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 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.