Thanks for sharing that, its a shame it doesn't include all the babies - but my concerns from the very start are absolutely enforced in the report
COUNTESS OF CHESTER HOSPITAL FINDINGS
To summarize, we found numerous problems in medical care related to the 17 cases, including:
1. Medical histories were incomplete
2. Failure to consider the obstetric history
3. Disregard for surveillance warnings about infectious bacterial colonization
4. Misdiagnosis of diseases
5. Caring for patients that were beyond their designated level of care
6. Unsafe delays in diagnosis and treatment of acutely ill patients
7. Poor skills at resuscitation and intubation
8. Poor supervision of junior doctors in procedures like intubation
9. Poor skills in basic medical procedures like insertion of chest tubes
10. Lack of understanding about respiratory physiology and basics of mechanical ventilation
11. Poor management of common neonatal conditions like hypoglycemia
12. Lack of knowledge about commonly used equipment in the NICU, e.g. Neopuff, capnograph
13. Failure to protect at risk patients (e.g. haemophilia) from trauma during intubation
14. Lack of teamwork and trust between the health professions
GENERAL FINDINGS
Statements given by witnesses point to serious resource and infrastructure deficiencies that impact on
general patient care at the Countess of Chester Hospital. Specific concerns expressed in witness
statements include:
1. Inadequate numbers of appropriately trained personnel
2. Lack of training for assigned nursing roles
3. Inadequate staffing
4. Work overload
5. Poor plumbing and drainage, resulting in need for intensive cleaning; this was a potential factor
in Stenotrophomonas maltophilia colonization and infection
6. Poor environmental temperature control in facility
7. Difficulty in finding a doctor when need arose
8. Congestion at medication cabinet and preparation trolley
9. Lack of appropriate facilities for sterile preparation, e.g. IV drugs prepared in corridor
10. Some high risk infants who should have been born and cared for at higher level institutions
were born and cared for in Countess of Chester Hospital because of a shortage of beds at
higher level facilities where they should have been admitted
11. There were delays in transfer of sick infants to higher level facilities when the need arose
