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Patient Safety – The Real Cost of Not Acting on Serious Incident Recommendations

Patient Safety - The Real Cost of Not Acting on Serious Incident Recommendations

When I read this article in my local newspaper about the number of serious medical incidents, I was surprised how little appears to have changed over the last five years. In 2015 my daughter received life-changing injuries in my local hospitals A&E department.

In 2019 my sister died in the same hospital, the same bay in the same resuscitation department. Both were tachycardic with high heart rates, both deteriorated with questionably ‘sub-optimal care of the deteriorating patient.’ which led to a cardiac arrest. Later both were reported internally as serious incidents requiring investigation, my daughter had brain injuries at only 23 years old, my sister deceased. (To be clear my sister had a DNR) so once she deteriorated, no attempt to resuscitate her was made.

I strongly believe my sister’s death was avoidable so therefore a matter of public interest, thus felt compelled to write this post. The hospital under their StEIS category deemed this incident as “an unexpectedly intentionally avoidable injury causing serious harm.” Horrifyingly on reading my sister’s report recently received, the language was reminiscent of the care my daughter received. The report was framed around the actual severity of the incident which the hospital describes as ‘moderate’ then goes on to describe the incident type as ‘sub-optimal care of the deteriorating patient.’ This sounded familiar and was again like that used to describe my daughter’s incident in 2015.

My Sisters Serious Incident Report Findings
The report identified care and service delivery problems, lessons learned, delayed screening for sepsis and the sepsis 6 bundle, lack of clear and concise documentation for review and lack guidance for escalation processes, the laboratory was unable to communicate with A&E (phone was busy.) There was a familiar term used ‘To seek senior advice early in complex cases.’ This is sickening to read and demonstrates why Serious Incident Recommendations must be published, shared and embedded with all NHS healthcare providers at an early stage.

I read on and discovered my sister potentially had Sepsis on arrival at 7:25 am and that this was missed due to various lapses in her care. Her blood pressure was good, within range and her heart rate about 90 BPM. She began to deteriorate around 2:55 pm and was pronounced deceased at 3:30 pm. I winced when I read this report,  as she arrived unwell, but was not deteriorating. She appeared stable and staff were awaiting pathology results which were late arriving. MEWS score and Sepsis screening were not completed in the expected timeframe although she had a Red and Amber flag on arrival. She was not pre alerted as there were no concerns about deterioration.

Problems began when the pathology lab attempted to contact the A&E department multiple times but was unable to inform those treating my sister of ‘deranged blood results.’ By 9:15 am a doctor had established sepsis, by 10:44 steroids and antibiotics were planned to be administered. Due to the Acuity of the A&E department staffing and my sister requiring blood cultures, there was then a further delay in receiving treatment. She was referred to the Medical Registrar around noon according to the contemporaneous notes and report chronology. She went on to develop short-lived episodes of ventricular tachycardia and agonal breathing, this led to a cardiac arrest and death was pronounced at 3:30 pm with family in attendance. This incident report and many others that refer to additional therapies or alternative treatments, all seem to conclude the same “It would have been unlikely to change the outcome of death for this patient.” or “This would not have changed the treatment” when referring to additional therapies or alternative treatment. Yet in reality, I have first-hand experience of these serious incident reports (SI’s) and have evidence in my daughter’s case where a Doctor explicitly said, “Had the indicated investigations been done, this would have changed the treatment pathway” this information was excluded from my daughters final SI report for reasons unknown. I am also aware that multiple staff changed their statements during this process. This behaviour is dishonest, unsafe and does little for public confidence in the medical profession. Clinicians accounts after serious incidents are commonly called ‘Records’ yet the families recollection of events are referred to as ‘Stories.’ What is clear from the conclusion summary in my sister’s case is that some staff in this department are not meeting the required ‘fundamental standards’ citing a reference too “poor documentation from a range of clinicians” and although it gets a mention in their report, it is apparent that little or nothing has changed.

The medical regulators and quality commission
The CQC, HCPC, GMC, NNC allow what I call weighted evidence that favours the clinician’s account, otherwise known as registrants. When a member of the public raises a concern, they face a process that is; adversarial to the extreme, procrastinated and requires extreme resolve from patients and family. In this latest article published by ‘the patient experience library,’ highlighted the huge divide between ‘patients’ and ‘clinicians’ when things go wrong. It talks about a year of ‘The Coronavirus’ But it has also been a year of large scale avoidable harm in healthcare ‘Inadmissible Evidence.’ Frustratingly, in my sister’s report failings differ little from that identified four years earlier in my daughter’s report. Systemic failings in healthcare are well known and common in many NHS Trusts, Morecambe Bay, East Staffs, Gosport and East Kent are but a few of the major healthcare scandals featured in the media. However, there is little appetite to enforce a change in practice or indeed hold those involved to account. Save for a very few who end up in front of a Medical Tribunal Service. View my sister’s serious incident report conclusion here.

The 14 Recommendations from my daughter’s Serious Incident Investigation
I pushed on and pursued these recommendations in my daughter’s case for three years. Supposed ‘lessons learned’ from my daughter’s SI had not been embedded locally, referencing a continuance of incidents from local women who had experienced postnatal ‘substandard care.’ I met with a Hospital Inspector from the CQC at Addenbrookes Hospital. I presented a detailed dossier around ‘Safer Maternity Care’ and included references to Charlotte Sheilds-Bayliss aged 29 from Stowmarket, Suffolk (deceased) who attended West Suffolk Hospital after my daughters incident, Kimberly Jefferies aged 29 from Colchester, Essex (deceased) and other names of patients who had experienced ‘substandard care’ postnatally. These cases and others related directly to @ESNEFT and I was particularly concerned about patients being sent away, sent home feeling unwell, told they had chest infections, later referred back by their GP and confirmed as suffering heart failure. Two Mothers I spoke to both arrived on blue lights as emergencies after repeated visits to their hospital’s ED department. One was diagnosed as having sepsis, the other passed out in Deben ward and ended up in a coma-like my daughter. She ultimately had preeclampsia but her symptoms had been missed during a weekend visit to A&E.

I successfully gained assurances that my local Hospital would implement my daughter’s 14 Serious Incident Investigation Recommendations. Some were possibly in place according to my Soundcloud recordings, unfortunately, it never happened, the contact I had at the CQC left her post, the hospital, the local commissioners and other medical regulators said “if I had any further concerns” take them to the Parliamentary and Health Service Ombudsman (PHSO.) I did present a file and call them twice to describe my concerns, however, they never responded.

Two of the recommendations from my daughters 2015 serious incident relate directly to my sister’s incident in 2019. They reinforce The Real Cost of Not Acting on Serious Incident Recommendations. In particular escalation processes around complex cases and national consultant attendance guidance.

5. Escalation processes should be reviewed and staff should be encouraged to refer complex or unusual cases to senior staff for expert review at an early stage.

7. The Medical Director should consider issuing clearer guidance relating to senior review and review existing national guidance regarding when consultants should attend patients in person.

East Anglian Daily Times Newspaper
In this latest article which begins with the words “Concerns have been raised after a hospital trust in our region recorded a high number of patient safety incidents.” and “91 of the incidents were classed as ‘severe’ and another two as ‘death’. The ‘severe’ statistics for ESNEFT were the highest for any acute hospital in England. It was the same case for statistics covering the period between April and September 2019, where 50 ‘severe’ cases were recorded.” Concerns around mandatory training, staff resourcing, escalation processes and guidance are consistently failing to meet the required ‘fundamental standard.’ It further supports why all serious Incident Investigation recommendations must be shared.

My Daughter’s Final Serious Incident Report
In July 2017, when a third and final serious incident report. A draft report given to my family had 800 amendments and deletions. I was shocked that my My wife and I were branded ‘Paranoid’ by the previous investigator. Tracking comments in this report included “take that out”, “leave that part out” and “I wouldn’t say that” were rife, whole pages were removed, whole paragraphs around identifiable ‘patient safety’ issues and ‘fundamental standards’ were cleansed from the report making it completely useless to any reader in the context of lessons learned. This independent expert medical panel was not shown all the available evidence. The panel seemed more interested in writing a covering letter to the GMC supporting the consultant who had been reported to them over fitness to practice (FTP) concerns. This was while being paid and commissioned to investigate my daughter’s care. They may not have known this doctor was already on GMC five year fitness to practice warning.

When I later read a note addressed to the Medical Director, which read: “Happy for XXXX to turn it into defensible language” referring to the terms of reference for my daughter’s investigation. And “I have tried to get a sense of an evolving emergency, let me know if it needs to be stronger?” and now two years later, 13 witness statements (on StEIS/Datix) had appeared when originally there were only three? CCTV footage, ECG’s, Maternity notes, Anaesthesia records, charts and clinical medical records were all still missing. How could this panel have even come close to investigating this incident properly with no root cause analysis identifying basic missed opportunities to meet standard medical practice or conduct indicated investigations? The chairperson will say “it’s not our remit, it’s not what this is about and this is not a medico-legal report” but she’s happy for the terms of reference, by contrast, to be finalised for this report as “defensible language” by a legal entity. This was a contradiction in terms and completely unacceptable.  ‘patient safety’ and ‘public confidence’ in their profession continues to be destroyed by this type of attitude.

I knew from that moment, openness, transparency and impartiality were a myth. My family and I were devastated. When things go wrong in the NHS, people get hurt, reputation protection comes before any ‘patient’ within these organisations and yet they continue spouting the same rhetoric “Patient safety is our top priority and we are committed to making sure we care for our patients in the best possible way.” is offensive, unsupported by patient experiences and misleading. In this latest article, Kay Hamilton the interim deputy director of nursing at East Suffolk and Norfolk Essex Foundation Trust (ESNEFT) said: “Reporting and learning from incidents is key to this and we follow all the national NHS guidance on reporting patient safety incidents to the letter.”

“All those involved in my daughter’s serious incident investigation at The Ipswich and Norwich and Norfolk NHS Trust lacked the curiosity to fully explore all the evidence, which is astonishing. They missed the opportunity to derive valuable learning from this incident and key lines of enquiry were either overlooked, missed or worse ignored. Had they acted differently, other lives may have been saved – Chris Rudland, 2020.”

Ipswich and East Suffolk CCG (IESCCG)
I drafted a letter to the local commissioners raising my continued concerns about collusion, lack of impartiality, conflicts of interest and felt some experts on this panel had engaged in a report aimed at ‘limiting liability’ and that they ‘smoothed over the cracks.’ The only other conclusion was the panel’s ‘independent report’ was not entirely contributed too by them and had been heavily edited after their involvement. I challenged the chairperson and medical Director at a meeting in my audio files below. I asked the chairperson “so you stand by this report?” and “I can’t believe you’re putting your names to this” They both supported the report, its outcome, conclusions and recommendations. The health and safety investigation branch (HSIB) recently published a summary report on outcomes of medical investigation and noted “Investigations noted that reviews by colleagues can be subject to ‘confirmation bias’. This is a situation described in human factors and psychology literature where people tend to favour information that supports previously conceived ideas and preferentially reject contradicting information.

Soundcloud audio files of that meeting are in the links below. I have published these files in the interest of patient safety and to support other patients going through this process. I have left the audio files as is but silenced some parts of the audio to respect my daughter’s privacy. Names of those involved have not been excluded and I make no apology, but hope and trust that some of those involved will learn from this incident and change their practice. The CCG after receiving my letter continued to be dismissive, completely unsupportive. I received this response from the Ipswich and East Suffolk CCG.

“Having been provided with the opportunity to review Version 2 of the report which contained some draft elements that were amended in V3, it appears that the amendments do not materially change the meaning of the report. However, some of the amendments have led to key points e.g. opportunities to seek advice and escalate concerns, being highlighted in the V3 report on fewer occasions than in the earlier version. This may reduce the impact to any reader of these learning points in relation to the number of opportunities to act.”

The Ipswich and East Suffolk CCG Policy Document
And that was that all investigations by the Ipswich Hospital were complete, the clinical commissioning group IESCCG agreed and formed the same view. As of today, GMC legal (the legal body of the general medical council) has progressed my daughter’s case to The Medical Practitioners Tribunal Service (MPTS), a hearing is scheduled 8th Dec – 20th December 2020. So knowingly, unknowingly or worse, just completely bias, the last investigation failed to meet even basic prerequisites for an independent investigation. Quality, the definition of, how, who, actions plans, responsibilities and governance. The CCG’s own 2015-2016 serious untoward incident (SI) Policy Document sets out in an appendix ‘the process for undertaking independent investigations for the purposes of learning to prevent a recurrence. It describes the circumstances in which an independent investigation may be required and the process for commissioning and managing these types of investigation.’

For that reason, we will be requesting a full enquiry into this process from IESCCG in accordance with their own guidance.

Finally – Epilogue
From our families perspective, our wish is that any future ‘serious incident investigations’ within all these organisations must undergo robust quality scrutiny and assurances in accordance with their own policy guidance. There is still so much that can be improved if Serious Incident Recommendations are shared, action plans are monitored and implemented. It’s too late for my daughter Jessica to be ‘fixed’ my sister received ‘sub-optimal care’ and is ‘deceased.’ Patient Safety is featured commonly in the press, but little has changed. I urge all clinicians from all specialities to read this, please listen to the Soundcloud audio to gain a better understanding from a patient, family perspective. There are many opportunities to derive valuable learning from this incident both for clinicians in primary care who treat pregnant and recently pregnant patients and medical investigators who conduct face to face meetings with harmed and bereaved families. NHS Resolution admitted a breach of duty in the care that my daughter received and liability in June 2020 at The Royal Courts in London. I am sharing this information for the wider general public interest and to help clinicians avoid the same mistakes.

Cardiomyopathy in Recently Pregnant Postpartum Patients
The indicated investigations, in this case, were not performed after triage. The Adult tachycardia (with a pulse) algorithm Resuscitation Council UK were not followed, an incorrect diagnosis was established. No identification of rhythm type was established. Rate control commenced pharmaceutically then electrically under an RSI. Intravenous Metoprolol, Magnesium, Adenosine, Hartmanns, Verapamil were used concomitantly as therapy in short succession. A detailed case study will be available at a later date.

Audio Audio Audio Audio Audio Audio
Meeting Review Summary Discussion Discussion Discussion
Hospital Records Highest Number of Patient Safety Incidents – 2020 Link to article
Blackwater Law Serious Incident Report at Ipswich Hospital – 2018 Link to article
10 Serious Incidents in One Month Ipswich Hospital – 2017 Link to article

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