Medics at the Royal Manchester Children’s Hospital have warned ‘dangerous’ levels of under-staffing at its critical care unit have been putting poorly youngsters at risk in an extraordinary letter leaked to the M.E.N.

Management at the hospital, which cares for the sickest children in the region, have been accused of ‘doing nothing’ in response to the concerns of ‘overworked, guilt-tripped and badly supported’ staff.

The letter, written at the start of December, lists a catalogue of serious safety fears raised through an anonymous honesty box placed in the unit’s staff room at the end of November.

They include fears that too few medics were being left to care for too many seriously ill children, warnings about lack of equipment and experienced staff, lack of support from management and claims children have been discharged to general wards too early in order to free up beds.

Several employees warned they were having to care for two children on ventilators at a time, a situation they said was not safe.

One medic wrote: “I worry that it will take a patient dying as a direct result of short-staffing before anything changes. We seem to keep saying yes to admissions when it is already terrifyingly unsafe.”

The letter says conversations about ‘dangerous’ staffing levels had become ‘an almost daily occurrence in the staff areas of critical care’ by November, adding that medics felt management were aware of those concerns but had done ‘nothing to address them’.

In a statement, Manchester NHS Foundation Trust, which runs the hospital, stressed that as soon as the letter was received six weeks ago it had ‘responded immediately with a series of actions to ensure that these concerns are fully understood and addressed’.

While admitting that winter had brought extra pressures to the department, it said staffing ratios do meet guidelines for high dependency patients.

It also said ‘only in very exceptional circumstances’ would one member of staff be expected to care for two patients on a ventilator.

Below the M.E.N has reproduced the letter to management in full, including the individual comments from staff, followed by a full statement from the trust.

Letter to RMCH management from critical care staff, December 1, 2017

To The Management of RMCH Children’s Critical Care,

Recently a conversation sprung up amongst staff about dangerous staffing levels and our fears for patient safety.

This conversation is an almost daily occurrence in the staff areas of critical care, and there are a multitude of other worries and concerns which are regularly discussed.

The feeling amongst staff is that management are aware of our concerns but do nothing to address them.

It occurred to us that this is an assumption, and perhaps we should do something to ensure that management are in fact aware of these concerns, and also put these concerns in writing so that there is documented evidence of them being passed on.

A box was placed in the staff room from 26/11/17-29/11/17 with a note saying: “Please comment with any worries/concerns you have about the current state of PICU/PHDU [Paediatric Intensive Care Unit/Paediatric High Dependency Unit] which you would like management to be aware of. Also, any suggestions you may have to improve our working life.”

Below are the responses received.

You will note some common themes and you may also note that staff concerns are by and large related to the health and wellbeing of our patients and ourselves. We don’t want luxuries, we just want our patients to be safe and to be able to give them the level of care they deserve.

Kind regards,

Children’s Critical Care Staff

Comments from staff, as sent to management

“Not enough experienced staff on shifts.”

“Lack of support and education on the floor. Minimal opportunities to learn new things on the floor and increase skills and knowledge.”

“Staffing obviously! Worry about very high staff turnover and losing experienced staff, leaving shifts with very poor skill mix.”

“Morale between staff is terrible - really hard when all you hear is negative comments about the unit when you’re trying to have your break in the staff room.”

“Lack of equipment! Makes doing tasks twice as long when you can’t find equipment or there isn’t any.”

“Not being listened to when raised concerns over the past few months!”

“Multiple texts per day! Not good! Guilt tripping people to come in!”

“Very poor staffing. Very unsafe. Doubling up vented pts with extubated and tubes not even secure or patient adequately sedated.”

“Staff are expected to come in on their own time to train on equipment necessary to care for children in our jobs. Surely it is the trusts responsibility to ensure staff are equipped with necessary skills to do our jobs and we should not be expected to do it in our own time.”

“Bed management - Discharging children to the ward who are not fully fit, in order to facilitate an admission. No beds should mean NO BEDS!”

“Previous skills and experience not recognised.”

“With the staffing levels we have, if caring for two vented patients becomes the ‘norm’, I will be looking for another job.”

“No sense of teamwork.”

“Too many non-clinical roles.”

“Two ventilated patients is unacceptable practice.”

“Lack of support - no one left free to support cubicles which are usually full with sick, heavy­workload patient with back to back drugs, infusions, transfusions.”

“Workload. The doubling up of patients down to level, rather than workload or demand.”

“Skill mix on shifts-leaves experienced staff to always have difficult shifts and makes new staff vulnerable and unsupported.”

“Understaffing ratio to patients leaves nurses and patients vulnerable to mistakes-always rushing.”

“There is very little support from managers - I have had over four weeks of shifts where I haven’t spoken to or seen a manager. When I have, they have been on shift and I have felt so unsupported and left on my own. We need more visible managers - asking us how we are. We don’t have any time away from our patients or have the confidence to speak to them. The ward can be intimidating and that can stop us from seeking help ourselves.”

“The education team are an invaluable resource but we don’t get to see them as often as we could. More staff or availability for them would be really helpful.”

“I worry about staffing levels and doubling up intubated patients. What happens if one self extubates when dealing with the other?”

“Not enough recognition just always expected to do more.”

“Lack of clear leadership. No one knows what the other is doing.”

“Support from management.”

“Please stop asking people to come in to help and then send nurses to the ward.”

“A lot of people feel we were not offered appropriate follow up support after the bomb and we had to seek this privately ourselves. These feelings are ongoing and didn’t just stop once the patients left.”

“Unsafe nurse to patient ratio.”

“As soon as we are ‘quiet’ staff get moved and there is no chance of anyone being doubled up to become competent with the equipment, eg CVVH.”

“Junior staff are being thrown in at the deep end with little support.”

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“It should be one rule for all instead of different rules for different colour uniforms.”

“Doubling up vented patients is not safe!!”

“We should be trying to keep the staff we have happy instead of upsetting them with emails about being moved to the wards if we are coming in on twilight shifts to help the unit.”

“***** shouldn’t be included in the numbers as most are of no use to us and don’t move from the desk.”

“I am scared for my registration every time I come to work due to staffing levels and a lack of support meaning I can’t give the quality of care I should be giving.”

“Skill mix on shift is not even.”

“***** in charge not competent on the filter.”

“Short staffed - no sphere for the cubicles.”

“Only one person sorts holidays, self rostering.”

“No teamwork.”

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“***** handing out quizzes on shift when breaks haven’t been covered and really busy patients.”

“Unsafe.”

“Having 2 ventilated patients is not safe.”

“Need to look at staff morale and how to retain staff both old and new.”

“For amount of staff shouldn’t we be closing beds if staffing is only at best 10/12 per shift??”

“Need more people on the education team.”

“More simulation training.”

“Support from Manchester attack???”

“Help. Support on shift.”

“Poor support from ******.”

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“No team day due to staffing.”

“Worried that due to loss of experienced staff, there won’t be a good support network, and that junior staff will have higher dependency patients without the support there.”

“Worried that patient safety is being compromised because people are so stretched, so meds being delayed because you can’t get checks; cares/turns not being done as often; people cutting corners to try and get everything done.”

“Need staff support/counselling for all staff to access.”

“No chances for further learning/university modules.”

“I worry that it will take a patient dying as a direct result of short staffing before anything changes. We seem to keep saying yes to admissions when it is already terrifyingly unsafe.”

“We used to be able to handle two patients arresting at the same time ... what on earth would happen now??”

“Lack of friendliness to new staff, students, TNAs, ward staff and each other. Nobody is nice to each other, no thank you, please or teamwork.”

“Please stop texting us every single day. We are all fully aware staffing is poor and there is bank out every shift. If we want to pick it up we will do so without a text on top - constantly being text at home means we can’t have a break from work causing unnecessary extra stress.”

“Junior members of staff getting more experience/exposure than senior band 5s.”

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“Staffing numbers.”

“Bringing in bank and moving staff.”

“C3PO?? When no beds!!”

“Workload of all individuals. No ease, just added on.”

“No support.”

“One person shouldn’t be in charge of self rostering and holidays etc. If you upset that person you’ve got no chance.”

“Feeling that no-one actually gives a ****.”

“Staff members not taking into account your workload. And sometimes covering two or three units! And still expecting everything done. Higher bands workloads being put onto Band 2s as they don’t have time, adding to our workloads.”

“When allocated a patient on something you are unfamiliar with, having the support around you for any questions and the nurse in charge checking in to make sure you’re okay midway through the shift costs nothing, but makes you feel more valued and supported.”

“There is nowhere to take your worries/complaints to as no one listens when we are giving unsafe and dangerous practices in PICU. Then we are patronised with what we haven’t achieved, the ‘corporate’ standards. This does not respect staff who are trying their hardest, with often 2x vented pts and a sphere.”

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Statement from Manchester NHS Foundation Trust

The children’s critical care Unit at RMCH cares for extremely unwell and vulnerable children referred to RMCH for its specialist expertise from other paediatric units across the north west of England.

Nationally there are pressures on all children’s critical care units with particular surges in demand over the winter months.

Following receipt of the letter in early December 2017, the trust and the RMCH management team have taken the concerns of the staff very seriously and responded immediately with a series of actions to ensure that these concerns are fully understood and addressed.

Members of the children’s critical care management team already maintain regular communication with the staff through a variety of mechanisms, which include daily huddles, a regular newsletter and a monthly open meeting to which all staff are invited.

As a result of this regular dialogue, most of the concerns that were included in the letter had plans in development to address them. We hope to build on this through the workshop events planned for this week in response to the letter.

In terms of patient to staffing ratios, we achieve a 1:1 ratio for paediatric intensive care patients and a 1:2 ratio for paediatric high dependency patients consistent with the Paediatric Intensive Care standards.

Only under very exceptional circumstances (for example in the event that a patient deteriorates unexpectedly on the ward or arrives in the paediatric emergency department) would staff be expected to care for two ventilated patients and this would be for a very short period of time to enable us to deploy additional staff as required.

We have a very clear escalation policy and process in place to support staff in such circumstances which includes involvement of the hospital senior leadership team.

Significant support was provided to staff following the Manchester Arena incident by the children’s mental health team and the trustwide staff support service.

Access to external counselling support was also made available to staff. Additionally, the management team has approved the establishment of a dedicated psychological support service for children’s critical care staff.

Senior clinicians and managerial staff support the team, given the pressure on critical care services and in particular the surge in demand for services in winter to balance on a daily basis our staffing levels alongside the demand for our services with the highest priority being the provision of safe care at all times.

The decision to admit or discharge a child to or from the children’s critical care service is always based on clinical need and an assessment of the resources available.

Every effort is made to accommodate these very sick children and we are very grateful to our staff for their commitment and hard work.