Meet Jessica Rae Rudland. Previously fit, and well, this is an introduction to her story. She suffered a Cardiac Arrest and Anoxic Brain Injury at The Ipswich Hospital NHS Trust. During her time in Critical Care Unit, she contracted Sepsis, multiple organ failure and was in a coma for over three weeks. She is 25 years old now and continues with her acquired brain injury (ABI) rehabilitation.
Patient Safety and Patient Harm
There are different levels of patient harm. Serious Incidents in health care are adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. Described by NHS England as acts or omissions in care that result in; unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm – including those where the injury required treatment to prevent death or serious harm, abuse, Never Events, incidents that prevent (or threaten to prevent) an organisation’s ability to continue to deliver an acceptable quality of healthcare services and incidents that cause widespread public concern resulting in a loss of confidence in health care services.
Severe harm represents prolonged and psychological harm to the service user. A permanent brain injury meets that criteria. Jessica was a very bright and bubbly 23-year-old before her injury. She had worked in a building society and recently given birth to her gorgeous son Lewin. She was 15 days postpartum and on maternity leave.
On or around the 1st August 2015 she became short of breath, lost her appetite and had signs of an illness. She had a fast pulsating vertical vein in the right side of her neck. When as parents we asked about this, Jessica said: “It had been like that since she was eight months pregnant.” She also appeared very anaemic looking, was very pale and felt very exhausted.
Jessica was by now caring for her son Lewin, had reported the vein to health visitors and the midwife who showed no signs of concern. Her GP also saw her two days before her delivery date and sent her to the local hospital because of reduced fetal movement (RFM). Jessica was seen by a core trainee Obstetrician, kept in the hospital waiting for four hours to see a doctor and released home with no concerns.
When Jessica attended the hospital’s Antenatal Day Unit (ANDU), she shared her CTG image scans and video with me from her phone. A record of her time there has been documented and kept, but the hospital’s Freedom of Information (FOI) request contained no recorded of her CTG image scans during her visit and her observations from that visit have not been commented on.
15 days Postnatal and unwell, we called 111
By the evening 2nd August 2015 we (Mum and Dad) rang 111 and reported our concerns, as Jessica was postnatal and with her combined symptoms she was advised to visit her nearest Accident and Emergency department at The Ipswich Hospital NHS Trust. After arriving at 11:58 pm and triage, Jessica went on to receive treatment for a Super Ventricular Tachycardia (SVT), she later suffered a cardiac arrest in the hospitals resus department after treatment for Atrial Flutter/Fibrillation. She was put in an induced coma after successful CPR and suffered multiple organ failures over the coming days.
Numerous serious incident (SI) investigations have been conducted since Jessica’s injury. An Independent review has been commissioned into the first (SI) process by the local Clinical Commissioning Group. There are still many unanswered questions which the family have raised with The Ipswich Hospital NHS Trust since August 2015.
The trust now refuse to engage with the family any further and have closed their investigation process. The local Clinical Commissioning Group have also refused to address our concerns and like the hospital suggest, we now contact the PHSO Ombudsmen.
With the CCG supporting the Hospitals decision to close the investigation process, Jessica’s treatment, care and outcome will not be investigated any further by this provider. Therefore the potential for learning from this incident will be forever lost.
(Improvement NHS UK, 2017)
1. Improvement NHS UK. (2017). Serious Incident Framework. [online] Available at: https://improvement.nhs.uk/uploads/documents/serious-incidnt-framwrk.pdf [Sep. 2017].
2. Maternal mortality. World Health Organization. 2017. [online] Available at: http://www.who.int/mediacentre/factsheets/fs348/en/ [Sep. 2017].
3. Maternal death. Enwikipediaorg. 2017. [online] Available at: https://en.wikipedia.org/wiki/Maternal_death [Sep. 2017].