Mrs Eva Green - Killed by negligence (due to lack of staff) at Wycombe Hospital????
Personal opinions and memories of Phil (Page first updated 1st December 2013)

This Sunday is one of the saddest days of my life. At 8:37 this morning, David (Green) called me to tell me that his Mum had died in the night, around 23:50 - less than 12 hours after she was deemed by the hospital doctor to be "fit and much better today". Mrs Green would have been 102 on 13th April next year. I have lost a dear and valued friend who would have lived for a lot longer. I first met her when she was 90 and she was caused to fall by a 6 inch hole in the block paving that the buses drive over, by Primark in High Wycombe. (At that time it was Marks & Spencer). She recovered amazingly fast from her broken wrist and soon continued to produce what must have totalled hundreds of beautiful little cardigans for babies; she donated these to Wycombe General Hospital for sale where the proceeds went to the Scannappeal. I kept in touch at Christmas time, over the years, but as her friends died we became closer friends as she had less "outsiders" to talk to. She had a loving family with her 2 sons, Chris and David and her daughter Mary. It got to the state that I was always associated with my Tuesday visit; were I (the bus) late I would be greeeted with a lovely smile and something like, "You are late. I had given you up". This was said in a so caring way and was just one part of so many wonderful Tuesday afternoons where we either 'sorted out the world' or reminisced about the old days, often prompted by the daily news of the archived Children's Newspaper. My visits were usually just over one hour yet we managed to squeeze in so much over a cup of tea and a biscuit. One day she told me to call her "Eva", but she happily conceded to my insisting that I was brought up to respect my elders and would never dream of doing so. Our last time together, at her home, was 12th November, terminating in the customary, "you will be down next week, won't you?".

On Monday 18th November, in the early evening, I got a call from Mrs Green's son, Chris, to tell me that his Mother was in Wycombe Hospital having suffered a suspected small stroke. I went to see her on the Tuesday and she was surprisingly chatty and well. One of the things that she said is now so memorable - "if anyone says ever anything against Wycombe Hospital, tell them that they are wrong and you just couldn't be looked after better" - I am unlikely to ever forget these words and the adamant way that she said it. She also pointed out that she had her alarm button "just in case she needed anything". In view of the lack of entertainment for her, during her stay, I offered her a radio with headphones to listen to for her own personal pleasure. In her lovely considerate way, she declined as "It may interfere with the other patients".

Initially, Mrs Green was in Ward 8 but soon moved to Ward 9; both of wards are for Stroke patients and are virtually adjacent to one another. She was doing ever so well, as you can see in this picture of her with her son, David, taken on 27th November. Please bear in mind that there were many more visitors than myself and David and that this article is just a snapshot of how I observed the treatment of a close friend

Although David and myself had briefly met previously, we got to know one another a lot better during the time of visiting Mrs Green, as we both turned up and left at about the same time. One of our little tasks which we tried daily, was to get get her to grip our hands with her affected (right) hand. The stroke was very minor. The grip of the 4 fingers of the right hand was as tight as the left hand but there was a weakness in the right thumb which would have almost certainly been fixed by physiotherapy. Please note that throughout this page the word "we" specifically refers to myself and David.

Before I relate more, I should point out that I am in no way related to the family - I am just an outsider who respected Mrs Green as a great friend. My Mum died in 1997, at home, but under some very unpleasant circumstances so I unfortunately know what a dying person looks like. In view of this, I interviewed one of the nurses yesterday and below is a summary of the Questions and Answers. I do not have the name of a single Nurse or Doctor that looked after Mrs Green. Any opinions that follow are my own personal ones and are completely unbiased. I hold no-one personally responsible except for doubt of one unknown person to be mentioned later. All of the Nurses and Doctors that I have spoken to during the past two weeks have been as helpful and courteous as expected. My accusation of negligence due to understaffing is directed to the Executives of the Buckinghamshire Healthcare NHS Trust 2010 - any comments from this Trust should be sent to me as directed at the bottom of the page

Q1) What is the Patient to Nurse ratio in this Ward (9)?
A1) We have 23 Patients and 7 Nurses

Q2) Why is it that when a Patient presses their alarm button, invariably no-one ever appears?
A2) The problem is that when the first alarm is pressed, usually two Nurses are required so we rapidly become saturated

Q3) So basically you are saying that you are understaffed?
A3) Yes

Q4) So, to whom should I address my comments to make my feelings felt?
A4) The Executives of the Health Trust

Q5) Do you live in Wycombe?
A5) Yes?

Q6) Do you remember Ernest Turner Electrical Instruments who used to be in Totteridge Avenue?
A6) Yes

Q7) Well, I used to work there and we supplied and maintained the whole radio program distribution system for this Hospital, around 50 years ago. Now we have progressed to having no entertainment for the Patients after a farcical and ridiculously overpriced TV and Internet system. (I am still an out-patient at Wexham Park Hospital and note that there is a WP hotspot for wifi. I have since spoken to the IT department at Wexham and confirmed that wifi is available, free of charge, to all patients in their hospital. When I told them that Wycombe had exactly nothing at all now, they were just flabbergasted.)
A7) Ah, yes. The problem was that it never made any money so it was removed

Q8) I am shopping for a hospital to repair my umbilical hernia and a newly borne ventral hernia. I looked at the NHS Choices website and see that your Mortality Rate during presence and within 30 days of discharge is higher than the expected?
A8) Well actually the Stroke Unit is virtually separated from the main statistics. Our mortality rate is far better than the national average

Q9) Mrs Green's heart rate and breathing are not at all normal. Are you sure that her oxygen level and food and water intake are OK?
A9) (flicks through notes) The Doctor saw her at 12:30 and she is fine. (This is the doctor that she pointed to but whom I had assumed was a student as he looked so young). We tried to give her breakfast this morning and she started reaching so we had to stop. We can't do anything with her over the weekend, not until there's more doctors around on Monday. (I would have at least expected to be presented with a container of Ensure Plus to offer to Mrs Green)

Q10) Wouldn't Mrs Green be better off in ICU (Intensive Care)?
A10) (Looks at me as though I am 2 years old) Of course not. ICU is only for people who need medical treatment. She's fine here.

I should add at this point, after Mrs Green's first fall, that I had asked a nurse (perhaps a doctor) if Mrs Green would not be safer at home. I was bluntly told that "we daren't do that. If she had another fall then we would be responsible". These are more words that I shall never forget as instead of moving her to a lower bed, with less falling distance, exactly the opposite move was taken. You will later see in the PDF of my futile attempts to obtain the 3 bed heights that I am not at present in a position to state.

I suggest that before reading further, you look at The Stroke Unit publicity. Reading this will lead you to believe that there really is 24/7 care and that everything works fine. Here are some of the facts that I have observed, first hand, as a visitor to Mrs Green, leading up to her untimely death. Please note that I was not taking notes of the exact dates so I have not quoted them. All I can say is that there are days in between most of the events.

1) The day after she was extolling the virtues of the alarm system she told me that it was completely useless as you can buzz a dozen times and you are just in a big queue and no-one comes to see you.

2) Mrs Green had her first fall on the way to the toilet. The damage was not too serious but hard hospital fixtures and fittings and a hard floor are not like a minor fall on a carpeted floor at home. One would expect to flag this in "the system" as a near 102 year old who needs to be moved to a place where she is constantly under observation. At this time we all had expectations of a full recovery and being discharged as the damage was mainly bruising.

3) Mrs Green has yet another fall whilst on her way to the toilet. We have had differing reports on this incident but progressing to being told that this happened "under supervision". This is where I query the competence of the person involved. Did they just watch her fall? Did they attempt to grab her to save the fall? Surely, if the first fall did not flag any alarm, then the second one should? I consider this lack of action to be unforgivable and the second step to the loss of a lovely lady.

4) Talking to a quite bruised Mr Green she commented, "These bars on either side of the bed just make me want to scream. It is worse than being in a prison". It was only a few weeks ago that she told me that her doctor had given her the yearly "M.O.T.". He concluded with words to the effect of, "I don't know what's up with you because you are not young yet you are 100% fit. You are a complete mystery to me." We experienced the complete lack of ability of the Trust employees to prioritise patient needs "on-the-fly". During our visit on 26th November, Mrs Green complained of chest pains. As I was nearest to the door, I rushed to alert a nurse. Chest pains mean one thing to me as I have experienced my life being saved by cardiology's Dr Piers Clifford in this very same hospital when I received Emergency Angioplasty. It took well over 10 minutes before anything happened. The mobile ECG was brought to her and the results were plotted. A nurse checked her blood pressure, pulse rate and oxygen level. She was fitted with the oxygen gear as seen in the picture. She was asked, on a scale 1 to 10, how bad is the chest pain. She replied "5". (knowing her strength I would immediately have taken this as 7). Mrs Green also complained of a pain in the left arm - this was noted by the nurse. We were told that she would have a blood test and X-ray later. We queried the shape of the ECG and were told that it was normal.

5) Remember that I had a mother who was born within 3 years of Mrs Green. Both of them lived through two World Wars and were brought up to do things for themselves and not rely on other people. The Nurses dealing with people are trained in so many things but I seriously wonder if they actually understand real people, especially the elderly and what they might get up to?

6) As I write this part I am becoming tearful and feeling very sick and very angry at "the system". Mrs Green simply wanted to go to the toilet, in the night. She has already said that the bars on the side of her bed "made her want to scream". Just like the rest of the patients, she knew that pressing her alarm was a waste of time. In her frustration she attemped to climb over the side bars and had a serious fall. David and myself saw many of her bruises but not all of them. When we went to visit her we were very shocked. (You will have the chance to see a picture of our poor, seriously damaged Mrs Green, but you should only look if you have a very strong stomach as she looks like she has really been beaten up. I would recommend that you DO NOT VIEW this picture. It makes me cry every time I look at it. This is how a dear friend who trusted Wycombe Hospital and gave so much time and labour to it was treated) We were told that she had been moved to her own room where she would be visible to the Nursing Staff as it was adjacent to the Nurses Station.

7) In respect of the family and Mrs Green I have changed my mind about 6). The only way that you may see this is by emailing the below and attaching Proof of Identity of your Medical Qualifications and the full reason that justifies your right to see it. Be warned that I am likely to reject your request now that I am told that there will be an inquest.

8) On the first day after the third fall, we realised that things were not good. We had previously asked about the blood test and X-ray results and had been told that they were both fine.

9) On the second day after the third fall, Mrs Green was not fully lucid and it was very difficult to communicate. For a time now we had daily been holding her hand, in turn, and most communication and understanding was from the squeezes; already these were weakening. By some accident, we then found that she had been placed on a 5 day course of antibiotics which would finish on Friday or Saturday (The doctor was confused because despite telling us that the course had started on Monday, she somehow made 5 days equate to Saturday).

10) When we visited on Saturday, we were both very shocked. Personally I would have expected to see her on a drip to negate the shock she had suffered. In fact the drip was removed when we were there as it had emptied. The nurse who did this switched off the drip and injected her directly with whatever the drug was, saying "it's a lot easier this way". (Easier for whom I ask?) David was told that his Mum "was a lot better than yesterday". We got just two words out of her, "Cheerio" and "Tuesday". As far as we can figure. "Cheerio" meant that she wanted David and myself to understand that she knew that the end was near. I stupidly replied, "You're not going anywhere" instead of, "Thank you Mrs Green for all of those lovely Tuesdays and God Bless You". She knew David was there as she looked at her loving son so much on Saturday. I am so honoured yet unable to think of it without it bringing tears to my eyes that "Tuesday" more than likely referred to me as she had said on many of my few hospital visits, "What are you doing here today? You come on Tuesdays". For the rest of my life, every Tuesday lunchtime I shall think especially of a kind and loving friend whom I shall no longer be able to visit - thank you Buckinghamshire Healthcare NHS Trust 2010 for your cuts. I also ask myself, "Is it also likely that Mrs Green dropped out of all priorities due to her age". I find the possibilty of finding true answers to any of my points ever being answered to be quite unlikely.

11) When I left her on Saturday I purposely left before David, so that he may be the last family member to see her. Fortunately, Chris Green went to see her later and left at about a quarter to eight. At no time was he told that "the end is near". On my way home I texted my friend in London to say "Mrs Green not at all well :-(", he rapidly replied, ":-(". He works in London and was on a later shift. As soon as I got home, I texted him again and also my friend in Birmingham to ask them to pray for Mrs Green, which they both acknowledged, so all three of us were praying for her. My London colleague gave me the usual phone call on the way home - by now I was in shock and asked him yet again to pray for Mrs Green as I said, "it will be a miracle if she makes it through the night". Already when David and myself left the hospital we both knew this was the last visit, despite my saying to him, "see you tomorrow, Inshallah". He replied, "I'll let you know if anything happens". This confirmed his understanding to me and I just had to cross the road quickly and get away, before I broke down in tears, in the street. I kept my phone on all night, expecting the SOS call relayed from the hospital to say that Mrs Green was seriously ill and that you should come immediately to accompany her on departure from this life. It would appear that hospitals no longer indulge in this practice.

Rest in Peace Mrs Green - we all loved you

Mrs Green was cremated on Wednesday 11th December 2013

I hereby accuse the Buckinghamshire Healthcare NHS Trust 2010 of supplying services not fit for the purpose and currently run in a manner unsafe to human life, specifically as the Health and Safety at Work Act only applies to the staff and not to patients in their care. Had Mrs Green been visiting a building site, using her walking frame, she would have not only been properly escorted by two people but had she fallen there would have been an immediate investigation and preventative measures immediately taken to prevent a repetition. Obviously a Health and Safety appraisal would have been undertaken prior to her visit. You, The Trust, have blatantly ignored updating the risk assessment and completely failed in the care of Mrs Green, not once, not twice, but THREE TIMES, resulting in her early and painful death from last fatal fall. A building site would have been shut down by now but you arrogantly allow dedicated nurses and doctors to work under these under-staffed and "patient-hazardous" conditions. There is a complete wall of secrecy around the facts that are given to friends and family. What we were told one day was invariably changed by the next day. The whole organisation is a hazard to the life of patients and I have no reason to suspect that things are any different in any other Wards. Personally, I was lucky on my last confinement to Wycombe Hospital, in the same way as many thousands of other people are. I know from personal experience that the patient alarm system at Wexham Park Hospital is equally useless and another friend found exactly the same at Birmingham Heartlands Hospital - she was in the bed next to another senior citizen. In the night, in just the same way as Mrs Green, this lady wanted to go to the toilet. She rang her alarm for so many times, with no response, that my friend, despite having a miscarriage that very day, took the lady to the toilet - on the way, she was reprimanded by a nurse who received a reply not fitting to come from a well brought up girl of 31 years old. If only Mrs Green had had a person like that in the next bed ...... I am not critiscising the wonderful care that is given. We have one of the best health care systems in the world, but apparently spoiled at rare times by "systems". I am only critiscising the lack of care that Mrs Green suffered.

I can only base my accusations on the limited time that I spent as a visitor. Were I asked for a Health and Safety Recommendation for this ward, I would suggest the following.

1) That EITHER the number of staff in Ward 9 be immediately doubled OR that the patient input be limited to a maximum of 12. The current under capacity of staff is a major risk to all patients at present.

2) That there be a permanent person (taken in turns), continually patrolling the patients to update patient priorities and needs on a real-time basis. This person would not attend to patients but initiate actions as required IMMEDIATELY. Considering that at any time there may be between 25% and 75% of the patients either asleep or observed to be perfectly safe, allowing 30 seconds per patient would result (currently) in a cycle time of 11.5 minutes. Time-of-day dependant we could approximate this to 10 minutes at night or 15 minutes in the daytime. This would allow for the complete removal of the alarm system which is currently only a frustrating feature to both patients and staff. My night-time thoughts say that this Nurse should be dressed in a distinctive green uniform and called a "Green Nurse", in memory of Mrs Green.

3) That all partition walls separating the main wards be removed so that patients taking risks or in imminent danger can be spotted immediately from the Nurse's Station and action taken before accidents happen rather than afterwards. (Mrs Green could never have been able to take the risk that she did, in climbing out of her 'prison'. Ask yourself how long it takes a weakened lady of 101 years, having already been subjected to TWO falls to climb out of this heightened bed. Who was patrolling? I believe that the cycle time as in 2) would prevent further cases like this.)

4) That the changeover period be changed on a basis of extending the time of the end of one shift by 15 minutes and making the next shift start 15 minutes earlier, resulting in a staff overlap period of 30 minutes. This would allow each new shift nurse / doctor to work with the previous one on a mirror basis so that they are up to date with things that are happening and they therefore preserve continuity, again in real time, also saving a lot of paperwork. The present system seems to involve a lot of paperwork and talking yet, as I witnessed, a lack of continuity where patient's requests were "lost" between shifts.

5) As The Trust seems to be so immune to complaints and to any Health and Safety issues anyway, a re-introduction of the ward "kitchen" with the basics of fridge, microwave and kettle. Although we were told that tea was available on demand for Mrs Green, this turned out to be more theory than fact. The increased risks to patients would be minimal compared with their current safety level. I am sure that no visitor would object to going to make a cup of tea or coffee for their nearest and dearest. A voluntary donation system for the provisions worked perfectly quite a few years ago.

6) It would appear to me that you run this Ward in exactly the same way as a Call-Centre. First come, first served, the rest of you stay in the queue. Some Call-Centres will tell you where you are positioned in the queue - no chance with the way you run your Trust at present.

7) The fact that patients have no hospital supplied entertainment seems rather poor. Most people have smartphones, touchpads, tablets or laptops to keep them company. Is it not time that this Trust came into the 21st Century and supplied free wifi in exactly the same way as Wexham Park Hospital and many others do? It wouldn't have helped Mrs Green, but it could certainly make many more patient's visits a lot more bearable. I just cannot imagine day after day without even being able to hear the news.

8) Finally, how many of you Trust Executives would like to lose your mother in the same way as we lost Mrs Green? Are you proud of yourselves for this?

At 15:55 on 4th December 2013, after final small updates and corrections this concludes my recollections of my visits to Mrs Green during her time in hospital. I attended her every day except for the first Saturday and Sunday.

Latest update, dateline Tuesday 3rd December.
I have never been one to take advantage of our freedom of speech yet never give the other party a chance to defend or reply or comment. In view of this I wanted to get some anonymous feedback from those on "the shop floor". This was my big mistake. I already knew that some of the patient-specific questions were unlikely to be answered but I just wanted to be able to honestly quote bed heights and the correct name of some of the equipment and drugs. This PDF is what I took to the hospital at around 4 p.m. this afternoon (3 Dec). You just cannot believe the difference in attitude of the staff between visiting a hospital to see a live patient and visiting after their death. To cut a short story even shorter, I was verbally ejected by a fuming, stony-faced Susan McTavish, the Stroke Specialist, as both the documents and my presence were deemed by her to be "inappropriate". As at 15:56 on 4th December, there has been neither any communication nor any comments. I trust that The Coroner will be able to get an honest answer to some of these questions as this publication is not only an open letter to The Trust but a true statement of affairs that I shall also offer to the inquest. Should I have any further recollections or afterthoughts, these will appear below this line. Except for any typo, grammar or punctuation corrections, the above is now "set in stone".

Points remembered after 4th December 2013

1) David and I had one conversation with a doctor regarding medication after Mrs Green was released. I would date this as 17th November plus or minus one day. We discussed the pros and cons of Clopidogrel and EC Aspirin. 5th Dec - I now recall that this was the doctor aforementioned who told us about the antibiotics course.

Feedback and Comments (No names will be given, even if requested)

6th December 2013

Q) Why did you stop any feedback after 4 p.m. on 4th December?
A) Sorry - I can now see that the above is ambiguous. The deadline was only for the hospital's members of staff. As you see, any comments may still be emailed.

If you have any comments you may contact me via
8 Temple End, High Wycombe, Bucks HP13 5DR, England
or just email