Change The Way Hospitals Investigate Serious Incidents

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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. 

See Jessica's Story (website)

See Jessica's Journey on her Facebook Page

15 Days Postpartum
She had given birth to our first grandchild 15 days earlier, so while she felt fine in herself, to be on the safe side in case of a postnatal infection or pe which we had thought about, we felt she should attend. Jessica skipped jokingly with her Mother across the hospital car park, it was 11:48 pm on a Sunday night. Five hours later with an unfortunate misdiagnosis and no clear treatment plan, the on-call Consultant Cardiologist was called. I remain mystified by the GMC's latest ruling on the #BawaGarba case as it highlights the huge inconsistencies in the GMC Investigation Process.

Particularly when Junior Doctors are left to make emergency decisions without senior support, urgent patient review or attendance. 

I am human, I do care, this is not a witchhunt
As a member of the public, a parent who has enormous respect for doctors and nurses, concerns and questions raised after a serious incident where severe harm or death has occurred are met with denials, obstruction and no respect for the duty of candour. I hope one day this can change, there is much discussion online, especially Twitter all about #patientsafety and many organisations profess to support 'openness and transparency' when things go wrong.

My experience is they do not, I am no longer in the minority either. Many people share the same experience I have endured.

Jessica's treatment and management were remotely managed, even though lengthy delays, phone discussion and extensive treatment meant she was perilously close to what was later described as 'peri arrest'. Jessica finally went into cardiac arrest in resus. Jessica was in a coma for three and half weeks, had Sepsis and multiple organ failures, dialysis and subsequently, she got transferred to Papworth Hospital, but she suffered an anoxic hypoxic brain injury.

Help promote a specific escalation process
I am hoping this petition may help promote a specific escalation process (worldwide) that I feel should be in place for pregnant and recently-pregnant patients presenting as an emergency. This was a recommendation made by Dr Pam Chrispin after the fourth (SI) investigation report. This report should have identified 'the multiple systemic failures within this Trust, that were later identified' but it did not.

The impact on our family was catastrophic as we rallied to care for her newborn son who is now two and it's been life-changing for everyone involved, not least of all Jessica. 

The SIRI Process (SIRI) V1
With this in mind, the Ipswich Hospital launched a SIRI (Serious Incident Requiring Investigation) to determine how this had happened. Currently, most NHS SIRI's are conducted internally by members of the same hospital and investigate their work colleagues.

‘The lack of escalation to senior colleagues at an early stage, or to contact specialist advice, is concerning in retrospect. There seems to have been a failure by some clinicians to recognise the potential for the patient to deteriorate suddenly, and in those who did recognise it, this was not communicated. The practice of leaving a nurse during her preceptorship period caring for a complex patient after anaesthesia without apparently adequate supervision is also concerning. There also seems to have been a culture of poor documentation and lack of care relating to making and keeping notes.’ 

The changes we propose
SIRI's must never be conducted internally, by colleagues or anyone who has a conflict of interest with the NHS Trust involved.

As in maternity deaths, there is hope new laws will force trusts to independently investigate serious incidents in the future. I hope this will be enforced.

I have collated over 64,000 words from all the meetings held with staff members from The Ipswich Hospital NHS Trust which have been transcribed into text documents. All accompanying audio recordings have been retained, should there be any confusion about the contextual information within this petition.



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