Change The Way Hospitals Investigate All Serious Incidents involving Death and Harm

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Overview
Meet Jessica Rae Rudland; my daughter described as a ♥ Social Butterfly ♥ by her friends. Very intelligent, bright and bubbly and loves all animals. On Sunday the 2nd August 2015 our beautiful daughter visited the local A & E Department at The Ipswich Hospital NHS Trust. She was, short of breath, and had a persistent cough. There was also a prominent bulging vein on the right side of her neck that looked to be racing. 

What Happened
When a member of the public attends hospital, they are entitled to receive safe appropriate and effective care. And when things go wrong we should be assured that everything that can be done will be done. In cases where severe harm occurs and death, the hospitals serious incident protocol is triggered which may result in a serious incident requiring investigation (SIRI)

Serious incidents requiring investigation
Are regulated by an NHS framework/process for the purposes of learning and prevention of reoccurrence, so far so good? The framework is comprehensive promoting engagement, openness and transparency. So you would be forgiven for thinking that when serious harm occurs to a patient then the investigation will in all cases result in all of the above and an external or independent investigation would take place - not so!

The majority of SIRIs are conducted internally 
In our opinion and experience, the regulatory duty of candour was not met and the level of transparency, openness and engagement sadly fell seriously short and in some areas was non-existent. We couldn't count the number of patronising comments followed by the shaking of heads and rolling of eyes. All we wanted was to help our local hospital to be the best it could be and learn from this.

Our wake-up call
The penny finally dropped - UK Hospitals have been marking their own homework for years and no one's battered an eyelid. Mistakes happen we get it! But, its how you handle them that really makes the difference. So help us, help our NHS be confident and comfortable to learn from its mistakes and conduct itself in a manner that reduces patient harm through learning.

After all, at some point in life, all of us will undoubtedly need to call upon the services of our NHS, which we are so very lucky to have.

The changes we propose
SIRI's must never be conducted internally, by colleagues or anyone who has a conflict of interest within the same NHS organisation where the incident occurred.
We will be presenting our petition to the UK Parliament when we have more signatures, please sign if you agree the law needs to change.

As in maternity deaths, there is hope new laws will force NHS healthcare providers to independently investigate serious incidents in the future. Our hope is this will be enforced broadly.



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