General Medical Council – GMC regulator investigations
Our hopes, our Trust
From a families perspective, all we ever asked for concerning Jessica’s treatment and care was the truth. We asked Ipswich Hospital, who themselves concluded Jessica’s incident was a serious incident requiring investigation (SIRI). This was back in 2015, we asked the Trust to conduct further independent investigations because their initial investigation was judged to narrow. The Trust lacked the professional curiosity to further explore key lines of enquiry. Whilst the SI may have uncovered some aspects of the medical management of the care of Jessica, a large number of areas remained unexplored.
Dame Clare Marx
“Although there already a great many processes ongoing. As a Trust, we have not as yet done enough to understand this case which has had such a profound effect on the patient and her family. We should now express that to the family and explain what we intend to do to put that right.”
Although another investigation did conclude, we were still left asking “how had this happened to her?” and how she had gone from a seemingly fairly healthy young girl who walked into Accident & Emergency laughing and joking with her Mother, to cardiac arrest in four hours. We never wanted to destroy any of the treating clinician’s careers and still hold them in high regard. All we wanted was the truth.
Our Experience with the GMC
We quickly learnt when asking the Ipswich Hospital to investigate its own staff when things go wrong, was like asking a schoolchild “to mark their own homework.” It was a miserable experience, full of denial and promises. We next went to the General Medical Council (GMC) to see if they would investigate more thoroughly. I will provide an update on this process in the coming months.
We still hoped recommendations would be actioned
The Ipswich Hospital would disseminate a specific escalation process which should be in place for pregnant and recently-pregnant patients presenting as an emergency. This would help safeguard other young Mothers presenting to ED nationally in a similar condition (postnatal) and would hopefully promote senior obstetric review earlier. This would be reviewed against a sample of other hospitals ‘policies and procedures.’ The Norfolk and Norwich University Hospitals NHS Foundation Trust NNUH had offered to share their procedure as an example. (This was a recommendation from the Ipswich Hospital’s Investigation by Dr Pam Chrispin’s report). We have no way of measuring the effects of any recommendations and will rely on the Clinical Commissioning Group to update us at a later date.
All staff must have competencies in basic, intermediate or advanced adult life support appropriate to their role, and this should be monitored by the Trust Board.
The CCG and Trust Executive should review resourcing in ED to ensure adequate performance against waiting times including time to triage and time to be seen by a
Senior Staff Review
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.