Meeting date of enquiry into Bo's death has been set. I need help in handling this. This is a long post.

[bubble99]

The Head of Maternity Services 'phoned today. The doctors, midwives and trust officials have reviewed my notes, are having another meeting next week to investigate further evidence and will then meet with Mr Bubble and I on the 29th April.
I know that some of you have followed my posts, from my excited ramblings prenatally to the sad, sad posts after the awful event and since. I thank you all on behalf of the whole Bubble family for all of your words of love and support. You have no idea how much they have helped when I have been unable to get out of the door, let alone speak to anyone in RL.

It's said that time is a healer. After Bo died the pain was beyond belief. Physical pain. My heart was literally broken. It's said that time heals and to some extent this is true. It makes the pain bearable but I don't think I can ever fully recover from losing my healthy term baby because of the actions of others. Not God, others.

We now will face the enquiry where we will hear a blow by blow account of my son's last hours. I need to establish what I want from this meeting. I think I can summarise as follows but I'd appreciate any input/ideas from all of you. Mr Bubble and I want to make sure that nobody goes through what we and Bo have suffered. You may be that person, so it is important that I go into this meeting with clear ideas on what needs to be done. My thoughts are as follows:

1. The MW notes from my booking appt ended with "Needs consultant appt" - no appt was ever arranged until my GP wrote to her at 30 weeks gestation. None came and I made one myself at 36 weeks.
   
   
2. At 37 weeks I took myself to hospital with headaches, 2+ protein in urine (self tested) and swelling. I was discharged after 24 hour urine collection. Results of which showed high levels of protein but were reviewd at 38 weeks in ante natal clinic and deemed OK.
   
   
3. After sweep at 38 week ANC MW booked me for induction at 39 weeks. When we arrived at the hospital the reception staff had no record of our booking and we were put into a room on the post natal ward. Had the ANC MW informed the mternity unit about our induction appt?
   
   
4. MW's on post natal ward did not seem to understand the seriousness of the CTG traces. Were they experienced enough to understand or were their skills "rusty?"
   
   
5. Were there enough staff on duty?
   
   
6. When the consultant on call 'phoned to see if thre were any cases he needed to know about and was not told about me, did I slip through the net because I was on a post natal ward. Did he 'phone the ante natal ward only. Why would he 'phone a post natal ward?
   
   
7. When the MW's from labour ward came to assess me why did none of them realise that the babies were extremely tachycardic and in distress?
   
   
8. Why did same MW's allow attending doctors to perform amniotomy and attempt vaginal delivery even though both babies were in distress?
   
   
9. When we eventually got to theatre why was it down to me, the patient, to tell the anaesthetist to abandon attempts at epidural anaesthesia and give me a GA? Why didn't the doctors or MW's speak out?
   
   
10. Why was my cervix not assessed for dilation until 03.30 am (seven hours after I was admitted) even though my notes clearly stated that I had had a show 3 days before admission?
    
    
    We want to know that procedures are in place to prevent this happening again. How can I know that this has been done? What tangible proof can I expect/ask for? We don't want to be fobbed off with words and promises. If changes are to be made that require extra funding, how can we make sure that the extra funding is provided from above and that the maternity unit will not be expected to fund changes from their already overstretched budget?
    
    Can we tape record the meeting, I know that I will be too upset to take it all in and I'll need to review it. I this allowed?

[milward]

Gosh cd - 25K for the loss of life of a baby due to all the terrible events bubble has described - seems such a small amount for such a catalogue of mistakes. I remember that bubble wasn't asking for compensation (if I have this correct here) - but even still is this all someone would get - the price of an nhs managers company car???

[MandM]

Bubble

I haven't posted to you before but have followed your threads with sadness and anger at the events that took place.
I went through a 'similar-ish' situation during my DDs birth and although thankfully for us she survived, it was very touch and go for a while and she has cerebral palsy as a result.
I have been trying to think back to the meeting that we had with the Consultant/Head of Midwifery etc etc to discuss my case notes and get answers to our questions and to think of some hints and tips for you.
I think a list of questions and a list of objectives that you want to achieve from the discussions is essential. I would also say, be prepared to ask supplementary questions and keep probing until you get a satisfactory answer. I think I went along to the meeting too soon after we were discharged from hospital and just wasn't in the right frame of mind. Had I left it slightly longer I'm sure I would have felt more able to deal with the situation and get a few more answers than I did. So please make sure that the meeting takes place at a time you and Dh are happy with. Also, definitely either take someone along to minute take or at least have a notebook and pen at the ready. There will be so many names and medical terms and high emotions flying around that it makes it difficult to recall exactly what was said.
Don't be afraid to get back in touch with them after the meeting either. The discussions will inevitably get you thinking and for me, that resulted in a whole load of more questions.
Please also make sure that you and DH concentrate on yourselves and your boys rather than other people - you can't change the world. Please don't take offence to that, what I mean is that you need answers and explanations for what happened to you and Bo and as a family you need to be able to move forward (as hard as that is). It is up to the hospital management to assess any training needs arising from your case and put those into practice. I gave permission for my case notes to be used in training as an example of bad practice as I was determined that nobody else would go through what we had gone through and we are suing the Health Authority for Clinical Negligence. However, DD was born 4 years ago tomorrow and horror stories are still coming out of the same hospital (two babies lost on Xmas Day last year ). It devastates me to hear about these tales, but my focus has got to be my DD and DH.
As hard as it will be, I hope the meeting gives you the answers that you need and I will be thinking of you all. x

[Marina]

I can't add anything to the excellent suggestions and links already here.
Bubble, do you and your dh have some to accompany you to this meeting? I think some kind of advocate/supportive presence is essential - sorry, not sure if you are taking a solicitor in with you or not.

Definitely record the meeting and then get it transcribed.

[foxinsocks]

Bubble, do you know who will be at the meeting representing the hospital? I mean, will it be the doctors or is it going to be 'people representing the hospital'?

I only ask because if it is going to be the latter, they may be more unwilling to answer detailed questions (thinking they are putting themselves in a difficult legal position).

I've been involved with several companies (not the NHS) to try and change processes that are not working effectively. So I would say the following: -

1. You need someone with some medical knowledge or NHS process knowledge to go through the whole process (from booking in to the eventual birth) and see why so many problems are occurring (e.g. that non-referral to the consultant is unbelievable). That person should preferably be independent to the hospital (so they start with no prejudices) but still have some knowledge as to how a hospital/midwife-doctor team should function. The NHS do have an internal audit team - but I'm not sure their remit would cover something like this. It may be worthwhile asking if they have someone who could do this for them (after all, it would be to everyone's benefit to do such an investigation). There seem to be so many gaping holes that there may be other areas that need looking in to, even in addition to the weaknesses your case has exposed.
   
2. If this person did such an investigation, you could ask to be kept informed of the progress. Normally, a report would be produced highlighting the weaknesses and then a report would be produced with a timescale, in conjunction with the hospital, showing exactly how they were going to improve. Normally, this would all be highly confidential and kept internal (for obvious reasons).
   
   I can't see why you couldn't record the meeting if you really wanted to. I would also document the questions you want to ask and if necessary, make copies so that you can give them to the doctors there. That's in case they can't answer any of them right there but also in case you find it more difficult than you think.
   
   I'll put my thinking cap on to see if I can come up with anything else.

[Heathcliffscathy]

bubble, i'm glad you've had a date set, and i'm thinking of you and your family and hoping that you get the answers, apologies and actions that you are to entitled to.

i know i'm stating the obvious, but the big thing that screams out at me everytime you post about your experiences is that as you were carrying twins you would have been defined as a high risk pregnancy from the start, but it seems as if none of the usual monitoring/consultant involvement that a high risk label warrants happened in your case, at any stage really.

think that someone taking notes would be a good idea. tape recording will inevitably change the tone of the meeting but i don't know that that would be a bad thing.

thinking of you.
x

[FIMAC1]

At my local Hospital they deem twin pregnancies as 'high risk' and they see the Consultant who deals with all high risk pregnancies - they would be treated as high risk throughout - and also have one of those florescent stickers on their notes

[foxinsocks]

for your info bubble, the hospital do seem to have their own clinical effectiveness team. They also seem to value patient input if you read their blurb in the link. I'm not sure how effective their work is or whether it is valued but it may be worth asking some questions about them because it sounds like they perform the sort of work that could result in a change in the practices.
kingston audit team

[bubble99]

Thankyou all so much for your responses and offers of ongoing help. The photocopies of my notes and CTG traces arrived this morning. Mr Bubble and I are going to go through them this evening. I've read them before but I think he's going to find it upsetting as it makes for pretty grim reading. I'm OK with the medical terms/language and will give a shout to you all, MW's and everyone if I need help with that.

For legal representation we will use the same solicitor that Jacob's parents used (little boy born brain damaged at St Georges.)if we feel we need to. TBH I'm truly hoping that the hospital holds it's hands up, sorts it's act out that the doctors/midwives admit that they screwed up and retrain where necessary. No plans to sue for compensation at the moment (though if we need IVF to conceive again we may consider a retrospective claim) but if there's a sniff of a whitewash we'll give the press a nice little pre- election NHS story. Again,thankyou all so much.

[hub2dee]

bubb, I was just wondering if it might be worth contacting one of the MWs on UK midwifery (yahoo board) or the Radical Assoc. of MWs if you wanted some 'on your side' to sit / listen / argue alongside you ... there seem to be some old hands with sound attitude and a ton of experience, sometimes within the NHS, but often as IMs...

(can post URLs if you need).

[Eeek]

Hi

Please also consider contacting the Multiple Birth Foundation. We talked to the Director, Jane and she was fantastic for us. They are independent and they really know their stuff. They offer counselling to parents in our situations, counselling to the lone twin (bit early I know) and a great leaflet about the death of a twin which I gave to everyone. It's basic but it helps when you just don't want to have to explain to yet another person.

For what it's worth - in my situation it was made very clear that there was an allowance of 30 mins between the planned natural deliveries of my dss.

Please also - a friendly warning - after I'd written my letter of complaint and received my response I felt a huge gap in my life. It was as if the anger and fighting the battle had kept me going. Once there was no more I could do the emotions hit even harder.

Good luck

E XXX

[throckenholt]

Hi Bubble99,

haven't time to read the rest of your thread. But just wanted to suggest you contact the local NCT branch. They should have a liaison person who goes to meetings with the local labour ward. They may be able to help you. They may also have someone who can go with you to the meeting and help you get the right answers, and maybe give a different perspective.

It certainly sounds like a thorough review of their procedures is essential - it sounds like a terrifying catalogue of mistakes.

Also - I missed your ealier posts on your pregnancy - but it sounds like you didn't get to see the consultant (we saw ours regularly when I had twins)? I think maybe a reivew of how they deal with twin pregnancies is also in order. Maybe Tamba could help with that?

[marthamoo]

Bubble, I don't have any expertise to offer - but I have read the whole thread and there is a lot of good stuff on here that I'm sure will be of use to you. Just wanted to wish you luck and strength for the 29th and I hope you can get some of the answers you need.

[mears]

bubble99 - just caught up with this thread. I hope that you do get the response you need from the hospital. Managing clinical risk has a high priority when delivering care and the hospital will be very keen to ensure an event like this never happens again.

[RTKangaMummy]

Bubble am glad you have got a date for your meeting although it will be a very difficult day for you all.

I am wondering whether you could have a video camera in your handbag set to record {they may have longer record time than tape recorder}

Is it actually illegal to record conversations without informing the other parties?

I have no idea but if it is not illegal perhaps you may get more honest answers if they didn't know they were being recorded.

Or get a secretary to do shorthand would be excellent idea.

I also think that they should not have a problem with you openly recording the conversation I am sure I would come out from a meeting like that and forget who said what and the finer details or the conversation.

Good luck with meeting

Good idea to print off all that you have put on mumsnet to remind yourself of times and dates etc.

[Spacecadet]

bubble99, i remember when we had a sudden death of a patient on my ward (when i worked in the mental health services),the relatives askled for an investigation into his death, i beleive that they were represented by a legal rep and were allowed to tape record the meeting, all staff on the ward on that day were interviewd seperately(inc myself) and our interviews were recorded in the written form. No amount of litigation, compensation will bring your darling son back, but what I hope comes out of this are not only full answers to your quetions, but the hope that this will never ever happen again, I hope that no one elsee ever has to go through what you have done bubble and I grieve for the fact that you, your husband, elijah and bo had to pay for this pure imcompetence...{{{hugs}}}

[LEWEI]

I am very sad to read your post, some of your points are very similar to our experience which ended in the stillbirth of our son. We have had many meetings with those in authority. All i can say is keep asking your questions until you get an answer. There are many steps which you can take, dont let them try to fob you off with medical mumbo jumbo. I dont see why you cannot tape the meeting, if they have nothing to hide then they should have no objection. I beleive that there are quite a few "rusty" apples in the nhs barrel that are causing many fatalities. My best wishes and thoughts are with you, i hope you get justice for your little one.

[munz]

nothing really to add except best of luck, thoughts are with u all (((((hugs)))))).

[jangus]

Hi Bubble, just wanted you to know that I'm thinking about you. Hope you are doing OK.
xxxx jangus

[hub2dee]

Thought I'd bump this thread instead of starting anew.

Mr. and Mrs. bubble99 have their enquiry tomorrow for their son Bo.

Don't know whether she'll be on today or tomorrow but I'm sure lots of us are hoping the meeting sees an honest exchange and concrete plans for change.

bub: we're thinking about you. Be strong. Go get 'em. X

[MarsLady]

Yeah, Go get 'em Mr & Mrs Bubble

[Potty1]

Thinking of you both. Stay strong. X

[logic]

I hope that you get the answers that you need, Bubble. Thinking of you...

[hub2dee]

. I'll bump a couple of times for Active Convos as it's no longer in anyone's Threads I'm On.

[Blu]

Bubble and all your family - I am thinking of you. Your description of little Bo with his determined chin is very vivid in my mind. I really admire the strength you are putting into this to ensure that it doesn't happen to another determined little life.
I do hope they acknowledge the truth and give you their heartfelt apology.

[RTKangaMummy]

Hope it goes well tomorrow Mr and Mrs Bubble

{{{{{{{{{}}}}}}}}}}}} and positive vibes ++++++++++++++++