Horton General Report Nov.2006

Report of the Independent Review into the Horton General Hospital Accident & Emergency Department
November 2006

“Ben Geen was effectively supervised throughout this period with staffing levels well above what is expected in an Accident & Emergency unit such as the Horton’s.”

“Events occurred during the winter period when there is normally an increase in the number of people with respiratory distress and anticipated increase in respiratory arrests.”

“Respiratory distress and or arrest are common in emergency care but sudden, unexpected and unexplained cases are rare. The number in December 2003 was six and this was only one more than in December 2002.”

“It was the concerns of individual clinicians that led to identification of Benjamin Geen’s activities rather than policies, systems and processes”

“The emergency department of any hospital is different each and every day and can quickly shift from the quietest to the most hectic department in the hospital in literally a matter of minutes.”

“It is not unusual for nurses to have a preference to work in an a particular area or with a specific client group and therefore his inclination to work with patients requiring a more major input or resuscitation was not a factor on its own that should have caused concern about any malicious intent.”

“The Healthcare Commission’s performance rating for Horton General in 2003: one star”

“Incident  reporting forms were described by one member of staff as ‘disappearing into a black hole’”

“The police investigation highlighted that results of blood gas analysers written in the clinical notes did not match data held on Radiance (part of the electronic patient record).”

“There is a good mentorship and buddy system in place for new staff to the Department and this was in place at the time Benjamin Geen worked in the Emergency Department.”


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