Unexpected hospital death - review/investigation
Fuuuuuckit · 12/06/2022 20:40
I won't go into details but my mum died quite suddenly and unexpectedly in hospital I February.
The hospital carried out a review into her care and discovered that her death required further investigation due to her not being treated for sepsis on admission (she had all the symptoms and had previous relatively recent admissions for infection bordering on sepsis).
I've been invited in to discuss the outcome. Has anybody had a similar investigation into a hospital death? What can I expect? Obviously their findings won't change the outcome, but I feel like I've been on autopilot since February and the shock has prevented me from grieving.
ZealAndArdour · 12/06/2022 20:47
I’m so sorry this happened OP, your poor Mum and you. I work in the NHS, and I can see myself that things are so stretched that patients are being unacceptably put at risk.
I can’t say I’ve much insight into the likely format of the meeting or the depth and breadth of the information that they’re going to give to you. But you can bet your bottom dollar that the trust solicitor will have been briefed, even if not actually in attendance. If you’re at all inclined to seek legal recourse about the possible failings in her care, then I would advise that you speak to a solicitor (specialising in these kinds of cases) and take them with you to the meeting.
Will there also be an inquest?
ZealAndArdour · 12/06/2022 20:51
I lost my sibling unexpectedly in 2016, at the age of 25, and it felt like I was just holding my breath from the day it happened until the inquest closed and all the official things were over with. I could then finally start to exhale and accept the cause of death and the fact that he was gone. It’s a very difficult time and the shock of a sudden and unexpected bereavement is horrific. The mind plays tricks, let’s you forget for a while that they’re gone, but the shock happens all over again when you remember.
Fuuuuuckit · 13/06/2022 00:21
@ZealAndArdour thanks for your thoughts. Especially that their legal team would have been involved already.
I may have a chat with someone legal before I go. There are a number of questions i've already raised, and I sent several texts at the time with updates to relatives as to what the doctors had said so there is quite a hard timeline for those short hours.
I think I mostly feel like I didn't advocate hard enough for her, but I definitely mentioned in those texts that I'd reiterated my concerns about what she was being treated for.
And she, and I, were treated so well at the time. Such kindness. Now I'm doubting the sencerity of their words - was it more of a 'oh we've fucked this up real badly, be super nice to the family'?
My sister won't be coming with me, says there is no point getting upset about it as it won't change anything.
AgeingDoc · 13/06/2022 02:57
I'm sorry for your loss OP and that you have had the added stress of an investigation which must make everything even harder to bear.
Before I retired I was heavily involved in Governance in the Trust I worked for and I did reviews of deaths and adverse incidents as part of my job for quite a lot of years. Different Trusts do things differently of course, but I can give you some idea of the process at the organisation where I used to work.
Serious Incident reviews aren't done by the people who were actually involved, but by someone senior who didn't look after the patient themselves but has enough knowledge of the clinical area and who has been trained in investigation, root cause analysis etc. In our Trust we would generally have two investigators, often a consultant and a senior nurse. We would review all the written records, do interviews or get written witness statements from everyone who was there to create a timeline, assess what contributed to whatever happened, assess what was avoidable or not, whether there were any mitigating factors etc, and then make recommendations on any improvements that need to be made as a result. In our Trust the report would then all be looked at by a panel including various directors who would decide whether there were any disciplinary issues or anything needed to be reported to higher bodies etc.
Our process involved there being someone with the specific job of communicating with the family to keep them updated on what stage we were up to, but we tended not to hold a formal meeting until the report was complete. I would normally expect the person who led the investigation to be the one who talks to the family, but it might also be the Head of the relevant department or the Medical Director of the Trust, often with a senior nurse present too. I can't recall ever having anyone legal with me ever, though that's not to say it doesn't sometimes happen. We would go through the main findings of the report - the timeline, what we've found and what actions have been taken as result, and do our our best to answer any questions that the family had.
Our normal practice was to offer a copy of the investigation report and to give the family the option of further meetings once they have had a change to digest what's been said.
There can be a lot of information to share, and of course it can be upsetting to recall events so it is probably a good idea to have someone along with you who can support you. Don't be afraid to ask for a break if you need one, or to ask questions if you are unclear about anything. You might not think of all the questions you have at the time so if you aren't offered a specific follow up meeting, make sure you have the contact details of someone so you can get back in touch with them if you have later questions. The report should be written in such a way that a non professional can make sense of it, but there will probably be a lot of technical information too so it would be totally reasonable of you to want time to fully understand it.
It can be a very draining and emotional thing to have to go through so please look after yourself. Don't rush into any decisions about whether you want to take legal action or not. Take your time to process everything, ask questions, talk to other people, and be kind to yourself. I hope the meeting goes as well as it can, you get the answers you need and you don't suffer any more avoidable distress.
Fuuuuuckit · 13/06/2022 07:45
@AgeingDoc thanks for that. I've had quite a few emails from the staff member leading the investigation, and it's as you described so far.
We are meeting with her specialist (who was not involved in her care at that time, but who was leading her treatment overall) and the matron who is doing the investigation.
I have a hundred questions (must start writing them down) and hoping my aunt will come with me.
I was quite surprised with their openness (I understand the term they use is candour) about the fact they believe mistakes were made prior to the investigation starting.
LIZS · 13/06/2022 07:56
You might want to look up the Duty of Candour process on the cqc website. There is a statutory duty for the trust to report it and it may be included as a Serious Incident in statistics reported at public Trust Board meetings.
mumboss1984 · 19/06/2022 23:40
Hello, I am very sorry for your loss. I have been through something similar with my dad (also Sepsis), it is currently being handled by solicitors. If you need to ask anything or just need to vent happy to help.
JellyBellyNelly · 19/06/2022 23:42
My cousin is going through this after she lost her teenage daughter to sepsis.
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