Norfolk health bosses criticised over Downham Market Health Centre failings

Receptionists at a West Norfolk health centre which serves 2,500 patients recruited locum GPs while the practice's two doctors were suspended, the NHS East of England board will be told tomorrow.

Board members will also hear how hundreds of unchecked pathology results were discovered at Downham Market Health Centre and how the practice was allowed to 'slip beneath the radar' of both NHS Norfolk and Norfolk Community Health and Care as it fell into managerial failure.

Norfolk's health bosses are expected to be heavily criticised during tomorrow's public board meeting in Cambridge but last night neither NHS trust commented on the report's findings or recommendations.

Ruth May, chief nurse of NHS East of England, commissioned a review of the centre, in Paradise Road, after four 'serious incidents', the suspension of two GPs and the death of a vulnerable patient between March 2010 and March 2011.

The first incident was in March 2010 when one of the practice's GPs was found to have issues regarding poor performance and also the prescribing of the controlled drug Pethidine.


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This was followed by an incident in July 2010 when a recently appointed locum practice manager found 374 unchecked pathology results dating back to April 2009.

One of these unchecked pathology results included an urgent referral that was delayed by 27 days and this incident led to another of the centre's GPs being suspended in September 2010.

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The GP involved in the March 2010 incident was then suspended following a second controlled drug incident involving a palliative care patient in January this year.

The final incident involved a locum GP, from Germany, who advised a patient during surgery opening hours to call the Out of Hours service and that patient later died.

The independent review was undertaken by the Collingham Healthcare Education Centre and covered the period before the service was taken over by Vida Healthcare in April 2011.

The primary conclusion of the review was that the four serious incidents revealed a 'deficiency in safe general practice'.

The report continues: 'When the practice manager left and later the nurse practitioner went on sick leave and the two GPs were suspended, the practice started employing short term agency locums with no clinical leadership.

'The Downham Market Health Centre practice should have been regarded as high risk. The reviewers have seen no evidence that this was recognised by NHS Norfolk or Norfolk Community Health and Care.

'Indeed much evidence suggests that this practice was allowed to slip beneath the managerial radar of both organisations.'

The report adds: 'In the evidence seen by the reviewers it appears that the locums were often recruited by reception staff.

'When [the second GP] was suspended, it was the initiative of the receptionists that secured a locum for the next day. It is not surprising therefore that processes of recruitment, induction and supervision were lacking.

'It should be noted that these issues were present during the time of temporary practice managers appointed by Norfolk Community Health and Care who did not ensure that these processes were adequate.'

But the report does say despite 'significant risks' in the health centre there were no 'definite examples' where patients have come to harm.

The report also highlights several positive aspects from the health centre.

'The employees of the Downham Market Health Centre, both clinical and non-clinical, have earned the admiration and respect of the reviewers,' the report continues.

'Their performance under difficult circumstances was remarkable. Despite the practice sliding into managerial failure, the staff held it together, going well beyond their job descriptions to ensure the provision of care to their patients.

It later adds: 'Although this report has highlighted some deficiencies in Norfolk Community Health and Care's management of Downham Market Health Centre, the reviewers were highly impressed by the commitment of the new management team, including the new medical director, to get a grip on the management and the clinical governance of their services.'

Nine recommendations were put forward in the report including that Vida Healthcare ensure that the two GPs who were suspended are offered appropriate clinical supervision and training.

The report also recommended that NHS East of England reviews all practices that are not on conventional contracts, particularly where the clinical leadership is not provided by a GP.

The final recommendation in the report reads: 'Norfolk Community Health and Care should reflect, as an organisation, on the contents of this review; acknowledge its responsibility; put in place robust measures to translate the findings into its organisational culture; and to ensure that the failures described here can never be repeated.'

South West Norfolk MP Elizabeth Truss and the centre's patient participation group are unhappy that the report does not name individuals responsible for the failures highlighted.

The Conservative MP said: 'It is a real concern that this health centre slipped below the radar and none of the warning signs were acted upon.

'Furthermore I am extremely disappointed that despite a catalogue of procedural failures at the health centre and by the health authorities, not one individual or individuals have been held accountable for this.

'The patients, family and friends of those connected with the review need to be reassured that appropriate measures will be taken and I feel this review fails to provide that assurance.

'I will be raising my concerns about the review with the Secretary of State for Health Andrew Lansley.'

Dan O'Connor, spokesman for the patients participation group, added: 'The review reveals that both doctors at the health centre were suspended - a fact deliberately withheld from our patient group by NHS Norfolk.

'But it ignores the [possible] �300,000 cost to the taxpayer of providing locum cover for the two suspended GPs - between �800 and �1000 per day - an outrageous waste of public money.'

NHS Norfolk declined to comment on the report's findings and recommendations before it is discussed by NHS East of England board members. Norfolk Community Health and Care was not available to comment.

Thursday's NHS East of England board meeting is open to patients and members of the public and will be held from 10am at Victoria House, Capital Park, Fulbourn, Cambridge, CB21 5XB.

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