172 petitions

Update posted 2 weeks ago

Petition to Therese Coffey, Sandy Martin


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. Her symptoms were described later as pale, shortness of breath, a persistent cough and a prominent pulsating vein on the right side of her neck.  See Jessica's Journey on her Facebook Page 15 Days postnatal She had given birth to our first grandchild 15 days earlier, so whilst she felt fine in herself, it was a case of just to be on the safe side in case of a post natal infection. Five hours later following what in our opinion was hasty treatment without investigating other causes and a cocktail of drugs that seriously impacted her ability to cope, then electric shock treatment, without calling for senior obstetric advice she had a cardiac arrest in A & E, was in a coma for three and half weeks and subsequently suffered an hypoxic brain injury. The impact on our family was catastrophic as we rallied to care for her new born son who is now two and it's been life changing for everyone involved, not least of all Jessica. We are told by experts, it is extremely uncommon for a 23-year-old otherwise healthy young lady to walk into an A & E department and have a cardiac arrest in resus following treatment. The SIRI Process 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 own work colleagues. What we are about to share, affects you too, all of you if you use the NHS. We believe we have opened up a can of worms and need your help to petition for a change in order to Safeguard Patients and ensure that families going through the SIRI process, are provided with the answers they deserve (where possible) and the duty of candour (openness and transparency) when things go wrong are properly legislated in accordance with the NHS regulations to improve openness and transparency. The changes we propose SIRI's must never be conducted internally, by colleagues or anyone who has an association or where there is a conflict of interest with the NHS Trust involved. Our daughter Jessica received 4 hours of intensive treatment in Ipswich Hospital's A & E Department for what was described as an Arrhythmia, commonly known as an SVT (Super Ventricular Tachycardia) The possibility of her symptoms being linked to maternity or child birth days earlier wasn't even considered or appropriately excluded in accordance with best practice. Obstetric senior support  Had an obstetrician been called to assess her they may have considered other causation VTE? Sepsis? both leading postnatal killers and yet it didn't occur to the treating clinicians until after they had given her electric shock treatment (Cardioversion). The Hospital's first SIRI report was found to be not fit for purpose by an expert SIRI investigator stating "The Trust failed on every level" in relation to the SIRI, least of all that Jessica's Mother who was with her throughout her stay in A & E and had witnessed her daughter in cardiac arrest, wasn't even asked to give a witness statement. As new grandparents, the past two years should have been simply full of joy, a time of celebration. The family challenges we face are easy to overcome our daughter survived. What's important is that she will improve and that any lessons are learnt. We expected the hospital SIRI report to be open, honest and transparent and thorough, instead, we were left reeling as nepotism, denials, dismissiveness and a distinct lack of curiosity presided. As business professionals with expertise in strategy, policy, process and technologies, we were well equipped to understand the process and as members of the community we wanted to work with the hospital to understand what happened to Jessica, we also possessed a genuine desire to aid the process and ensure that the report was representative of the facts. Nearly two years on liaising with GMC, NMC, CCG and The Ipswich Hospital NHS Trust, it is evident that most written policies are never disseminated nor followed by the majority. For some, Serious Incidents Requiring Investigation are a duty undertaken in addition to the day job and therefore sketchy and incomplete and keeping abreast of legislative changes is secondary to the pressures of the day job. CCG's are meant to oversee the process with Robust Systems and a Quality Assurance system so this does not happen. In Jessica's case, her SIRI report and its findings were signed off and closed without it raising any red flags. What does that say about the CCGs policing of the process? The History 1. Meeting One August 5th - 2015 A & E Department Ipswich Hospital. Because of concerns about Jessica's condition and a real noticeable lack of information from staff, I asked to speak to someone in A & E two days after my daughter's cardiac arrest to understand how she had ended up in a coma. Senior staff were gathered, a Doctor apologised for what had happened to Jessica and everyone appeared to be very helpful, continually assuring us they could not answer all our questions but that would all be covered in the Investigation that was likely to take place. We were advised a Serious Clinical Incident Group (SCIG) meeting would take place in days and requested that we are involved in any investigation and be allowed to record all our meetings so we could write them up afterwards. We completed a walk through the A & E Department ending up in resus where Jessica had her cardiac arrest.  2. Serious Incident Investigation Report (One) The Ipswich Hospital NHS Trust (IHT) conducted an internal SIRI September 2015 using one of the consultant Anaesthetists who treated Jessica in CCU. I was again assured by multiple senior staff this would be a full and comprehensive investigation into the Treatment and Care my daughter had received using The Root Cause Analysis Methodology (RCA). It later transpired the lead investigator had undergone half a days training in-house in RCA and subsequently produced a report that quickly raised concerns. Not least because many of the treating clinicians involved in my daughter's care had not been formally interviewed, provided serious incident statements or were ever contacted. He (the lead investigator) had also excluded Jessica's Mother's eye witness account from his formal investigation. It was also apparent some clinical records, medical notes had gone missing or were no longer available. 3. Meeting Two 11th November 2015 Ipswich Hospital HQ I raised concerns with the IHT as the first SIRI report findings were not fit for purpose in my view and IHT's initial approach after we met Meeting Two November 2015 was one of denial, defence and no recognition of the serious harm that had affected the patient. I quickly I learnt accountability, responsibility and ownership when things go wrong in this NHS Trust bear no relationship to the nationally recognised Duty of Candour which they promote on their website when significant patient harm occurs. In March 2016 I wrote to the commissioners at the Ipswich and East Suffolk Clinical Commissioning Group (IESCCG) and outlined my experience in dealing with the Ipswich Hospital, my concerns and decided to raise a complaint about the handling of the SIRI process at Ipswich Hospital and the conduct of some of the senior staff we had dealt with in meetings.  My complaint was duly heard and a further meeting arranged at the CCG to discuss a way forward, I felt the investigation into the first SIRI investigation process needed to be completely independent of The Ipswich Hospital NHS Trust. This was agreed and an Independent Investigation from Essex was commissioned to investigate the SIRI process at Ipswich. The report was conducted in late 2016 and concluded with Trust wide failings, yet we received no formal apology for over 15 months. The Independent Report Commissioned by IESCCG  The Independently Commissioned Investigation into IHT SIRI Process 4. The Ipswich Hospital NHS Trust failures include: Failure to Secure Witness Statements from all those involved, on or close to the index event and they lacked the professional curiosity to further explore key lines of enquiry including those raised by the family with Trust staff, including SCIG members consistently from 5th August 2015 including CCTV footage, Vital Sign Reports and questions about the competencies of staff left with Jessica. A disjointed chronology and clinical narrative exist because Key witnesses were not interviewed, gaping holes exist in clinical notes and observations of a seriously ill patient are missing. Including but not limited to the lack of a formal statement from Jessica's Mother who was a direct witness during the treatment and care. Other medical staff including Doctors, Radiographers, and ODP staff were not found, have never been identified or sought since the incident. Recognition of cardiac arrest, the alarm was raised by the Mother, previous SI investigations have already confirmed her attendance before CPR commenced. Concerns were raised in relation to the training and competencies of the nurse who was still in her preceptorship and left attending the patient before and at the time of the cardiac arrest. Missing data sets from vitals machines lost or missing ECG's Anaesthesia Assesment, Anaesthesia Drug Charts, Observations and Instructions in Post Anaesthesia and a general lack of signed and date stamped monitoring observations. MEWS scoring prior to Cardioversion was the only documented record in clinical notes. (Good Medical Practice 'Keeping Records' General Medical Council and Generic Medical Record-keeping Standards 2007 Royal College of Physicians, London). 5. Meeting Three 26th February 2016 Ipswich Hospital HQ At this meeting in February 2016, I took along a family friend who was experienced in the management of ill patients and a Qualified Advanced Life Support Instructor and fully trained in the unsupported aeromedical repatriation of critically ill patients. He had read all the medical notes I managed to get during my Freedom of Information (FOI) request from Ipswich and questioned the lead investigator and the chairperson. Unfortunately there appeared to be some collusion between the those attending from The Ipswich Hospital. The meeting was stopped abruptly by Jessica's Mother and the chairperson was asked to move behind the lead investigator so we could question various aspects of the previous SIRI without them making eye contact. and better understand the discrepancies we thought existed within the report findings. Although various admissions were made about initial diagnosis and the drug Genuine questions about discrepancies with the report We felt we needed to understand the many discrepancies we had found in our observations and had posed genuine questions why these still existed within the report. Although a few admissions were made about the initial diagnosis, drug regime and medical management of a postnatal patient, there was some progress, there was a very obvious reluctance to discuss in detail the medical management, lack of differential diagnosis and the missing records. The lead investigator left the meeting after very critical questioning when his beep went off but did agree the Mother had raised the alarm to Jessica's cardiac arrest. We were left with the Governance Director and Head of Nursing in Division 1 who made very clear undertakings they would follow up on, both failed to follow up on any of their commitments and left the family feeling upset and let down.Letter of Apology Hospitals first letter of apology 13 months after the incident 6. Meeting Four 19th August 2016 Ipswich Hospital HQ After writing a formal complaint to The Ipswich Hospital NHS Trust and requesting a meeting with a senior board executive I met Clare Marx President of the Royal College of Surgeons with Jessica's Mother Sue. She listened, was empathetic to a point but would not discuss the previous failings. She wrote a very clear report after our meeting and instructed The Ipswich Hospital Trust in the next steps. This included what she called "A full investigation along the lines of "A Maternal Death Enquiry" which although sounded alarming meant we would probably get a detailed review of Jessica's treatment and care from Maternity up to the A & E visit on the 2nd August 2015. We were grateful she had seen us and remained hopeful The Ipswich Hospital NHS Trust would follow her recommendations. Clare Marx Report and recommendations 7. Meeting Five 12th May 2017 Report - V2 Ipswich Hospital HQThis meeting was to gain sight of the draft report from the Clinical/Medical investigation Clare Marx recommended in 2016. Promised in January 2017, it was now six months late and much anticipated by the family. It was to be conducted independently of the Trust. The Chair person was Dr Pam Chrispin and a panel of experts. On seeing the report I quickly realised key lines of enquiry had again been ignored and various clinicians had not been contacted as was agreed in the Term of Reference (TOR) Moreover, the format of the report did not resemble the RCA Methodology and appeared to be one person's summary, rather than the expert panels views. The report had no appendixes or attached supporting evidence from the panel, no tabular timeline and did not use the fishbone diagram. We also noted there was no reference to dated witness statements. 8. 15th May 2017 writing to The Ipswich Hospital NHS Trust I wrote to the Ipswich Hospital within two days of receiving the report"Personally as a family, we are dismayed at the lack of consistency and had thought some cooperation early on in this investigation process would have made our position very clear when we presented the terms of reference to the Trust. Having gone through the experience of the first SIRI report from the Trust and the independent investigation into that process, which found Trust wide failings. I was confident this investigation would do far better." "We are sorry our observations may sound over critical in view of the time the Trust has taken to do this investigation. However, we make no apologies for the overall feeling of distrust for this whole process and some 21 months after the index event (Jessica’s Brain Injury) we still do not have answers to our questions." In summary, I asked if the report could be rewritten and formatted in accordance with nationally recognised RCA investigation standards as a comprehensive investigation. I would like all expert reports any supporting evidence included as appendices as in the first SIRI report where a Consultant Cardiologist added his section in his own writing. I would also like to gain sight of all statements as they form part of this investigation document and have been used, they are no longer privileged. All references to interviews and signed statements that were taken need to to be detailed in the Information and evidence gathered section. Where evidence including CCTV, ECG’s and other medical notes including anaesthesia charts are not available, that needs to be documented in the report so all those reading will understand the full clinical picture and understand where assumptions are being made. I would like the report written in plain English and either reduce all the medical terminology or provide a description at each section in plain English for the layperson. Where the timings, drug regime and procedures take place I would like the supporting evidence included as a narrative. If the supporting evidence is no longer available for whatever reason, that needs to be clearly described as in section 4 above. Where there are clear conflicts with the accounts provided by the eyewitness and the hospital staff, that needs to be clearly identified in the context of its importance.  "These are some of the observations we have made but by no means all of them. Please, can you get back to me so we can discuss matters further?" From 15th May until 17th July we made various phone calls, sent emails and tried to get a meeting with the Trust to discuss the final report version we were now calling V3. We thought we had finally made some progress with Dr Pam Chrispin and hoped there would be some minor amendments and missing interviews would be conducted to bring the final report completely up to date. Then we received this letter from the CEO Nick Hulme at The Ipswich Hospital NHS Trust suggesting we go to the PHSO as the Hospitals Investigation process had now concluded. This was the first direct correspondence we had received from him in nearly two years despite many emails, he answered apologised for not intervening earlier, the protracted 2-year wait to get this far and then closed the door to any further engagement. Finally, we received this letter from the CEO at the Trust Nick Hulme 9. 19th July 2017 - Went to the Hospital to collect a Final V3 Report On comparison of the V2 draft from 12th May and the V3 report finalised by Dr Pam Chrispin 19th May 2017, I noted the Trust Board members had made 877 deletions including complex information and whole paragraphs about the incident, some included the expert views on what should and should not have happened. The Trust Board members had also re-worded many sections to suit the Trust's story of events. More worryingly the Ipswich Trust now include 12 Witness Statements in their V3 final report mostly backdated to August 2015. When the Independent SIRI investigation was conducted in September 2016, only four witness statements existed within the Trust's Datix system. A message to the Trust board members To all those Mums and Dads amongst the board members that have contributed to my daughter's Report, Revisions and Deletions. I do hope you are proud of your contribution at work last week and go home satisfied that your actions represent your professions conduct at the highest level. Clare Marx 2016 recommendations "By failing to cover all aspects of this episode we have missed the opportunity to derive extremely valuable learning from this incident." Chris Rudland July 2017 "The Ipswich Hospital NHS Trust had taken four steps forward in my daughter's investigation and now board members have demolished that progress with their latest actions. Shown a blatant disregard for (the duty of candour) when things go wrong and ignored all legislation." 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.

Chris Rudland
703 supporters
Update posted 2 weeks ago

Petition to University of East Anglia, Jon Sharp, David Richardson

Reintroduce Subsidy For Medical Certificates

The University of East Anglia (UEA) will be ending their subsidy for some students, which ensures that students do not pay for medical certificates. Learning and Teaching Hubs at UEA demand that students provide medical evidence if they apply for more than one extension. Extenuating circumstances often mean that students are in a bad place already, and now students registering in September are expected to pay £35 for a certificate. This is outright financial exploitation. It will only discourage poorer students from applying for extensions, whilst those with disposable income can afford to pay. Not having to worry about fees made my applications for a certificate simple and worry free, and I want every student to have these opportunities. I'm calling on UEA to reintroduce the subsidy and ensure that all students have access to help and support. Concrete, the campus newspaper, noted: 'From September, new students will have to pay a charge to the UEA Medical Centre (UMS) for a medical note. Students who need a medical certificate to apply for extenuating circumstances or an extension will be charged the standard NHS levy of £35. There will continue to be no charge for exam certificates. The university currently pays a subsidy to the UMS so students are not charged for a UEA Medical Certificate. For the next academic year the charge will apply to first year students. From September 2018 only first and second year students will have to pay and from September 2019 it will apply to first, second and third years. The charge is expected to be staggered so by September 2020 all students will have to pay.' Full Concrete article: It is clear that this will only disadvantage poorer students, and those with a limited disposable income who cannot afford the £35 fee. Illness should not result in students being exploited for financial gain. If UEA desires medical evidence so badly, then they should cover the associated costs. Students pay enough. Education is not what it used to be, universities are becoming more like companies and less like educational institutions.

Tom Howard
1,323 supporters