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Care Quality Commission Issues Damning Report On Marie Stopes Abortion Practice

The Care Quality Commission (CQC) have released a report detailing the abuses and failures in the abortion facilities of Marie Stopes International (MSI), the independent sector group that performs over a third (70,000) of all abortions in the UK.

The initial public notification of the CQC findings in August led to the suspension of not only all their surgical abortions, but also all ‘medical’ abortions for young people and children, as well as those with learning impairments.

The issues in the CQC Report can be summarised as affecting:

    • Enabling of legal abuses by ‘bulk-signing’
    • Safety:
      • Reporting of incidents
      • Resuscitation / life support
      • Anaesthesia
      • Safe surgery
    • Safeguarding of children and people with impairments

Some of the most notable sections mention:

Enabling of Abuses by Bulk Signing HSA1 Forms:

Page 36 describes the bulk signing of HSA1 forms, which could enable illegal abortions (e.g. sex-selective abortions):

“The Required Standard Operating Procedure (RSOP) standard one requires providers to ensure that the completion of legal paperwork (HSA1 and HSA4 forms) is undertaken in a timely manner. However, on inspection we found that in two centres there was bulk signing of HSA1 forms by clinicians, of between 30 to 60 forms at a time. Surgeons and anaesthetists were requested to do this as the demand was too great for remote doctors and we were informed by doctors that HSA1 forms were being signed on the basis of the ‘reason for termination’ information only, which was printed or handwritten on the back of the form. We were not assured clinicians had access to all patient information. Completion of HSA1 forms was mentioned specifically in job plans for remote doctors, surgeons and anaesthetists. We noted that there was no allowance for time taken to review patient information as relevant, within these specific job plans.

“We were also concerned that there was a lack of assurance that two signatories had been obtained before prescribing abortifacient medication. We raised this matter with the provider, who undertook a review of the signing process and issued further guidance to MSI staff. The provider undertook an audit of the process which demonstrated that 95% of audited forms were signed prior to the administration of abortifacient medication. However, there was no evidence of on-going monitoring of the new processes”.

Safety:

Page 19 describes experimentation with a new kind of abortion procedure, without notification of the potentially dangerous risks to patients:

“During four location inspections we raised concerns regarding the way in which the treatment option of the simultaneous administration of abortifacient medicines in order to effect an early medical abortion (EMA) had been introduced on 22 February 2016. Corporate emails and consent forms were circulated across the service’s locations regarding these practice changes. However, the MSI policy dated October 2015 had not been updated to reflect the introduction of simultaneous administration of medicines”.

“Staff at the locations, including the centre managers, had not participated in the development and implementation of this treatment option and were unable to provide us with an explanation or evidence of the decision making process behind the introduction of the new treatment. Staff could not assure us that treatment was evidence–based. Managers could not direct us to risk assessments or action plans for the evaluation of this treatment, or any evidence of outcome monitoring since the practice had changed. One member of senior staff stated that this treatment option had been introduced on the basis of one paper. MSI had not informed patients that this was a trial, did not have evidence of efficacy and did not inform patients of the potential of any increased risks of a failed abortion or the retention of the products of conception.

On page 7, the report mentions that there were 2,634 ‘incidents’ in 2015/2016, an increase from 704 in 2014/2015. The reason for the increase is given by MSI that there had been an increase in ‘activity’ (presumably, abortions demanded).

On page 8, the report describes an example of an ‘incident’:

“During our inspection of one location, we observed an incident involving a patient who became very distressed, where we witnessed inappropriate behaviour by a surgeon. Although we wrote to MSI to inform the provider of the incident and ask for an update as to how it had been dealt with, the incident was not reported through the MSI incident reporting system. However we did not witness the practice of dealing with patients with a learning disability at the other seven clinical locations”.

With regards to investigation, page 8 states that:

“One investigation report showed that the investigation was not commenced until two months after the incident”.

On page 9, the report states that only half of members of staff at 13 registered locations had basic and intermediate life support training, and in Manchester just a quarter of staff did. Meanwhile, a fifth of their anaesthetists lacked advanced life support training:

“A review of the training records indicated that not all staff had the required level of life support training in place. Across 13 registered locations, a total of 51% of staff had completed basic life support (BLS) and intermediate life support (ILS) training as at May 2016. In some locations, training compliance was as low as 26% (Manchester) but in others, it was higher, such as 83% of staff trained in the Maidstone location”.

“We asked the provider for information about advanced life support (ALS) training. There were no records that were readily available. Following the inspection, it was confirmed that 79% of anaesthetists had ALS training in place as at 26 August 2016. Senior staff were unaware, however, of the requirement for staff that have ALS training to undergo an annual update as per Resuscitation Council (UK) guidelines and confirmed to us on 28 July 2016 that there were no records of any annual updates”.

Page 26 of the report describes a lack of means of checking the competence of anaesthetists:

“There was no effective system in place whereby the competence of anaesthetists administering general anaesthesia and conscious sedation was assessed and monitored to ensure they were carrying out their practice in line with national guidance. In the action plan sent to CQC dated 26 August 2016 the provider stated that this was achieved on this date through “Competency checklist; tracking of competency assessments, Quarterly reports filed on Open Door.” However, no evidence of such a system has been provided to the CQC. We noted from the action plan that the quarterly reports were to be completed by the lead anaesthetist by October 2016. However, no evidence was submitted that an initial assessment of competency had commenced”.

Page 21 of the report describes occasions of poor quality hygiene standards:

“Each location had an audit programme which included: hand hygiene, medicines management, infection control, safeguarding, medical records, equipment monitoring and health and safety monitoring. However, we could not find discussion of any issues at any of the governance meeting minutes. Whilst most centres scored above 90% in these audits, there were some notable exceptions such as handwashing at the Norwich clinic was 67%, infection control was at 82% in the Central London clinic and safeguarding was between 42 and 67% at the Essex, West London and Norwich clinics. Health and safety compliance was 69% at the South London clinic and between 84 and 87% at the clinics in Essex, Norwich and Maidstone. We saw no action plans to address these deficits.

Page 36 describes the lead surgeon and anaesthetist. The former is retired and had been for a year-and-a-half, the latter was not on the GMC register and there is no assurance that they are clinically competent.

“There was a lead surgeon and lead anaesthetist in place. The surgical lead was a retired professor of obstetrics and gynaecology. They had been retired for around 18 months. There was no succession planning in place for this post”.

“The lead anaesthetist was not on the General Medical Council (GMC) Specialist Register. The lead anaesthetist was responsible for providing clinical leadership and oversight of the One Call centre. We were not assured how the provider ensured the lead anaesthetist was clinically competent”.

Safeguarding:

On page 29, a disturbing story about a woman with learning impairments having an abortion performed on her without her informed consent:

“Whilst inspecting at one location we observed a woman with a known learning disability attend the clinic without a friend or supporter. The patient had noted on their record from the telephone consultation that they had learning difficulties. Although advised to attend the clinic with a friend or relative for support, they came alone and the treatment continued. Consent to treatment for this patient was not carried out in a way they could understand and we observed the situation was poorly and insensitively handled by doctors. It became apparent that staff had not checked discharge arrangements for this patient.

Page 29 also describes disregard for proper informed consent, including staff unable to inform patients, and some consent forms only filled in by healthcare assistants (and not counter-signed by clinicians):

The Royal College of Surgeons document Surgical Good Practice (2014) at 3.5.1 states “Ensure that consent is obtained either by the person who is providing the treatment or by someone who is actively involved in the provision of treatment. The person obtaining consent should have clear knowledge of the procedure and the potential risks and complications”. During our inspections at locations, we found that healthcare assistants were obtaining consent from patients against a checklist which comprised of complications for the individual procedure. Where the patient asked a question, in some instances the health care assistant had to leave the consultation room to find another member of staff who could answer their question. This did not allow for a two-way discussion about the intended procedure and demonstrated that the person with delegated responsibility did not in fact have su icient knowledge of the proposed investigation or treatment and did not understand the risks involved. Also, at inspection we found that some consent forms were only signed by healthcare assistants despite the policy stating that these would be countersigned by a clinician”.

Page 7 summarises that “[s]taff had no training in respect of female genital mutilation [FGM] or child sexual exploitation, putting these patients at risk of further abuse”. On page 12, further detail is given that:

“The training provided to staff at the time of inspection did not address the issues of child sexual exploitation or female genital mutilation. We found that there was no evidence to demonstrate that any training was given to staff on these issues. However, we also found that in seven locations staff were aware of the issue of female genital mutilation through previous experience or recent training. The proposed training outlined from a new training provider and from MSI’s safeguarding lead, for future training content, did not refer to staff receiving training on child sexual exploitation. Therefore, we were concerned that staff would be at risk of failing to recognise this factor of abuse. During our inspections of the locations operated by the provider, some staff were aware of issues relating to child sexual exploitation from their own personal knowledge. However, the provider had not provided training on this issue”.

Pages 11 and 12 state that a fifth of MSI staff lacked basic safeguarding training that was in-date. In two facilities, this drastically increased to over two-thirds.

“However, on review of the data sent to CQC dated May 2016, we found that only 81% of staff had level one training that was in date. In Leeds the percentage trained at level one was 36.4% and in West London the percentage was 33.3%”.

Page 12 states that, just over 40% of MSI staff had level two training (necessary for referral if abuse is suspected). In their Maidstone facility, less than a fifth of staff had received safeguarding training in the previous year.

“The policy stated that “Level 2 training is intended for all that staff that are able to take responsibility for making a referral if abuse is suspected. This would include clinical staff (registered nurses, doctors, anaesthetists). Additionally client liaison officers, Supervisors at call centres, and the management team within the clinical centres and call centres should attend this training.” On average we found that 59.8% of staff were trained at this level in child safeguarding identification and processes. In Maidstone only 16.7% of staff had had training on child safeguarding in the previous year. This does not comply with the Intercollegiate Document for Healthcare Staff  (2014) which states that all staff who have any contact with children or young people should have level two training. This includes non-clinical staff”.

Page 38 describes continuing failure to care for young people and assure their safety:

“The provider increased training provision to ensure that 80% of the workforce would be trained in level three safeguarding by the end of August, with the remainder to have been trained by the end of September. However, whilst this training is in place there is no assurance that children and young people will be assessed, managed and cared for by staff with the appropriate skills and competency to identify any potential safeguarding concerns. There was no evidence that the provider had taken active steps to mitigate known risks of failing to ensure the timely identification and reporting of potential safeguarding incidents in order that the safety of children and young people is assured”.