and the treatment of complaints at the top of his list when he visits hospitals around in the country.

May I press the Secretary of State on one point? He said in his statement that “all patients will be able to access independent help in making their complaint”. How exactly will that be done and how will it be resourced? I am grateful to the many thousands of people who wrote to me during the course of the review who complained about similar experiences to mine on the lack of care and compassion. That applies not just to nurses, but throughout the NHS from top to bottom. I hope that this will address some of the many complaints from Stafford and elsewhere.

[Mr Hunt]

I congratulate the right hon. Lady on the extremely good report that she produced. I hope she will not find herself in a position of wanting to complain to me about the way in which I have implemented her report on complaints, because we intend to take it extremely seriously. She knows that I basically accept everything she said in it, although we will have to work carefully on the implementation of some things to make sure we get them right. She highlights one of the most fundamental problems. Probably the biggest problem is that some hospitals treat their complaints procedure as a process rather than something that they can learn from. Every NHS patient whom I have met who has had problems only ever says the same thing. They just want to know that the NHS will learn from what has gone wrong. That is all that they are interested in.

The point that the right hon. Lady makes is a very important one. People do sometimes feel that it is them against the system, and taking on a big establishment that might be well funded and is not really interested in hearing what they have to say is a very lonely process. It is vital that everyone who wants it can get independent support. One thing that we will be requiring is a sign, prominently displayed in every ward of every hospital, telling people, first, how they can make a complaint, and secondly, how if they want it they can get independent help and support. That could be a very good role for the new healthwatch organisations, but it may not be them in all cases, so most importantly, we will insist that people everywhere can access that independent help.

Managing Risk in the NHS

Ann Clwyd Excerpts

Wednesday 17th July 2013 Commons Chamber

[Ann Clwyd (Cynon Valley) (Lab)]

As on six previous occasions, I shall read from testimony showing a lack of care and compassion from the 2,500 people who sent letters and e-mails to me.

The family of an 89-year-old patient wrote:

“During our daily visits, we had to locate a cup from the kitchen on the ward in order to give her some fluid. She never had a drink of any sort within reach. This resulted in severe dehydration, which was apparent by her sunken eyes, dry, scaly skin, fatigue and her unquenchable thirst when we provided her with drinks. The staff informed us that she was not eating but we found she would eat any food we brought in for her. Whilst in bed the staff neglected to move her on a regular basis and this resulted in circulatory problems and ultimately necrosis of both feet. She also developed many infections…the wound on one heel was so advanced that the bone was visible.”

A man whose son suffered further brain damage due to lack of care said:

“He was left lying in his own urine, faeces, etc. He was left without fluids for over 12 hours then he had a huge seizure. The doctor would turn up at 5 o’clock stating ‘What’s the plan for today?’ when the day was clearly over…I witnessed nurses allowing drugs and feed to go to the floor…the floor was in such a state my feet were sticking to it. You can’t blame the cleaners for MRSA!”

A woman writes about her father’s death in hospital:

“I used the term ‘conveyer belt to death’ at the time we lost our beloved dad. On that chaotic Friday afternoon, when all the Consultants and senior staff are dashing off for an early week end finish, a poor young doctor was pushed into our path by one of these Consultants from the palliative team and uttered the immortal words that will stay with me—“Is Tuesday OK?”…I only twigged later that night that that was the date to cancel any care and pull the plug.”

A woman writes of her father’s experience in hospital:

“I’ve tried to find out what he’s eating and how much but no one seems to know and the nursing staff just tell me they have too many plates to clear to remember who was eating what. My Dad is wasting away in front of my eyes and they just keep telling me they’re too busy to help. My Dad is 76 and he has always been fit and well but I’m fearful now that he will never come home from hospital alive.”

Another woman wrote:

“Having continually pushed for the best care available during his time there, it seemed that complaining wouldn’t make any difference, other than making me relive every humiliation, discomfort, stupidity and indifference…My father spent a month in hospital, and he said it was worse than his experiences in the Second World War…We watched one man fading away, naked apart from a soiled nappy, in full view of visiting families.”

The wife of a whistleblower wrote:

“My husband was a senior nurse who recorded what he considered to be gross ill treatment of patients to his senior Consultant…he was subjected to prolonged bullying campaigns and subjected to pseudo disciplinary procedures. He was supported by the RCN who managed to keep him in his job…To cut a long story short, after six years of abuse, stress and fear my husband suffered a major stroke while working at the hospital. He was later subjected to a vicious attack”

by the management

“at his back to work interview. He retired from the NHS on medical grounds. He was 46 years old. He lost the job he loved. The NHS lost a highly skilled super intelligent practical nurse who loved his patients and worked hard for them. His colleague who supported him lasted a bit longer but was also forced into retirement after her health was destroyed by bullying because she also witnessed and reported the abuse of patients”.

[Jim Shannon (Strangford) (DUP)]

The right hon. Lady is telling us some very compassionate and emotional stories. Does she feel that the voice of families, which she has illustrated very well, needs to be heard more by management and staff, and does she feel that the process should be improved to enable that to happen?

[Ann Clwyd]

Many people are afraid to complain. Some complain many years later, and some never do so at all. It must be made easier for people to complain.

[Glyn Davies (Montgomeryshire) (Con)]

I was reluctant to intervene when the right hon. Lady was giving all those examples, but this seems to be a natural break. I share her huge concern about end-of-life care in hospitals, and she may share my concern about the Government’s announcement this week that the Liverpool care pathway will end this year. I hope that the Government are clear about what will replace it, and that we do not end up with confusion about responsibilities in hospitals, which could lead to less dignity and care as people reach the end of their lives.

[Ann Clwyd]

I thank the hon. Gentleman for making that point. My next piece of testimony comes from a man who wrote this about his mother’s death in hospital:

“'My mother died under unspeakable conditions. The treatment she received, being deliberately dehydrated to death, on the so called ‘Pathway’, and total lack of sedation resulted in a death of anxiety, pain and total lack of dignity, which I personally witnessed.

The callous attitude of the staff beggared belief. My mother suffered incredible levels of neglect and abuse. We initiated a complaint, resulting in several distressing meetings. The whole procedure was to no avail as we only received platitudes of regret resulting in written statements of denial of any lack of patient care”.

Another man wrote:

“I left my wife with the assurance from nursing staff that she would be given a bath. I found her the next day some 15 hours later in her own excreta and vomit. Her face had been wiped clean. Nothing else. I was told the hoist was not working and that the bath was not plumbed in, and, in any event, nursing staff did not have the time to bathe her. Having found the equipment in perfect working order I bathed her.

I was caring for a fragile lady. I couldn’t make a complaint, I was frightened because my complaining would upset her and more uncomfortably, I had no trust in the nursing staff. Complain and how much worse could the callousness be? I took her home saying nothing. I'm still ashamed”.

Another man wrote this about his treatment for a punctured lung:

“My drip was not changed for six days, my chest hair that was shaved was left to fall under my bed and not cleaned up properly. I was never washed and in the end went by myself to the shower past the nurses station pulling my drip trolley—no one helped or worse enquired what I was doing. Water was taken away very early in the morning and not returned for at least two hours although there was obvious chatter coming from the nurses station”.

All the testimonies that I have read out come from Wales.

Accident and Emergency Waiting Times

Ann Clwyd Excerpts

Wednesday 5th June 2013 Commons Chamber

[Ann Clwyd (Cynon Valley) (Lab)]

As colleagues will know, over the past few months I have read from the direct experiences of the 2,500 people who have written to me about their treatment in the health service. This time, I am going to speak about my husband, who died in October last year. That is because I have had the 117-page report from the hospital, which I asked a GP friend to have a look at because a lot of it is gobbledegook to any ordinary person.

My husband died from hospital-acquired pneumonia. One of the concerns that I have talked about is upheld by University Hospital of Wales in Cardiff. The report says:

“A delay in review by medical staff did occur in AU. Mr Y”—

it is anonymised, ridiculously—

“remained in EU for 6 hours longer than the target timescale of 4 hours. Mr Y then remained in EU for approximately 21 hours, significantly longer than the target time of 8 hours for this type of area.

Mr Y should not have been nursed in the EU/AU for the length of time he remained there. The length of time Mr Y spent in EU and AU fell significantly below the standard expected, and this is unacceptable.

The distress this poor experience caused is acknowledged and the Health Board apologises that the standard experienced by Mr and Mrs Y was below that expected.

This concern is upheld.”

There are many other things I would have liked to talk about, but there is not enough time. I asked my GP friend to look at the hospital’s record, and she said:

“I don’t think that the notes you were given are supposed to be a complete record that Owen was properly investigated or treated.”

She goes on to say:

“Of course Owen spent too long in Casualty. The analogy with a ‘battery hen’ is apt: cooped up on a too small trolley for 27 hours, pressed against the bars…no record of adequate food or water and unclothed.”

She goes on to ask:

“Why ever not? In 27 hours Owen is recorded as drinking 150 ml and eating one ice-cream—and he was dehydrated when he came in.”

There was apparently a “Do not resuscitate” notice. She goes on:

“The DNR notice and records are lamentable, and reinforce my impression that because Owen’s care plan on 11 October could not be fulfilled, there was no other clear care plan in place for him…But I am not surprised you did not fully comprehend what they were not going to do. The enquiry papers state UHW does not follow the Liverpool Care Pathway; this is a pity as they wrote Owen up for the LCP recommended medication after antibiotics were stopped yet failed to attend to the spiritual needs of the patient in this critical juncture.”

[Mr Lammy]

Will my right hon. Friend give way?

[Ann Clwyd]

No, I am sorry, I cannot.

Finally, my GP friend said:

“These matters and the ways you expressed your concerns are so similar to the events described in the many many letters you have received from others who have described similar misgivings. It must be very difficult to have to ‘use’ your own very personal experience as a prompt to drive the response and search for answers that so many want from you. But that is your job as Member of Parliament, to identify what, if anything—”

[Madam Deputy Speaker (Dawn Primarolo)]

Order.

A and E Departments

Ann Clwyd Excerpts

Tuesday 21st May 2013 Commons Chamber

[Mr Hunt]

Absolutely. It is extraordinary that in this debate in Parliament today, Labour Members have their heads in the sand about the low public confidence in out-of-hours GP care, which is a major driver of the problems in A and E departments. We are going to sort out that problem—[Interruption.] If they do not want us to, they are just going to have to watch while we do it.

[Ann Clwyd (Cynon Valley) (Lab)]

I ask the Secretary of State to deplore the personal attacks that are being made on Julie Bailey, who was responsible for drawing attention to the many deficiencies in Mid Staffordshire hospital. She has suffered personal attacks in the street and has had faeces pushed through her letterbox. We should all deplore the fact that that is happening to such an important and brave whistleblower.

[Mr Hunt]

The right hon. Lady speaks wisely, and I completely concur with her comments. Those attacks are totally reprehensible and I condemn them utterly. Julie Bailey is a remarkable lady, and it is thanks to her that the standard of compassionate care in hospitals across the country is going to improve dramatically. We all owe her a huge debt.

Health and Social Care

Ann Clwyd Excerpts

Monday 13th May 2013 Commons Chamber

[Ann Clwyd (Cynon Valley) (Lab)]

I am grateful to the 2,500 people from England, Scotland, Wales and Ireland who have written to me since last December, when I first raised the issue of compassion in nursing. The e-mails keep coming and I want to quote from some of them.

A man whose elderly mother was in hospital asked how many staff it takes to cut a fingernail:

“The hospital staff won’t cut my mother’s fingernails. They won’t clean them properly either. The excuse given to me is that this amounts to an ‘assault on patients.’”

My mother…has for the past several weeks been positive for a new superbug which is carried in faeces and would cause havoc if it got into the bloodstream…she’s in an isolation ward now. Barrier nursing, rubber gloves and pinnies for all staff and visitors. And still the nurses won’t do her fingernails, and they can’t or won’t see that filth under fingernails or wherever it is located, is intolerable in hospitals and needs to be eliminated—most especially in infection control units.”

The e-mail continued:

“I had a rant at the…staff for leaving the buzzer button and water out of reach of bedridden patients [i.e. people in beds near to my mother who were calling out to anyone for water]. My mother’s buzzer was also out of reach. I was then told these elderly patients might strangle themselves on a buzzer’s cable.

My mother tells me that if staff are dealing with a patient [e.g. bathroom visit] when the food trolley arrives then sometimes the patient may not get any meal. It is delivered, uneaten, and taken away. The idea the patient might still be in the land of the living and come back to their bed later and need some food seems not to bother them”.

A man whose father was on a ventilator wrote:

“There were no issues with the treatment he received, but the comment I received when going to say goodbye to him when the decision was taken by medics to switch off the machine is not one I will ever forget. After going to see him and saying goodbye, the nurse—whose Christian name and face I will always remember—said to me, ‘Can we crack on now?’”

A woman whose husband died of cancer at 53 after, she alleges, years of mistreatment and misdiagnosis wrote:

“When I complained to PALS—”

the patient advice and liaison service, which some hospitals have—

“my initial complaint was ignored. So I complained to the chief exec. I had several meetings with PALS and was told they would do an independent review. This took them two years and they denied any wrongdoing. No proper investigation took place. I then contacted a solicitor and had an expert review of the case. He said the treatment was nothing short of criminal…it has taken me four years of fighting for justice. They have now finally admitted liability for breach of care and duty and causing his death. But what happens to those responsible? Nothing. This was not one mistake, it was a catalogue of errors that went on for 3 years. They should be tried for manslaughter.”

A man whose wife suffered mistreatment wrote that

“she was regularly left to lie in her own faeces for half an hour or longer, and on more than one occasion for well over an hour. This led to a severe rash on her backside to the point that her bottom and the backs of both thighs were red and raw. The buzzer would be left hanging out of reach, either by accident or on purpose…at one point she was lucky enough to be able to reach her mobile phone as she rang me in tears during the middle of the night asking me to ring the high-dependency unit desk as she’d been desperate for a nurse…I had to bring her a fresh bottle of water every evening so that she could sleep with it in bed as the water on her tray was often pushed out of reach after her visitors had left for the night.

She was never weighed when in hospital despite multiple requests of both doctors and family. The staff allowed her muscles to atrophy to the point she could not even get herself out of bed…she was so badly undernourished, many family members doubted if she would ever come out of hospital.”

A woman writing about her mother’s mistreatment stated that

“nurses frequently chatted and laughed at the nurses’ station at night, showing a complete lack of consideration and respect for patients. Standards of cleanliness left much to be desired, and we were sometimes greeted by soiled dressings left lying around and on one occasion, splashes of blood which did not appear to be hers, left over the end of the bed. Generally there was poor liaison between the two hospitals and the GP, with outpatient consultant appointments being sent to my mother’s home address, when she was in hospital dying. We did not complain at the time as we were too distressed by my mother’s condition and after she had died unable to bear reliving her last months.”

A man wrote to plead that the right kind of person is selected and supported for a nursing job:

“I have seen nurses walk onto a ward chatting loudly about their social life, approach a patient and see to his needs while continuing their loud chat, apparently oblivious to the sad human bundle they were treating, as if it was a spare tyre that they were changing. I expect you have seen groups of nurses chatting at the nurses’ station and ignoring patients on their ward who are calling out for a nurse. Yes, we know, some of these will be demented or disorientated souls who do not need medical attention as such and are possibly a regular nuisance, but they are in the care of those nurses and should not be ignored.”

A woman, who after the experience of her last operation is dreading the next one, wrote:

“Upon being admitted I was placed in a storage area and left for hours in pain, and alone, and very frightened. A specialist came and took a cursory look and said I was to go home and come back the next day. I live alone and was very unwell to say the least. I became very upset and was treated like a naughty child. I then blacked out and upon waking I was in a bed with some very anxious nurses around me…I had blood poisoning. A nurse later stated that, ‘We have lost patients not as bad as you have been’. Later that night my abscess burst. I called a nurse who looked at the bed and then told me to sleep on a clean bit!”

One of the biggest problems is that of patients being starved. One account describes cleaners who

“put trays at the bottom of beds—unhygienic for a start—then come around half an hour later and lift the trays. Nobody checks to see if the patient has eaten it. It is fortunate if visitors or some of the better patients are around to help the more frail. I never saw any staff feed or help patients to sit up...I hope this is not common practice, but sadly I fear it is.”

A and E Waiting Times

Ann Clwyd Excerpts

Tuesday 23rd April 2013 Westminster Hall

[Mr Philip Hollobone (in the Chair)]

It is a huge privilege to chair the debate. Had I not been in the Chair, I would have asked to speak, because there is an issue with accident and emergency waiting times at Kettering general hospital, but as it is, we go straight to our main speaker, Ann Clwyd.

[Ann Clwyd (Cynon Valley) (Lab)]

Thank you, Mr Hollobone. It is a pleasure to be here under your chairmanship. I am sorry that you are unable to be on the Floor making your own points, but I am sure you will find other ways to do so.

I shall start by going through some press headlines from the past few weeks: The Mail on Sunday, “Shock 250% rise in patients waiting more than 4 hours in A and E: Six-month total soars by 146,000”; Mail Online, “Major hospitals have missed A and E targets every week for 6 months”; The Daily Telegraph, “Crisis hospital sets up tent for A and E patients…A hospital set up a makeshift tent to treat casualty patients amid a deepening crisis in emergency services across the country”; The Guardian, “NHS failed to hit A and E target for two months”; Mail Online, “Mother barely conscious with pneumonia was treated in a cupboard because hospital was ‘too full’ to give her a bed”; The Guardian, “The latest casualty of health reform: casualty itself …A and E departments are the pressure valve of the health system, yet the Government is moving rapidly to turn it off”; The Daily Telegraph, “Inquiry into failings in NHS emergency care...MPs are to launch an inquiry into NHS emergency care amid fears that patients are being put at risk by catastrophic failings in the operation of a new 111 helpline”; and Mail Online, “A and E patients ‘still waiting too long’”.

As you know Mr Hollobone, official figures this month show that many A and E departments are failing to meet their target of dealing with 95% of patients within four hours. The NHS in England has missed targets for major A and Es for 29 weeks and missed the target for all A and Es for the past 12 weeks. The failure to meet targets on so-called “trolley waits” happened despite the Government’s reducing the target figure from the previous target of 98%. In the past six months, more than 530,000 patients have waited more than four hours at A and E departments—a rise of almost 30% since last year. England’s A and Es are struggling. One in three patients now waits four hours or more for emergency treatment in the worst affected areas.

About 14 million patients a year are seen in major A and E units. A Department of Health spokesman has said that the NHS is experiencing an extra 1 million patients in A and E compared with two years ago. Research by the King’s Fund shows that A and E attendance was up by 353,457 patients in the first three quarters of 2012-13 compared with the same period in 2009-10. Unfortunately, the Government also propose to close or downgrade 34 more A and E departments across the country in the coming months. Most trusts are reducing the number of beds as part of their quality, innovation, productivity and prevention plans. Pressure on A and E is felt at both ends of the system. A lack of free beds on wards means that staff cannot admit patients and, with A and E full, paramedics cannot hand over patients.

The resulting strain in A and E departments was nowhere more obvious than outside Norfolk and Norwich university hospital. Over the Easter weekend, the east of England ambulance service was forced to erect a major incident tent outside the hospital to treat patients and relieve pressure on the A and E department. Reports say that there were queues of up to 15 ambulances waiting with patients. One patient was made to wait more than five hours under the West Midlands Ambulance Service NHS Trust. Given the pressure they are under, we must all applaud and commend the work of Britain’s ambulance men and women—they are doing an extraordinary job.

Hospitals continue to make severe cuts to front-line staff, with many operating below recommended staffing levels. The Care Quality Commission has warned that one in 10 hospitals is failing to meet the standard on adequate staffing levels. Worryingly, a recent CQC report found that patients report not only longer waiting times, but a reduction in the quality of care in A and E. Thirty-three per cent. of respondents said that they waited more than half an hour before they were first seen by a doctor or nurse—up from 24% in 2004 and 29% in 2008. One in 10 respondents said that they could not attract the attention of staff, nearly a fifth felt that staff were not doing “everything they could” to control their pain, and 59% were not told how long they would have to wait for an examination. Compared with previous years, fewer patients had conversations with staff about their condition and fewer felt appropriately informed. Senior doctors now say that lives are being put at risk, because people are unable to get through to the new 111 number, which replaced NHS Direct. Many argue that it is difficult to access and mistrusted by patients, which has led to an increase in emergency call-outs and trips to A and E. Desperately ill patients are left waiting for hours while ambulances are dispatched to less critical cases.

I have had something like 2,000 e-mails and letters over the past few months since I first raised compassion in nursing, and they are still coming in. They are obviously not all about A and E, but some are. One man told me that he took his wife, who had injured her lower left leg, to A and E at 7.20 pm on a Thursday evening. On arrival at the hospital, he registered at reception at 8.10 pm and about one hour later his wife was seen by a male nurse, who said that the injury needed to be seen by a doctor because the damage was extensive—about 1.5 square inches of skin was only partially attached. The husband sent me a diary of his time in A and E. The male nurse cleaned and dressed the wound and said that it would be less than one hour before the doctor could see her:

“Apparently there had been a longer wait but he assured us that several more doctors were now attending the minor injuries section. With about 6 other patients we were told to wait in an ante room closer to the surgery rooms. At 11.15 pm after we had waited for over 3…hours an announcement over the loudspeaker system said ‘It would be a further 6 hours before a doctor would be available to treat anyone’. This was a general message, and indicated that no one would be seen for 6 hours. The voice then said ‘anyone feeling that they were fit enough to leave without seeing a hospital doctor should visit their own doctor in the morning’. It must be stressed here that these people were previously told by the nurse that they must see a hospital doctor. If the injury was so minor that they could go to see their doctor in the morning then why not tell them then?

One young lady had already spent 6 hours the previous day waiting to see a doctor because she was vomiting blood. She was there again with her friend and had already waited another six hours to be told that she was required to wait another six hours. Intolerable! She should have been admitted straight away the previous day. Another…young man was waiting almost as long as us because he had been in a three car pile up on the M4 and had damaged both knees and his back. He left after the announcement. He could have had internal injuries as well but was untreated.

How could my wife, and most of the people who were instructed to wait for a hospital doctor have the medical knowledge to leave hospital and wait another day? I went to reception to state that my wife needed to take her medication housed at home and could not wait another 6 hours on the off-chance that she may see a doctor. That was greeted by a shrug of the shoulders. I asked if any doctors were at all present and was told that one was on duty. There were 20 to 30 people waiting there at that time and most were casualties.”

On the way home, at about midnight, the man took his wife to a local hospital—no A and E there—to see if she could be treated the following day. His letter continues to tell how the next day he

“took her to this hospital and she was registered and treated within one hour not by a doctor but by a sister and a nurse. The skin flap had shrunk by that time and attempts were made to re-stretch it back over the wound. We were informed by these nurses that injuries such as this must be treated straight away to avoid shrinkage of the skin flap. This was an extremely painful process for my wife, but very necessary. Butterfly stitches were put in place that were intended to pull the skin flap back to its original size and cover the open wound.”

That is just one of many letters I have had. I have the consent of the people concerned to quote from their letters, and I will briefly read from two others. The first says,

“my wife miscarried at 10 weeks and I had to race her down…at 4am. She was left to sit in A&E for ages and I feared she was beginning to go into shock. I was pleading with the people behind the screen to help but kept being told with increasing irritation by them to sit with her and wait. Eventually they found a bed for her but there were no sheets, no drip. I had to cover her with my coat to keep her warm while nursing our sleeping 2-year-old in my arms. It took both of us a long time to get over that. To be honest we have never got over it. The sheer lack of sympathy and comfort, and being made to feel that you were an irritant. I should have made a formal complaint at the time but just didn’t have the energy.”

The second letter is from someone whose elderly mother needed an urgent blood transfusion:

“an ambulance collected mum and myself around 7pm and we arrived shortly after. Mum was placed on a trolley in A and E where we waited and waited. After an hour or so I could tell mum was deteriorating, she was in pain and distressed, I asked for help from various different nurses, I wanted a doctor to look at her. I can’t tell you how upset and frightened I was, I knew something was seriously wrong, I broke down and cried in front of everyone I was so desperate, at this point it was about 2 o’clock in the morning”—

that was after five hours—

“I begged a nurse for some pain relief for her and she gave mum a paracetamol that had zero effect. Mum was transferred to an observation ward at the side of the A and E, she was put in a bed with a tiny blanket over her, I tried to keep her warm and calm myself, no nurse came to see how she was, a lady in another bed was crying that she needed the toilet, I tried to find a nurse with no luck. We waited there until around 6am coping as best we could, it was a nightmare. Finally around 6am a consultant and 2 doctors came, they examined her and she called out in pain, the consultant advised me that mum would be put on a ward and a blood transfusion would be carried out, and she would be returned home later that day.”

The upshot was that the lady died at 11 o’clock that night.

I could go on and on with the letters. They illustrate that behind the stark figures and the problems in A and E, there are many human stories of people in distress, and left in distress, and sometimes the outcome of their very long waits is a tragedy for them and their families. The King’s Fund has recently published a report on the increasing demands on accident and emergency departments. The fund says that there are no easy answers—something we all know.

Few health policy issues have received greater attention than that of how best to meet the demands on A and E departments and manage the associated unscheduled admissions to hospital. I think that hon. Members of all parties know that there is a problem and want it to be resolved. The sooner it is resolved, the fewer the people who will suffer the long anxieties of waiting in A and E and the unfortunate outcomes that there are for too many people.

[Several hon. Members]

rose—

Accountability and Transparency in the NHS

Ann Clwyd Excerpts

Thursday 14th March 2013 Commons Chamber

[Ann Clwyd (Cynon Valley) (Lab)]

I congratulate the hon. Member for Bristol North West (Charlotte Leslie) on securing this debate. It is with great regret that I continue to speak about issues of abuse and neglect in our national health service. As of now, I have personally received more than 2,000 e-mails and letters. The letters continue to come every day; I want to mention just a few. All who have sent them want their stories to be heard.

The first letter says:

“My mother died in August this year”—

that is, last year.

“I still feel so angry about her treatment. She caught a hospital-acquired infection that certainly contributed to her untimely death. The lack of care and compassion that I saw horrified me. Oh yes, the boxes were all ticked. Water jug, food, medication. And all left out of reach. A nappy put on her because they couldn’t be bothered to answer her calls for assistance to the toilet. A proud and dignified mother left to sit in her own vomit. I haven’t put my complaints in writing to the hospital, as it’s not going to change anything. But maybe writing to you will help. I need my voice to be heard.”

The second letter says:

“Our Dad died in January last year. His death was quite unexpected by us as he was an active, cheerful pensioner, who went into hospital in October 2012 to have a knee operation. Unfortunately, whilst in there, his condition deteriorated, he also acquired hospital-acquired pneumonia and died. Throughout his stay in hospital his family visited him regularly and our experiences were very similar to yours. We found it very difficult to find any staff to talk to or to help him and our Dad told us about all kinds of mistreatment, neglect and mistakes that he was having to endure. Unfortunately, although normally a strong character, he also became afraid of some of the staff, who appeared to be bullying him, but he was absolutely adamant that he did not want us to mention any of his mistreatment to anyone as he was convinced that, once we left, these staff would then treat him even more badly. So we found ourselves in an impossible position, watching our Dad deteriorate before us—he had stopped eating—and hearing shocking accounts of his ‘care’ where he refused to give us any names, and yet feeling quite powerless and unable to speak to anyone about this.

Of course, at this stage, we did not know that he was going to die and we were just counting the days till we could get him out of there, but that never happened in the end.”

I have a third case:

“My memories of my father’s treatment in hospital are still so raw. He, like so many others who have suffered under the ‘care’ of NHS staff, was a man who had shown such bravery in the war (he was a veterinary officer in the Chindits in Burma, behind the Japanese lines) and in his life after, he was a true gentleman and would do anything for others, and he would not complain. He had faced death many times and through his bravery had survived against all odds, but in the end his death was to be hastened because of hospital-acquired infections, and from care bordering on neglect. Tragically he died sad and utterly disillusioned. He simply could not believe that medical staff, including consultants, could treat him and others as they did. He had placed utmost trust in them, and most of them could not care less. He looked at me one day, with utter anguish and despair in his face, and in great pain, and said, ‘Oh Annie, I would never have treated any of my animals in this way.’”

The next letter says:

“My husband of 84 underwent extensive tests to determine the reason for his illness, which didn’t manifest itself until the pancreatic cancer which had remained undiagnosed spread to his bladder. During all this time my main concern was the lack of nursing care.

He had been shunted into a side room on his own for being ‘difficult’ and as far as I could see was simply ignored. On one visit I found him lying in his own excrement while the staff were gathered gossiping round the nurses’ station. All my requests to see a doctor were fobbed off, until one doctor mentioned casually in passing that a lump had been found on my husband’s bladder. No attempt was ever made to discuss his diagnosis with me.”

I have some shorter examples:

“I went to the nursing station on one occasion to see the entire Team bidding at the end of an eBay auction. I was kept waiting, ignored, until it was ended!”;

“first time in hospital mother had 2 broken wrists. No one would feed her when meals were delivered, despite the fact that she had 2 arms strapped up in the air! My aunt had to travel over 2 hours by bus every day just to ensure she was fed”;

“When visiting my wife… after an operation to mend her broken hip, I asked a nurse for help as she was being very, very sick. She announced ‘I am a graduate, I don’t do sick’, and left me to deal with the situation”.

As I said, I have received many letters. I have tried to acknowledge each one and respond, although obviously I cannot do so in detail. They keep coming. It is not something that pertains only in England; the same is true in Scotland, Wales and Northern Ireland. I have received similar letters for all parts of the United Kingdom.

Dementia

Ann Clwyd Excerpts

Thursday 10th January 2013 Commons Chamber

[Ann Clwyd (Cynon Valley) (Lab)]

I apologise in advance for the fact that I will not be able to stay until the end of the debate. I congratulate the right hon. Member for Sutton and Cheam (Paul Burstow) on securing this debate on what is a very important subject, and I thank the Backbench Business Committee for giving time for it to take place.

First, let me emphasise that this issue is not only about money; it is about people who care about other people and about being compassionate. Since I first spoke out about compassion in nursing, my office has been overwhelmed, receiving more than 1,400 letters and e-mails from people who have experienced poor standards of care in hospitals throughout the country. Many of them are from the friends and relatives of people with dementia or other forms of progressive neurological disease. I shall read out a few extracts from this correspondence.

The first concerns a 73-year-old man with Parkinson’s and early dementia:

“We found him barely able to speak, sitting in a chair with no trousers, shoes or socks on. On another occasion on Christmas day afternoon we went to see him and asked him what he had eaten for lunch. The answer seemed to be ‘nothing’. We returned at lunchtime the next day to find him sitting with untouched food in front of him. He had spilt a cup of water over himself, his dentures were not in, and he was incapable of picking up a cup or food. A member of staff came to clear away the untouched food, but we stayed for an hour and fed him, piece by piece. He ate the whole meal. Other family members and friends then repeated this process on subsequent days. We were told by staff that during his stay of 37 days this quite slim man lost 3 stone in weight. We believe that the care in the ward with respect to medication and feeding was negligent.”

Another letter states:

“I had a similar experience when my mother spent some time in hospital. Registered blind and suffering with dementia, she was left hungry, thirsty, dirty, frightened and lonely until visiting hour. She also fell more than once and the staff were quite rude to us when we queried why she was complaining of being in pain.”

Another letter says:

“Myself and my family have also experienced similar treatment in the case of my late mother. She suffered from dementia and was admitted as an emergency following a fall at her care home. At the age of 82 she survived the surgical procedure but the care she later received was abysmal. We spent most of the valuable visiting times ensuring she was kept hydrated and feeding her the meals just left in front of her. After a few days we noticed she was deteriorating and despite repeatedly questioning staff, we found they were avoiding us.

After 6 days we were informed that her deterioration was due to the fact that she had been given not only her medication, but also that of the patient who occupied the bed before her (including the contraceptive pill). My mother died shortly after discharge.”

Finally, I want to highlight the case of an RAF veteran of the second world war who now has vascular dementia:

“Right from the very start with his admittance to the emergency ward there has been a lack of communication and understanding of his condition and care needs. Staff in the induction ward had no comprehension of his dementia and informed me that my father was violent and disruptive. Not only has his condition deteriorated but the level of care is absent

He has been left in a bare bed, naked in his own excrement, excrement ground into his fingernails, left without a blanket (there were no blankets available in the hospital). If for whatever reason we cannot attend he is not fed, his tablets were not given to him and left on the table.

My father is an RAF Veteran of the Second World War. He did not serve his country or pay his taxes for 43 years of continuous employment to approach the end of his days in a filthy, poorly administered establishment.”

I ask the Minister this: can we really call ourselves a civilised society?

NHS Funding

Ann Clwyd Excerpts

Wednesday 12th December 2012 Commons Chamber

[Ann Clwyd (Cynon Valley) (Lab)]

I am not going to make a speech as such; I am just going to read some quotations from the hundreds and hundreds of personal testimonies that I have received in the last few days.

“I am a former director of nursing at a university teaching hospital…Since my retirement…there have been four occasions when it was necessary for me to visit family and friends in hospital. Each visit resulted in a serious formal complaint about the standard of nursing care and medical diagnosis, experiences that have caused me to be ashamed of the profession I was once very proud of.

In the first incident a friend, dying, was left sat in a chair at visiting time with no pyjamas and his genitals exposed. On making inquires we were told that no clean pyjamas were available.

My mother was in hospital suffering from a bladder infection some weeks after bowel surgery for cancer…When we arrived she wanted to use the toilet, having asked for help several times. We found her being completely ignored so I took her to the toilet myself. On our way there she could not hold the flow of urine, most of which poured onto the floor of the ward. Naturally she felt ashamed, embarrassed and humiliated. At that time, and in full view, not one nurse was attending patients at their bedside and we counted eight nurses and a doctor doing nothing at the nurses station. My family insisted that mother be transferred to another hospital where within two hours she was diagnosed with malnutrition and dehydration—mother had been in the previous hospital for three weeks! Unfortunately the new hospital, a few days later, ran out of colostomy bags and just left mother in a faeces-covered bed.”

Another statement says:

“I was trained as a nurse myself when I was young, and subsequently retrained as a Community Worker and then a Social Worker. I worked in community care Social Work for 20 years. I also witnessed many incidents of inhumane treatments in hospital settings whilst working in Community Care…My… father was admitted to hospital due to some long standing serious bowel problems...Not long after being admitted, my father contracted C. difficile, from which he did not recover. He was frequently left lying in his own faeces. His basic care needs were neglected on every level, and he was made to feel guilty every time he soiled the bed. He developed such severe Thrush in his mouth, he was unable to eat or wear his false teeth. Despite numerous requests for treatment, it was never treated. I also tried numerous times to have him transferred to the small local hospital for palliative care as it was obvious to me that he was dying, but the staff insisted that he was NOT terminally ill…In the end, I DID stand in the corridor in desperation and virtually scream. I shouted at the nurse in charge, ‘The treatment of my father is f***ing inhumane’ and demanded that he was moved for palliative care…This happened after I found my dying father lying half out of a chair with freezing cold bare feet and one light blanket in late afternoon. According to other patients he had been sitting there since early morning. (It was easier for nurses to clean him up if he soiled himself in the chair, although they used the excuse of it being good for him.) He died in the small local hospital 3 days later. The staff there said his bed sores were so extensive and severe, there was nothing they could do for him. They kept him comfortable, and thankfully allowed him to finally die with some dignity and tender, loving care. However, by this time, my beloved gentle father had endured 3 months of indignity, abuse and misery.”

Another testimonial said:

“Your story was so similar to the loss of my dad exactly 2 years ago in our local hospital…he had worked from the age of 14 until his 65th birthday, he was in the RAF in the war and he was treated in the most dreadful way by most of the nursing staff, doctors and administrators at the hospital. We became frightened of pushing them to be kinder whilst he was in their care, in case, if possible, things became even worse. Surely something must be done about this situation. I could hardly believe my ears the other day when a representative of the nursing profession was saying they are pushing for an emphasis on compassion and consideration in nursing—when did this disappear? I would have thought it was part of the human condition to want to care for and help a person or a creature who is suffering.”

Another letter says:

“My friend and I have both experienced appalling neglect and abuse to close relatives at the hands of NHS nurses (at completely different hospitals—one in the Midlands and one in Surrey) who received no dignity or care right up to the moment they died…We find it equally sickening when we hear people…describe nurses as ‘Angels’! We also have to endure the continual mythology surrounding Nursing as a profession, e.g. ‘it’s low paid, low morale, poor staffing levels etc.’—when in reality nursing pay scales have increased dramatically over the last decade and it is now a well paid profession compared to many other jobs like hospital porters., and crucially, even if there is genuinely low morale it never excuses such blatant cruelty.”

Another letter read:

“When I sat at my husband’s bedside I did wonder…why some of the so called nurses bothered to put on their uniforms. The arrogance and indifference of some left me bewildered. The Ward Sister of the ward my husband had the misfortune to be sent to after the excellent intensive ward did not bother to speak to me for the whole 17 days he was on her ward and I am told that she was so busy running the ward she did not have time to talk to relatives…As a Doctor said in an article in the Daily Telegraph a few weeks ago since they made nursing a degree course the wrong kind of people are entering the profession and they think they are above the menial tasks that the old fashioned nurses undertook from day one. We do not need a load of snooty nosed pen pushers, we need compassionate nurses who are entering the profession because they care for people not for the salary.”

Another letter read:

“My father, who was a GP…had a severe stroke. He went to hospital and they would leave the food in front of him to ‘look at’. He was paralysed and could not use his arms or legs. If we were not there, he would not be fed or given any fluid. Then they didn’t pull the side gates up on the bed and he fell out and broke his femur.”

Another letter read:

“I feel that indifference by nursing staff to patients’ suffering and needs is all too common, and those nurses who show kindness and take time with their patients stand out as the exception.”

Another letter read:

“I do know how understaffed the nurses were in my mother's ward but I found a dismissive attitude from all levels of medical staff including nurses, consultants, surgeons and ward orderlies. Nobody cared about our mother or took a moment to get to know her. I barely managed to keep my temper, fearful that an angry outburst from me would rebound on my poor mother. Cruelty, indifference and a cavalier attitude to my mother's care marked her final weeks of a long life in which she devoted herself to the care of others.”

I ask the Secretary of State: what is going wrong?