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Doreens Story..
2014 is the fifteenth anniversary of Doreens collapse. Her experience has been a microcosm of
the health services. She has had the best medical care anyone could receive anywhere in the
world; she has been looked after by hundreds of different people at six locations who have given
loving care. On the other hand a small minority have shown complete indifference to her care
and have then been protected by the health services who should have made Doreen their first
priority and not the defence of failed nursing. Fortunately that period has passed and once again
Doreen is in caring hands. I have briefly described that first couple of weeks at Walton Hospital
and then the experience at Elderholme Nursing Home.
Four thirty am, Saturday 19th June 1999.Doreen wakes me up with the loudest screaming.
She is clutching her head and saying she has the worst pain ever. She wants to be sick so I
help her to the bathroom where she collapses to the floor, retching but unable to vomit. I
pull her back into the bedroom. She is throwing her legs at all angles and she says she
thinks she is having a stroke. I call an ambulance and Doreens last words to me are Dont
get upset then she lapsed into unconsciousness. In less than half an hour we were at
Arrowe Park hospital a and e. I went to reception to check her in then found my way to the
serious injuries section.A nurse met me with a cup of tea in her hand. I am afraid your
wife is critical and near the end. Her eyes are nearly closed with the internal pressure
within her brain. Drink this. Can I see her? I ask. She takes me to a side ward and
explains that they have placed her in an induced coma to alleviate her pain. She looks so
relaxed. The nurse explains that they are going to give her a brain scan just to confirm their
prognosis but she says that even if she were to survive she would be a vegetable. I agree
that she would not wish that. The nurses are so considerate and their calmness exudes
confidence in their care.They take her off to the scanner and I wait outside. I pray for her to
recover but no one has given any hope that it is a possibility. Our son and his wife arrive
and we all sit round the bed in intensive care, waiting for the end.
The telephone rings at the nurses station. A nurse asks will I speak to Walton Hospital. I
listen as a surgeon introduces himself and explains that he has seen Doreens scan, which
is automatically forwarded to Walton for confirmation of brain injuries. I recognise the
problem. I may be able to save her life. Do you want to let me try? Yes, yes, yes. What
other answer could be given. I pass the phone to the nurse and she starts shouting
instructions to get Doreen ready for an emergency ambulance through the Mersey Tunnel
to the Walton Centre.
I am not allowed in the ambulance and make my own way to Walton.When I eventually
arrive and find out where to go a nurse tells me that the surgeon wants to see me. He
explains that they have already done an angiogram and the condition is more complicated
than first thought. Doreen has an arterio venous malformation (avm).
A brain avm is an abnormal connection between arteries and veins in the brain. It is
believed that an avm develops during foetal development. The arteries taking blood to the
veins in the brain normally pass through capillaries which slow down the flow of blood.
With an avm blood bypasses the capillaries and flows direct from arteries to veins.
Surrounding brain tissue cannot easily absorb oxygen from the fast flowing blood causing
damage to brain tissue resulting in stroke like symptoms. As you grow the body produces
more arteries to supply blood to the fast flowing avm. As a result the avm enlarges putting
more and more pressure on the brain. A brain avm may not show any signs but on looking
back Doe always felt nauseas, suffered with high blood pressure, headaches and had
terrible pains across her shoulders. I just thank God that Doe was not aware of the real
problem and that it was not fatal earlier in her life.

The surgeon explained that he would have to take out three large artery roots from the
brain so the chances of success were very slim but without the operation she would
certainly die in the next few hours. I obviously gave permission and wished him good luck.
The nurse said that miracles happen at Walton. She said, believe me or not but this is true.
A patient was riddled with cancer. The priest came to give the last rites. The next morning
the cancer had disappeared. There was no explanation. Later that morning the church
telephoned to say that the priest had died during the night.
At six thirty the surgeon looked into the waiting room. The operation was a success, her
life is saved for the moment. They are just putting her back together again. The relief was
indescribable, but it was another three hours before the anaesthetist came into the room. I
believe it was a success I said. He looked perplexed. Im afraid notthe surgeon meant
that he successfully removed the pathology which was the size of an orange and more
complicated than we thought so we are not sure about the after effects. Doreen was
returned to the intensive care ward.I was surprised to see that she had no bandages on. Her
hair was shaved on one side of her head and a panel in her skull, about four inches square,
was kept in place with raised staples. She looked beautiful.just like a punk rocker!
On Sunday I went to Walton at visiting time but was told that there had been a flood of
blood in the brain cavity and she was in theatre again. This time it was five hours before
she was back in the HTU. They had placed a probe in her brain connected to a machine
which measured the pressure within the brain. The monitor read 19/20 and the nurse
explained that it should read 15 but if it crept up to 25 another urgent operation would be
needed. I sat watching the monitor. It was slowly increasing by the hour 16 then 17 now
18.It dropped back to 17 then shot up to 19. By eleven thirty it was 24 then it fell to 23 and
hovered between the two for some time. It appeared to have stabilised at 24 in the early
hours and I went home and the night nurse promised to call me if there was any further
Monday visiting and the internal pressure had fallen to 20 so the immediate emergency was
over. Doreen was placed on a ventilator to help her breathing. She does not move at all. A
monitor shows when the ventilator takes over her breathing. Just when you think she is
managing on her own the ventilator kicks in and hopes are dashed again.
On Tuesday the doctors have decided to bring Doreen round from the induced coma. She
starts to move slowly as the drugs start to wear off. Then her movements become more
definite. As they do her shoulders start to shrug, faster and faster. She is pulling her left
arm up towards her face which is not a good sign. She pushes her right arm outwards that
is good. Her legs move slightly when prodded with a pen. She starts to panic over her
breathing. We watch her willing her to open her eyes. The nurses decide that it is too early
to stop the sedation and the induce the coma again.
Wednesday and Doe is still in an induced coma. They do a tracheotomy to help with her
Thursday and every now and again Doreen is breathing on her own. At ten in the evening
they turn the respirator off and leave Doreen to breathe on her own through the trachea. A
consultant anaesthetist tells us gently that there is little hope of Doreen recovering enough
to know who she is or undertake rehabilitation. She says that Doreen will never be going
home again. No one can be sure if she hears what is being said and cannot signal or
whether she has lost all capacity. There is always hope.
By Friday Doreen has been breathing on her own for twenty four hours and sedation has
been stopped. She has no movement but reacts to pain. On Saturday she is moved from the
HTU to another ward. She has oxygen through the trachea. She has still to open her eyes. I

feel that if she opens her eyes everything will be ok.I ask the nurse if she will observe
Doreen at midday on Sunday.
On Sunday at midday many of our friends pray at their different churches for Doe to open
her eyes. When I visit her at three I ask the nurse if she looked at Doe at midday. She says
she was too busy. At six the nurse attends to Doreen, then as she pulls the curtains back she
says Oh by the way.she has opened one eye Prayers answered again!
There is little change over the next three days then on the Wednesday Doe caught a chest
infection and is treated with antibiotics.
On Monday the surgeon and his registrar came to Doreens bedside and explained that the
original operation was successful.Nothing had been left behind. The scan was better than he had
anticipated but he was disappointed that she was not coming round. He thought that she may
well hear but be locked inside herself, paralysed. Her problem was going to be infections. We
must keep trying to stimulate her brain. Meanwhile she would be transferred to Arrowe Park
where they could treat her infections. The surgeon explains that it was a difficult decision to
operate knowing the probable outcome but every time a procedure is carried out a little more is
learnt. Just before this happened to Doe I was given the BIG E with life threatening
spontaneous DVTs. Her friend later told me that Doe had been praying that she would be taken
rather than me. This happened to Doe and I havent had another DVT since.

Nursing home experience is bound to be subjective and one person can receive the best
service and another the worst.Of the many nursing and care staff who have looked after
Doreen there has only been a handful that have shown no empathy to her situation. Most
have become firm friends and have really put themselves out to provide for Doreens needs.
We are both really grateful to them.
Doreen was transferred to Elderholme Nursing Home in October 2000.Care was excellent until
a new matron arrived in 2008. Doreen has complex needs set out in a comprehensive care plan
which should not be altered without a review by her consultant. The matron took exception to
parts of the care plan and I said that if she disagreed with anything she should have a review of
the risk assessments and alter the plan in conjunction with Doreens GP and the NHS. Instead she
made a unilateral decision to stop certain parts of the plan.
All that I wanted was for the care plan to be followed. I made several complaints to the matron
and to her directors expressing concern at the failings in care. Directors referred me back to the
matron. As a last resort I approached the Nursing and Midwifery Council through Doreens
MP.They declined to investigate after receiving assurances from Elderholme that there were no
concerns. Elderholme gave notice to remove Doreen because I had taken my unresolved
complaints to the NMC. My solicitor asked Elderholme to withdraw notice pending an
application to the Court of Protection for a Court Decision but Elderholme refused. They would
not wait until after the holiday and evicted Doreen just before Christmas 2011.

In November 2011 Elderholme wrote:
You accuse our Matron Manager of making false statements to your wifes GP that would be
detrimental to your wifes care, giving incorrect information to the dietician, failing to monitor
urine and altering a care plan without following proper procedures and that our Matron Manager
are aggressive towards you. We had to address each of your allegations with Matron. She
refutes them all categorically. The management are satisfied with the responses our
Matron has given to your allegations and management rejects each and every one as being
unfounded. As a result of your actions and conduct our Matron Manager has lodged a formal
complaint with the management of Elderholme. Our Matron Manager is feeling upset, harassed,
victimised and stressed as a result of your conduct. The management consider that the Matrons
complaint is justifiedWe find her complaint upheld and as a result we are giving notice for
Mrs Beddows to leave Elderholme.
Doreens GP wrote: As far as I know these matters have not been investigated by Elderholme
because I have never been asked by them to confirm any of the above points nor have they ever
asked me for my opinion either orally or in writing I have never found Mr. Beddows to be
confrontational or anything but helpful regarding the care of his wife and always found his
observations and comments helpful and useful. I think the fact that he visits her daily and is so
concerned for her well being is to his credit and something to be admired. I find it sad that after
so many years Doreen was effectively made homeless and this created enormous stress and
uncertainty for Len at the time and I feel that this whole situation was completely avoidable and
unnecessary and really need never have happened.
The NHS have now completed an investigation with the following findings:
When I mentioned that some staff were not giving Doe enough water, Elderholme told the
Dieticians that Doe was passing too much urine and they should lower the fluid input. This
could only have been determined by an accurate fluid balance chart. Elderholme were told to
monitor urine.Throughout the whole review period the daily inputs and urine outputs are not
totalled. Elderholme gave incorrect information to the dietician and failed to monitor urine.
When I asked a nurse for information about the supposed urine problem he complained to the
matron.There is evidence from the GP that the Matron told the GP that I was interfering and she
made unsubstantiated accusations that professionals involved in Does care had complained
about me . The records show that no complaints were made by any external professionals.There
is evidence that the matron complained to the GP that I was insisting on three people to transfer
Doe by hoist when this was a requirement in the discharge plan from Walton Neruo
Rehabilitation Centre.There is evidence that the Matron informed the GP that I had consented
to a Do Not Attempt Resuscitation order. I did not give such consent.The Matron gave false
information to the GP that would have been detrimental to Doreens care.
There is evidence that the Matron behaved in an aggressive manner towards me,
interrupting me and speaking down to me. At this meeting the matron complained that Doreen
received more care than any other resident and she had 59 others to look after.
When I said that hourly checking called for in the care plan was not happening the page detailing
the requirement was taken from the care plan.There is evidence in the nursing home and PCT
records that the CHC Nurse recommended referral to the Consultant for review; however
this was not done by Elderholme.

The matron told the GP that she had not followed NHS suggestion of arranging a review of Mrs
Beddowss care by a consultant because her needs had not changed. However she also altered
the care plan which should not happen without a review. Her reasoning to the GP was
contradictory. Elderholme should not have changed the care plan without a review of Mrs
Beddowss care needs by the GP or Consultant; evidence clearly indicates that this
happened.The care plan was altered without following proper procedures.
The NHS report that Elderholme failed to acknowledge that Mr Bedddows was correct in
requesting that the home adhere to the care plan as agreed with her consultant and GP.
Although Elderholme had written that they had addressed each of the accusations the NHS
reviewer reported that the Home appears to have incomplete records because none of my
complaints are entered in their complaints log. Elderholmes lack of evidence available would
suggest this was not managed in an appropriate manner. They had no documentation available
to highlight any actions taken to address the complaints and therefore no formal record of
complaint investigations in a recognised format.
It is the requirement of the care home and its care staff to keep contemporaneous and accurate
records for each patient.The reviewer concluded that the charts identify that there is a lack of
intervention for repositioning on a daily basis. There is also a lack of evidence to identify
how skin integrity is managed. Overall the timescales for interventions vary considerably.
None of the daily intervention charts are signed on a regular basis. Daily records and
summaries of interventions
were not detailed. In one sample month only 46% of required
interventions were made with gaps between observations of up to five hours. The NHS
Investigation now reports that due to poor record keeping it was not possible to evidence that
care was given in accordance with the care plan.Whilst the care plans for Mrs Beddows
reflected all of her care needs the daily charts did not reflect that the care had been
consistently managed. It is the opinion of the reviewer that due to the lack of consistent
record keeping clinical care was compromised and fell below expected standards.
Elderholme failed to deliver the care package as proscribed by the PCT and from the GPs
perspective presented a risk to Mrs Beddows safety
The NHS admit that their Continuing Care Team failed to follow expected standards in respect
of its responsibilities and duties under its Continuing Healthcare commissioning responsibilities
in relation to Doreen. DASS failed to follow both their own and statutory policies. Both have
apologised. Elderholme have ignored the findings.
The Care Standards Act 2000 set out the requirements that nursing homes must abide by. The
care plan and complaints policies are important parts. They are meant to be enforced by CQC. I
approached the CQC for help to enforce the care plan but they said that they do not deal with
individual complaints. The Mental Capacity Act 2005 applies to Doreen as she has no
capacity. This sets out how decisions should only be made in her best interests, and only after
discussion with all parties, including relatives. The GP told the NHS that moving to another
Home was not in Doreens best interests but he was ignored. The Local Authority Social
Services and National Health Service Complaints (England) Regulations 2009 set out the
way that complaints should be handled by both the NHS and DASS. These regulations were
ignored. No one is responsible for ensuring that legislation is followed. The prime concern of all
parties is to protect their colleagues.
I pressed CQC for help but they said that they could not. I gave details to Wirral Department of
Adult Social Services but they did not enter the complaint through their system. Both DASS and
CQC inspections failed to notice that the care of Doreen was below expected standards. Both did
not query why these complaints had not been processed through the Homes complaints system.

I asked the NHS to enforce the care plan. They should have helped but left me to resolve matters
myself. Safeguarding were advised but have now confirmed that contractually the eviction
should not have gone ahead. Safeguarding failed to investigate the reasons for the notice or to
follow up action points therefore the process was not completed according to their own
Safeguarding policies. I approached the Local Government Ombudsman who advised that
responsibility lay with the Parliamentary and Health Services Ombudsman. The PHSO advised
that the NHS were responsible to resolve the complaints and they agreed to an investigation.
Although NHS complaints policies stipulate a maximum period of six months they took over two
years to report. The PHSO said that as long as the NHS said that they were making enquiries
then they could not intervene.
I asked the Minister of Health if he could ask these organisations to follow their own complaints
time scales. His office replied that it would not be appropriate for ministers to intervene in
processes of local accountability. The CQC is an autonomous body completely independent of
both the Government and the NHS and so is the PHSO. Any complaints about the CQC could be
taken up with PHSO. The eternal complaints roundabout!
When complaints are not investigated by those responsible and legislation is ignored in favour of
supporting colleagues you have to reach the conclusion that all of this legislation and the various
bodies set up to protect the vulnerable are in fact only there as a veneer of respectability but with
no intention that they should be applied by anyone or that any one person has responsibility for
ensuring that they are applied. Organisations have good conduct policies, legislation is quite
specific, numerous people are employed in complaints departments all that is required to
improve care and safeguarding is for those people to follow their own policies, do their jobs
without favour or pre judgement and accept that even organisations with wonderful reputations
can make errors of judgement. Investigations should rely on evidence and not just on the
integrity of those who are complained about.
Since moving home the review which Elderholme would not co-operate with has taken place
and Doreen has had her medication reduced, is more alert and is receiving intensive therapy
from an NHS neuro rehabilitation consultant. She has received her first review in fourteen
years from both OT and Physio departments. Checking hourly, which was
unnecessary by Elderholme, is routine for ALL residents in bed at her new home.
Read the NHS Final Report at
Read the NHS Clinical Report at
Read more about the government, health and social service failings to resolve complaints at
Read the Which magazine article at
This experience is not about the actual complaints as such but about the lack of integrity and the
difficulty in resolving straight forward complaints when those responsible fail in the duty of