Nursing and Midwifery Council – NMC regulatory investigations
Our hopes, our Trust
After Jessica’s injury, 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 professional curiosity to further explore key lines of enquiry. Whilst the SIRI 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 NHS investigation did conclude, we call it SIRI (V3) or (V4) 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 a cardiac arrest in four hours. We never wanted to destroy or ruin any of the treating clinician’s careers and still hold them in high regard. All we wanted was transparency and the truth. So we went to the NMC Investigation.
Our Experience with the NMC
We quickly learnt that 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, broken promises and betrayal. We next went to the Nursing and Midwifery Council (NMC) to see if they would investigate more thoroughly. I will provide an update on this process in the coming months. What is apparent, is there are systemic failings within the Accident and Emergency department that were never investigated or mentioned during any of the Hospital Investigations. So in a sense, we are glad we involved the NMC Investigation regulators.
We still hoped above hope
The Ipswich Hospital would disseminate the recommendations from the final SIRI report. 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 (postnatal) and would hopefully promote senior multidisciplinary team 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 would rely on the Clinical Commissioning Group to update us at a later date when we requested that information.
When should consultants attend?
Procedures outlining when consultants are expected to attend patients in person should be reviewed and changes disseminated and monitored to ensure compliance.
Anaesthesia in a remote setting
All patients having an anaesthetic outside the operating theatre must have AAGBI guidelines standards applied with regard to monitoring, anaesthetic assistance, and recording of interventions and observations. This would be best facilitated by the completion of a standard anaesthetic chart. This is now a requirement from the Royal Colleges and recognised by the NMC Investigation.
Post anaesthesia Instructions
Post-anaesthetic instructions must be clearly documented and those caring for patients after an anaesthetic should be trained to observe, monitor and provide appropriate interventions. In other words, nurses should have competencies. They should be trained in ALS and airway management.
The RCoA publication ‘Raising the Standard’ audit recipe book should be used to audit current local practice against accepted national best practice with a view to ensuring the quality of care provided to patients undergoing anaesthesia outside the operating theatre environment. This was part of the NMC Investigation.