NHS Investigation Process For Families
What did happen Following our meeting with staff members in my Stage one post, we discovered there were many unknowns concerning my daughter’s incident in accident and emergency. We knew the NHS Investigation Process For Families was not really a process or procedure people were familiar with. It was very apparent from all those involved in the meeting they were not on shift that night. It was also abundantly clear, some although not all the medics involved had moved on [rotation]. I believe they called it. We were alarmed as many of them had not been interviewed or supplied [serious incident statements/reports]. At the time of the index event [the incident], it is essential all those involved provide and account of their treatment and care.
What should happen Unlike the aircraft industry [NTSB] or Health and safety executive [HSE] investigations, there seemed little curiosity about what had happened to an otherwise healthy 23-year-old Mother, in the context of securing all the medical evidence, notes and CCTV footage. For want of a better word, I wanted the area locked down and all evidence secured. My daughter had walked into accident and emergency five hours earlier and no one seemed concerned about her awful outcome. Little regard was given to our questions about this evidence being vital to any investigation although Dr Hartin did make a sincere apology on behalf of the department he was the clinical lead for A&E, but not on shift during the incident. My daughter had suffered a cardiac arrest in this departments resuscitation area and no one seemed to know how or why she had deteriorated to such an extent that she had collapsed [cardiologically] and needed resuscitating.
Phillips Heartstream and Intellevue Capnography Equipment
What didn’t happen No one could or was willing to export the data from the Phillips Heartstream or Intellivue equipment my daughter was connected to and I found that extremely hard to understand. There seemed little interest in investigating the readings from the capnography equipment which appeared vital if any investigation was to be conducted. Mr Duane Elmy (DE), Asst. Lead Nurse, Emergency Department told me he purchased most of this equipment so I thought he would have the knowledge to extract vital signs data that would assist any investigation.
Agitated by our constant questioning
Overall, we found the staff dismissive, a little agitated by constant questioning and signs that all was not well. Dr Hartin’s neck became almost crimson in colour when we concluded a walkthrough of minors, majors and resus. He appeared very agitated either because he did not know the answers, or could not find out but he did allude to problems he was having contacting people after the incident due to the rotation.
Neither I or my wife blamed Dr Hartin or Duane Elmy for their efforts to help us, but I and my wife felt the tension, the atmosphere was uncomfortable and a level of contempt was growing. Dr Hartin may remember he used the phrase “I can only surmise” over and over again, but all we wanted to know was what was our daughter’s treatment pathway.
What decisions were made and why and who had attended to her? It’s not rocket science and in retrospect, a 15-day postnatal patient would normally require a senior review by an obstetrician or Cardiologist much much earlier, particularly if her blood pressure had taken a plunge and in light of failed pharmaceutical attempts and electrical cardioversion to reduce her heart rate.
The lack of Clinical records and observation
With regard to Anaesthesia, again retrospectively, because the anaesthetist made no written assessment, kept a record of monitoring, anaesthesia chart or post anaesthesia instructions in recovery, I am not surprised Dr Hartin failed to answer any of my questions. I have since learnt my daughter received a rapid sequence induction [RSI] in a remote setting [outside of theatre].
There was no statement from an Operating Department Practitioner [ODP]. To date, no ODP has been named or accounted for during my daughter’s procedure and no witness statement has been sought. This is accurate as published in November 2017. As and when disclosure documents become available I will release a full account of my daughter’s treatment.
This will likely be in 2020.