Staff and patients expose turmoil at A&E amidst overcrowding and understaffing

Leicester Royal Infirmary (LRI) is one of the busiest emergency departments in the country, seeing hundreds of thousands of patients every year. However, this winter, the hospital has sometimes felt 'unsafe' and 'chaotic' as it battles with soaring wait times, overcrowding, a lack of staff, an overreliance on agency workers, and thin on-the-ground resources despite minor improvements. We reached out to patients and staff who, over the last three months, had one of the most challenging winters ever, having faced the drop in quality of care first-hand.

What are the challenges?

The most apparent issue across the NHS is wait times. As recent as two weeks ago, nearly half of LRI ambulances experienced delays of 30 minutes or more in transferring patients to A&E staff during the week commencing 12 February, despite the expected handover time being 15 minutes. However, there has been a notable improvement since then, with now just over a quarter of ambulances facing similar delays.

According to the Care Quality Commission (CQC), which inspects hospitals and healthcare providers, there is "poor patient flow across health and social care" that has "further increased the significant pressure on this emergency department". Long delays in ambulance handovers have, in turn, resulted in many hours lost to the ambulance service whilst their crews wait outside the hospital. This causes further delays in responding to 999 calls to patients with severe conditions.

This pressure has had a knock-on effect, leading to long delays in care and treatment. 43% of patients were waiting longer than the target time of four hours in January, compared to a 30% average across England. A&E wait times have seen no improvement since this time last year. In December, 44% of patients waited longer than the target of 18 weeks for routine treatments. However, this has improved on the previous year and currently sits close to the England average. There has been some success in reducing the number of people across the region waiting more than a year for treatment.

Underpinning both these issues is overcrowding and poor staffing. The University Hospitals of Leicester NHS Trust (UHL), which oversees LRI, is one of the busiest NHS trusts in the country, serving a large population that spans Leicester, Leicestershire and Rutland. The trust employs around 17,000 staff and operates multiple hospital sites, including LRI, Leicester General Hospital, and Glenfield Hospital.

Exposing the reality

The CQC is England's independent health and social care regulator. It monitors and inspects services to ensure they are safe and effective and provide high-quality care. LRI's current inspection rating is 'Requires Improvement', the second lowest score between 'Outstanding' and 'Inadequate'.

During its last inspection of the emergency department, which was unannounced, the CQC highlighted they had "concerns about the quality" of core services, including A&E. These concerns included waiting times for patients, delays in their care and treatment, delayed discharges, and delays in being able to hand over patients waiting in ambulances. There were nurse vacancies in A&E, and on some days, not all services operated entirely due to staffing shortages. A&E did not always have enough nursing staff with the right qualifications, skills, training, and experience, which increased the risk of patients suffering avoidable harm.

A&E relies mainly on bank and agency staff and nurses from other wards or departments. According to the CQC report, new bank and agency staff underwent a local induction in the department. But The Gazette has heard first-hand accounts of agency staff neglecting core responsibilities and standards of care. Other actions by the department included opening and closing areas as necessary, including the GP assessment unit and asking matrons and senior nurses to cover clinical shifts.

The inspectorate has not returned to A&E since it declared a critical incident in 2022 and 2023. Still, in a subsequent report about the maternity ward published in September 2023, poor staffing was identified there, too. They said, "Service did not always have enough staff to keep women and birthing people and their babies safe". Staff levels continually missed targets, "putting the safety of women, birthing people and babies at risk".

By the CQC's standards, these areas have only slightly improved over the last few years.

A frontline perspective

We spoke to one nurse who works at LRI under the condition of anonymity to protect their employment. The nurse said, "In the wintertime, it felt unsafe, chaotic. There's not enough staff and too many patients. Like it was not a realistic expectation that everyone would be able to be looked after properly".

They previously worked as a healthcare assistant at LRI, where they observed patients in the waiting room "because no one's really keeping an eye on them, because it's a packed out waiting room". Often, the department would get so busy people would be "sat on the floor, vomiting into bowls". Because it was so busy, they were forced to pull people out of the waiting room "into a little box" and get through as many patients as possible throughout the night. Some patients "needed to be in a bed" and "needed to be seen by a doctor, like, urgently", but there were "people getting missed left, right and centre".

The pressures on NHS staff at LRI are insurmountable. "It's a horrible job for the nurse in charge because they are trying to manage a sinking ship and just manage and mitigate the risk, and it's impossible". Now a nurse themselves, they said: "It's drilled into you, like if you fuck up, your head is on the chopping block", and "you're gonna go to jail". Some of his colleagues left the NHS after they felt like they "[couldn't] provide safe care in that department".

While staffing has improved, according to their observations, bolstered mainly by nurses from abroad, "nothing has changed in the department physically" because "there is no room for more beds". They commended their colleagues, saying, "The people who work in that department are incredibly efficient, and they work with what they've got". However, their department "heavily relies on agency staff".

On any given shift, they work with around three agency staff. "That's quite a big proportion of the team," they said. At most, their department will have eight to ten nurses, including the agency staff. "But it can be more often. If there's sickness, there's even more”.

While they love their job, there's "a lot of uncertainty from shift to shift", and they like to "know that you're going to come to a shift that is fully staffed every single time", but more often or not, that isn't the case. Their department sometimes requires specialist care for vulnerable patients, which only NHS staff can administer. In contrast, agency staff "cannot do a lot of stuff" because they're "unfamiliar with the area and not as experienced".

In late January, LRI and Glenfield Hospital declared a 'critical incident' for 48 hours after hundreds of patients were left waiting hours to be seen, threatening patient safety. One person claimed on social media that "seriously ill people were waiting for nine hours in the back of ambulances". The Gazette could not independently verify this claim. However, at the time, the Chief Medical Officer, Dr Nil Sanganee, echoed long-running issues like "high number of patients needing care", "a challenging ambulance handover situation", and "limited ability to discharge patients to onward care or home". It wasn't the first time a critical incident had been declared either. UHL also entered crisis mode last winter across all three of its hospitals, LRI, Glenfield Hospital and Leicester General Hospital. It was declared on Friday, 30 December 2022, and stood down 48 hours later on Sunday, 1 January 2023.

Unsafe and chaotic working conditions directly impact staff, affecting the quality of care. Our nurse source noted, "A few years ago, I had time off for my mental health because I really wasn't having like – I just – I just was not enjoying the job".

"There's a culture of being okay, especially after traumatic stuff has happened. I have many colleagues who say, 'Oh, that stuff just doesn't bother me anymore'. Like if someone dies, I'm like, of course it does. We are entitled to a little bit of counselling. That could be better. The focus on staff wellbeing also comes within the team itself. There could be dedicated people who are there for them".

During these critical incidents, UHL encouraged people to call or go online to NHS 111 instead to avoid further overcrowding of A&E. However, many claim it's almost impossible to stop these incidents from happening without additional funding from the central government. Despite the government's most recent budget, between 2022/23 and 2024/25, expenditure on health and social care is projected to increase by an average of 0.1 per cent annually in real terms. But it is important to remember that this masks additional investment during the Covid-19 pandemic.

At the bedside

We also spoke to patients who visited LRI during its rocky season. Rebecca Richards, whose daughter Ellie, 21, is autistic and was showing "clear signs of appendicitis", recently called 111 to ask for advice. They requested she visit A&E, but the call handler felt that "the four-hour wait for an ambulance was too long given the fact her symptoms were so severe", so they paid for a taxi to get her to the emergency department immediately. It took two hours for Ellie to be seen despite her neurodivergence, and when she was caught, she was told to visit the walk-in centre in Oadby instead. "She was given no pain relief, nor did they bother to actually examine her. At this point, it was all too much for Ellie. She was absolutely devastated that they wouldn't help her, and she wanted to just go back to her flat, which is her safe space, and deal with the pain on her own".

In the end, the family decided to go to Queen's Hospital Burton in Staffordshire, where they immediately recognised the situation was severe and gave Ellie morphine to help with the pain. "But before the surgery could happen, her appendix ruptured as so much time had passed," her mum said. Ellie had to spend extra time in the hospital due to infection from the rupture spreading, further distressing her as "she does not do well outside of her home in any circumstance, let alone in a strange place".

Recounting the experience, Rebecca said:

"I am absolutely disgusted and sickened by the behaviour of LRI. I feel that being sent in a taxi didn't help, but unfortunately, here in Ashby De La Zouch, the waiting time for an ambulance is absolutely outrageous. If Ellie had just gone home, she could have ended up with sepsis or worse. I have been waiting to hear back from PALS [Patient Advice and Liaison Service] for weeks now, so I presume they must have a lot of complaints. I won't rest until I have an explanation for Ellie's treatment or, rather, lack of treatment. It's unbelievable that someone as sick as she could be turned away without an examination. I wouldn't attend LRI now as I don't trust them".

Another resident, who chose not to be named, told us that their "mother-in-law has been at LRI for weeks, recovering from a nasty chest infection which saw her O2 levels drop to 70%". Speaking frankly, they said, "Money issues aside, some of the staff would do well to find other careers. I've had to stay by her bedside for almost two weeks due to the constant issues on her ward".

Some examples they gave included catching staff "trying to give her plain water despite being written on her door she needed thickened fluids as she's currently at risk of choking" and "the same with soft food". According to our source, they repeatedly tried to give her biscuits and other unsuitable foods. "On New Year's Eve, the kitchen sent boiled potatoes and omelette and told the domestic ‘that's all you're getting, so deal with it’". According to the individual, the domestic staff were "so ashamed" and "embarrassed" when they brought the food in that they couldn't apologise enough. They encouraged them to complain.

While at risk of hypoxia, on multiple occasions, they found their mother-in-law's O2 pipe disconnected, machines beeping, and staff just outside the room "on the desk, not even slightly concerned". They said, "I've observed staff that cannot figure out how the IV machine works".

Because they have spent so much time at LRI in recent weeks, they have witnessed other incidents of poor quality of care, including one woman whose carer started an argument with staff because "she had been left uncared for in a pad all night and hadn't been changed. Nor had she been washed or fed. Her hair was all matted up".

"I understand that they are busy, which is why I'm here to help care for my mother-in-law, but despite our best efforts to work with [the staff], they just don't listen or care. When your back is turned, they drop the ball, and standards drop. And some of their attitudes are just plain disgusting. How dare you ask them anything! Or, god forbid, ask some of them to do anything. They look at you like you've asked them to chop off both their arms!"

In recent weeks, their mother-in-law was transferred to the Leicester General Hospital, where the standard of care has appeared to improve.

• If you or a loved one have experienced poor quality of care at any of Leicester's hospitals, you can share your thoughts and feedback anonymously by filling out a form on the UHL website here. If you believe you or someone you love has experienced severe neglect, you can make a complaint to PALS here.

Additional reporting by Emma Guy.