Frequently Asked Questions

Who is Jessica and what did she do before her injury?

Jessica is a 27-year-old Mother to Lewin who was just 15 days old when she visited The Ipswich Hospital NHS Trust. Jessica used to work for the Nationwide Building Society. She was in an eight-year relationship with Lewins Father. That relationship ceased in October 2016.

 What happened in A&E that evening and when?

Jessica visited her local hospital because she had symptoms after the birth of her son that worsened. She was breathless, lethargic, anaemic and had raised neck veins which were pulsating rapidly. She had a fast heart rate of 196 beats per minute (BPM) and had lost her appetite. Her blood pressure was normal. She continued to feed her son and had cared for him since his birth for fifteen days.

  Which Hospital Trust did Jess visit?

The Ipswich Hospital NHS Trust 

Jessica visited The Ipswich Hospital NHS Trust, now known as (East Suffolk and North Essex Trust) this encompasses Colchester and Clacton in Essex. She walked into A&E unaided. Her parents had called 111 and were advised to go to A&E quickly.

  Was the initial diagnosis and treatment correct for a 15-day postpartum nursing Mother?

Jess was treated for Atrial Flutter/Fibrillation. This was incorrect, no obstetric, cardiology or emergency medicine consultants were initially contacted and drug administration began quickly.

  What basic investigations were considered before drug intervention?

Jess had her venous blood gases (VBG) checked, she received no chest x-ray or echocardiography. An echocardiogram (ECG) was conducted which demonstrated her high heart rate. There appeared to be zero indexes of suspicion of infection or blood clot (PE) in her presentation or assessment and drug intervention continued.

  Who was involved in her treatment, care and emergency medicine?

Jess was seen by trainee doctors in the second and third year of their training. They all reportedly lacked obstetric experience and their differential diagnosis failed to consider the challenges faced by a recently pregnant patient in her postnatal period. Cardiovascular Decease (CVD) Blood Clots (PE) and Infection being three of the highest rate of silent killers in the world. After Anaesthesia Jess was left with a nurse in the preceptorship period who lacked even basic advanced life support (ALS) training.

  Who did what and what happened over four hours?

During a prolonged period of treatment, subject to many delays and regrettably a lack of observations and clinical notes, Jess deteriorated further. Her blood pressure fell to 70/43 after drug intervention began and this therapy was ceased. Other therapies were tried but her condition worsened until it became necessary to intubate her under general anaesthetic. Electric Shock treatment called Cardioversion was now used to try and reduce her heart rate. By now Jess was in a peri-arrest situation and an on-call Cardiologist was called at home. No diagnosis of her heart rhythm had been established but trainees pursued the heart rate control treatment pathway. The Cardiologist did not attend, gain sight of tests or assessments. He is now under GMC legal review and is due to attend a Medical Practitioner Tribunal Service (MPTS) public tribunal hearing this year.

By now Jess’s Mother Sue was becoming more concerned by the seemingly experimental therapies, relying on the trainees and on-call consultant, she trusted them to provide the safest, effective and best standard of care possible. Further drugs were administered to Jess while she was still unconscious and staff assured Jess’s Mother she would be ok when she woke up, would be groggy but could go home later. Her heart rate now reduced, but quickly rose again. (We know this from equipment printouts in A&E.)

  Jess was shifted to the Hospitals Resuscitation Department?

Still, under the influence of the anaesthetic, Jess was laid on a bed. Sue tried to speak to Jess, held her hand, but Jess was totally out of it, she was a dead weight and completely unresponsive. The trainee anaesthetist left, the other doctor left. Jess was with her Mother and the bed lined she was on needed changing. Two nurses and Jess’s Mother pulled Jess’s tight jeans off, nurses disconnected monitoring of Jess’s vital signs including Saturations Co2, blood pressure, heart rate. Jess remained unconscious throughout and never rousable during gowning up and the bed linen change.

  When did the Cardiac Arrest happen?

While Jess was on her back in the resuscitation department she began to go blue. One trainee nurse was left with Jess and vital signs equipment had not been reattached. No alarms sounded and Jess went into Cardiac Arrest and crashed. Jess’s Mother witnessed the arrest and recorded this audio while left alone briefly with Jess. The only nurse present fled through the double doors of the resuscitation department. Doctors and Nurses began to arrive, equipment including a vital oxygen bag valve mask (BVM) was missing, the Lucas mechanical CPR machine was knocked off the wall and smashed, another was collected, this had a flat battery, another battery was found. The scene was one of complete chaos and panic with no one in charge as Jess’s Mother pleaded with them to “do what you’re doing” and asking “what have you done to her?” She was finally led away some eight minutes after CPR began.

  What affects and impairments have Jess suffered?

Jessica suffered an Anoxic Brain Injury. Definition: Anoxic brain damage is an injury to the brain due to a lack of oxygen. Hypoxia is the term to describe low oxygen. Jess lost her sense of taste and smell. She was pensioned off her from her job one year later, she cannot drive and has lost her capacity to manage her own affairs. She lost her relationship, has cognitive processing disorder (CPD) and muscle and nerve damage. She does not socialise and lives with the support of her parents.



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