NHS Investigation Process The Ipswich Hospital NHS Trust

NHS Investigation Process For Families Stage One

NHS Investigation Process For Families

What can happen  Anyone can be affected by an unforeseen incident in their medical care. Things do go wrong, we are all human, and doctors and nurses do not go to work each day to intentionally injure or kill anyone in their care. Except for Dr Shipman, who made it his job to do just that. When your relative has received a serious injury or death has occurred, a process should be triggered. The NHS Investigation Process For Families or Serious Incidents in health care is adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. A serious incident requiring investigation is abbreviated too [SIRI] or serious untoward incident [SUI].

What Should Happen

Someone within the trust identifies and decides the incident is serious enough to escalate to the serious clinical incident group [SCIG]. A meeting is conducted with various members of trust staff including clinical and governance to decide if the incident is a SIRI. Then, according to the serious incident framework, a panel is formed by the health provider to discuss the terms of reference, who will investigate/chair and who has direct ownership of any investigation. At this point I must emphasise the experiences from this point forward, are based on my own experience after being involved with The Ipswich Hospital NHS Trust hospital after my daughter received anoxic hypoxic brain injury in their care.

What Did Happen

A few days after my daughter’s incident, (the index event) while she was in a coma in the Intensive Care Unit [ICU], I wandered around the hospital grounds aimlessly at random times of day and night, wishing, praying and begging she would get better and wake up. I wandered into Accident and Emergency day three and asked if I could speak to someone medical as none of the ICU consultants was providing any information about my daughter’s condition. With the exception of one nurse who explained she had a fast heart rate. I knew this because that was why she had attended the hospital.

What Didn’t Happen

No staff members from any part of the trust either clinical or management approached me or my family to advise of the seriousness of my daughters incident. I had to initiate direct, formal contact by approaching the staff in the accident and emergency department. Staff were hastily gathered together including Dr David Hartin (DJH), Clinical Lead Emergency Department, Frances Bolger (FB), Head of Nursing and Clinical Services, Division 1, Mr Duane Elmy (DE), Asst. Lead Nurse, Emergency Department and a PA from the Trust, Taking Minutes of the first part of the meeting. All of us (my family) were very traumatised by what had happened to my daughter and did not understand how she had seemingly walked into the hospital a few days earlier and now she was in an induced coma and no longer responsive to my voice.

Key Points of Learning for any Health Care Provider

Honour your duty under all circumstances to contact the family and relatives immediately after a serious incident has been identified. Be open, honest and transparent. You have a ‘duty of candour’

Encourage a senior medically qualified member of staff to meet and explain in laymen’s terms what has actually happened to their loved one. Describe what has led to the event(s) to the best of your knowledge.

Leave families and relatives wandering around in ICU without a single designated point of contact, this may be a catastrophic situation, make sure a buddy or friend is on hand for them to go to for support.

Put in place a family liaison officer from the health care provider, give that person accurate information to relay to the family and relatives daily or regularly. Make sure this person remains their single point of contact as the treatment progresses.

Manage the families questions in a coordinated way, give consistent messages to everyone involved and avoid meeting different family groups separately as this will lead to conflict in the family room.

Engage don’t ignore and avoid family members, this will only lead to a feeling of ‘the closing of ranks’ and inevitable suspicion.

#HelpMe  simple and easy to remember, this should be embraced by all healthcare providers and adopted as a general process when things go wrong.

This post forms part of my personal experience when dealing with ‘NHS Investigation Process For Families’ every week I will add more stages and information to cover my journey and experiences dealing with a local NHS Trust. This will be after my civil case has concluded as I do not wish to prejudice my daughter’s case.

NHS Serious incident investigation Forum

Next :: NHS Investigation Process For Families Stage Two

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