This is a father’s story, a story about his daughter, and is called Jessica’s Story. The experience and journey to a place no parent would go willingly, bereft of all control, a feeling of overwhelming frustration, loss of control and sheer panic. The consequences when things go wrong in the NHS and the process after serious incidents occur which result in harm. Jessica was a bright and bubbly 23-year-old when she visited her local Accident and Emergency department at The Ipswich Hospital NHS Trust. After treatment, she later suffered a cardiac arrest within their resuscitation department of ED. Jessica was put in an induced coma after successful CPR and went on to suffer multiple organ failures over the coming days, she needed dialysis, contracted Sepsis and suffered Anoxic Brain injury due to oxygen starvation.
The results of the first internal serious incident requiring investigation (SIRI) failed to properly investigate her incident, an independent review commissioned by the CCG cited, the investigation was too narrow, key lines of enquiry were not followed up and all those involved were not formally contacted or interviewed in accordance with NHS England Serious Incident Framework.
Other investigations into Jessica’s treatment and care continued to omit vital information and all the available documents were not shared with the recent expert panel when they formed their expert views. As Jessica’s Father, I continue to hold the view that the opinions of some Hospital experts have not been impartial and so have continued to seek advice from other specialist independent experts. Some of the expert findings remain confidential until other investigations conclude, but it is apparent that crucial differences still remain between my independent experts and the Hospitals.
Independent Research has provided valuable insight into the NHS SIRI process, commonly used interventions for Arrhythmia and heart rhythm conditions in an acute setting and to date, much of my original concerns about my daughter’s treatment have now “received recognition” retrospectively.
Jessica’s Story the narrative.
History Jessica was a young Mother enjoying the birth of her son Lewin, 15 days postnatal she became unwell with a high heart rate and was taken to the local accident and emergency department at Ipswich Hospital. During her treatment and from the onset, she quickly deteriorated after drug intervention. She became hemodynamically compromised for over an hour with a recorded blood pressure at its lowest of 70/34mmHg and a sustained arrhythmia. She had presented with a blood pressure of 131/90mmHg two hours earlier but following Betaloc Metoprolol IV for suspected AF (atrial flutter/fibrillation), she quickly deteriorated.
The original diagnosis of AF was wrong, the type of arrhythmia was later changed to a narrow complex tachycardia type called AVNRT (AV nodal-reentrant tachycardia) from this point on in Jessica’s treatment opportunities to call for both senior medical and expert obstetric support was missed. The panel agreed senior expert help should have been called for and wrote: “the Panel considers that there were sufficient factors to indicate that both senior medical and expert obstetric support should have been sought once the initial treatment had failed.”
Failure to restore/convert Jessica back to sinus rhythm, (Sinus rhythm generally means a normal heartbeat, both with respect to the heart rate and rhythm.) Heart rate between 60 and 100 beats per minute. Further discussions among clinicians led to a plan to move to Electrical Cardioversion (electric shock through pads placed on the patient) This would require Anaesthesia and again “The panel considers (the clinician) should have sought senior advice unless (the clinician) was familiar with anaesthetizing obstetric/puerperal patients.”
As a parent, all control has gone and you now rely on the medical professionals to do what they do. The unwavering protection you have surrounded your child with and nurtured from birth is now beyond your reach, a stranger has your daughter’s life in their hands. You must rely on their professional advice, expertise and opinion when everything around you is screaming “Something’s not right.”
You must trust they (the clinicians) are being open and have honestly disclosed their concerns, naturally, if like me, you were taught to have high regard for medical professionals you trust they have explained the treatment options available and have reasonably disclosed any risks and or benefits of further interventions before proceeding.
Over time I will publish the daily handwritten diaries from Jessica’s Story, a journey beginning in ED and CCU (Critical Care Unit) to her treatment, prognosis, final release and rehabilitation. There have been multiple investigations instructed originally by the Hospital’s Serious Incident Requiring Investigation (SIRI), then an Independent Review by the Clinical Commissioning Group, the GMC through their (Fitness to practice) and the NMC (Fitness to practice). Throughout a two-year period, Jessica’s care and her treatment have been scrutinised by many experts, reports have been produced and the findings of these reports will be released in time to help spread the key learnings from this incident.
Many recommendations have been made in reports by investigators, specialist experts and the Ipswich Hospital NHS Trust has recognised these and recently acknowledged by the CEO Nick Hulme. “On behalf of the Trust, I have fully accepted the recommendations made in the final report from Dr Crispin and will make arrangements to ensure that these are implemented”
As a family directly affected by a serious harm incident in the NHS, we hope these recommendations have been actively disseminated nationally to help avoid the occurrence of another incident directly related to or in connection with the management of heart rhythm conditions in obstetric/puerperal patients.
References to ‘the panel’ refer to comments made by the expert panel members in the latest medical review conducted by Dr Pam Chrispin in July 2017.