Bo's death.Response from Hospital Chief Executive. I don't know what to think/do. But I feel angry. This is a long post.

[bubble99]

This is a cc'd letter from Susan Kramer written by The Chief Executive of Kingston Hospital.

I write further to my letter of 12 July 2005, as I am now in a position to respond to your complaint received on that date. I apologise for the delay in replying to your concerns; please be reassured that this in no way means that we have taken them less seriously than they should be taken. I have now had the opportunity to complete the investigation into this matter, having received comments from out Maternity and Gynaecology managers. I will draw on their findings, and I hope the following information serves to clarify the circumstances surrounding your constituent's treatment here at Kingston Hospital.

Obviously, this has been a very tragic case, and it is entirely understandable that Mrs Bubble has ongoing concerns about the care and the very sad outcome of her delivery.

I can assure you that we conducted a very detailed risk management review of this case, which was forwarded to Mrs Bubble. She then accepted the invitation to meet with Miss -- , Consultant Obstetrician and Gynaecologist, and - ----, Head of Maternity and Gynaecology Nursing (HMGN), to discuss the issues further.

During this meeting, all aspects of the care that she received were discussed in a frank and open manner, and the staff unreservedly apologised to her and her husband for the shortfall of skills, knowledge and communication in the management of her care, which may have contributed to the adverse outcome. However, at no point during this meeting, did -- ---- (HMGN) promise that the bleep holder role would be given supernumerary status. However, she did reinforce that we would be reviewing the role of the Maternity bleep holder. I therefore sincerely apologise for any misunderstanding that was caused to Mrs Bubble on this point.

I can confirm that this review of the Maternity bleep holder has been undertaken, and a decision was made to re-evaluate the existing measures that are currently in place within Kingston Hospital, such as the Hospital at Night Scheme, which would offer non-clinical bleep support to staff on the Maternity Unit, allowing them to concentrate on clinical aspects of care.

It had been recognised earlier in the day that there was a potential problem with staffing levels within the Maternity Unit for the evening that Mrs Bubble was admitted. The HMGN had addressed this, and another area of the unit was closed to allow staff to be disseminated through the unit, so that adequate levels of the appropriate skill mix of staff were in the appropriate areas of the Maternity Unit.

The bleep holder in the unit that night was not overwhelmed with work, but a breakdown in communication meant that she had not been notified of Mrs Bubble's admission and the complications that were occurring with her babies. Once the bleep holder was aware of the situation, I can assure you that she acted on it immediately.

How are you feeling about this Bubble99? They don't seem to be offering a written apology, just referring to the apologies given by staff during your meeting. Sorry, what is the bleep holder's role?

Hi Bubble, I can understand why you are angry, is this supposed to be some form of closure on their part?? I'm sure you still feel like issues are being skirted around etc, particularly in the case of the on-call consultant, are you taking legal advice on this, i have read your story but can't remember what route you have taken. Sending you lots of love and hugs x

Dont know what to say, It all seems vey impersonal and bluffy. Thinking of you and your family.

I typed this, nearly deleted it, then here it is anyway. Not suggesting that you should do anything.

Bubble, having read this and looking at your comments, two questions stand out;

Does this letter mean that they are introducing Hospital at Night, stopping its introduction, changing it or what? I certainly can't tell.

What action did the bleep holder take 'immediately' when notified of what was going on?

Under the Freedom of Information Act you presumably could see the comments made by the managers that were used to write this letter, if you wanted to.

Hope this doesn't read brusquely, bubble. I don't see how you could know what to think or do in such an awful situation.

Hi Bubble, what did you hope would be the outcome?
And how are you and your family?

bubble.... don't know what to say. Keep thinking I don't understand what they've said!

I'm sorry

I'm assuming that you wanted a change in the bleep protocol (sorry for clumsy lang, but iykwim) and that this bloke is saying that would not be forthcoming (any chance it would cost money?).

i'm not surprised you're angry.

what comment if any does susan kramer have on this?

xxx

Bubble, sorry you're angry. It's a very business speak kind of letter, saying very little isn't it?

I'm so sorry, I don't know waht to say. I'm not really sure what they are saying to be honest.

Haven't heard from Susan Kramer yet about this. Our main sticking point is that the bleep holder or senior midwife should not have to rely on being told what is going on. She/he should be physically able to leave whatever she/he is doing to go and find out. In our case there were only junior doctors dealing with a difficult delivery. They didn't recognise or know what they should have been asking the senior MW (bleep holder)Even if the unit is quiet, a bleep holder who is expected to carry out normal MW shift duties ie. delivering babies. Is not free to go and have a nosey round to see what's happening ( and in our case, going fatally wrong, on the unit.

I would put money on that letter could having been written by a solicitor.

Expound, please. I'm confused and tired and angry and I think I'm supposed to go away quietly.

what a crap, legalese, letter. Resolves nothing for you, and is almost unintelligible in its wording.

try to put it to one side for tonight (i realise that might be impossible) and then think about a way of not going away quietly would work best for you in terms of making you feel that some productive change has happened as a result of bo's death.

for example, if susan kramer is on your side she could help you in terms of replying that his response is just not enough and not accepted by either her nor you.

or ignore my drivel...bubble, i don't know what to tell you. i think if i were you i wouldn't be able to let this lie either despite the potential futility of carrying on.

i guess what i feel is that lying down and apologising, but not implementing the change that you feel is so important isn't enough. v new labour. but not enough.

i'm sorry, i feel on the one hand that i want to post about this and want to offer support to you, but on the other as if i'm pouring petrol on a fire and should be advising you to try to leave all this behind (not your greiving obviously, but this aspect of the aftermath of bo's death).

i'm thinking of you.

Sophable this has been Bubbles way of dealing with it for a while now. I think it has helped her cope (hope you don't mind me saying this Bubble).

I don't know what to say Bubble. You are now caught in an awful childish game of 'he said' 'she said' and I don't see the way out. What a bunch of selfish incompassionate arseholes. I'm so sorry.

flossam i don't understand your post. i was saying that i totally understood why she wanted to continue to pursue this and that i would do the same....

"but on the other as if i'm pouring petrol on a fire and should be advising you to try to leave all this behind"

My eyes are half open v v tired so perhaps I got the wrong end of the stick. Don't often cut and paste either but hoped it might be easier! This is what made me think thats what you meant anyhows.

So, are they saying they are maybe going to make more staff available for routine deliveries so the bleep person will be more readily available to provide care? They are being very careful in not commiting to anything in particular, aren't they?

Though they have said they are looking at the role of bleep holder, they do say they have implemented changes in the delivery suite guidlines, particularly regarding twin pregnancies and deliveries.

If I were you I think I would ask to see a copy of their new guidelines, to assure myself that they are making the changes they mention.

FWIW, I think the tone of the whole letter is patronising and unnecessary.

I can't remember whether you contacted a paper Bubble (the Guardian maybe?) TBH, I feel like going down there and performing a protest!

I don't know what to say Bubble .

Thinking of you xx

Oh bubble, I am so very sorry that you aren't getting the answers you want and deserve. What would be the right response from the hospital?

bubble99 - what are these people playing at? SO annoyed and upset for you. It seems to me that the only thing they'll understand is money and legal action. Sad as it is plus why they can't apologise and sort the situation out. 8hrs before the bleep medic knew - shock here. Get the best legal help you can and just go for it. Once the financial balance sheet is affected perhaps things will change. I remember you don't want any money for what happened & I respect this. Thinking of you and family xxx

Thanks all. I'm going to sit down this evening and go through my notes again to see if I can pinpoint the time that the bleep holder became involved. A lot of entries are written retrospectively but in each case the individual has said what time they became aware of the situation.

I'm also going to ask for a copy of the Hospital at Night policy and for a copy of the staff rota and bed occupancy for the evening concerned.

edam. I wanted to hear that the senior MW would, in future, be physically free to oversee the unit and practice of junior staff. In an ideal world the unit would be staffed with 'known quantities', staff who were known to have the experience and abilities to carry out their duties properly. On the evening we were there there was a locum senior registrar on duty who, quite obviously, had no idea what she was doing. Failing to report to either the senior MW or the consultant on-call what was unfolding. The NHS relies heavily on agency staff and as an ex agency nurse myself I know how hit and miss the abilities of such staff can be. All staff will have certificates of qualification and registration, of course, but abilities can vary. If the senior MW had been free to stick her beak in, by literally checking each ward/room to see what was going on, my son would have been alive. This used to be the case and when I last did night duty in the early 90's a senior clinical nurse would visit the ward at least twice during a shift to see what was happening.

The senior MW is either in charge of the unit or she is acting as a regular MW, delivering babies etc. She can not currently do both.

bubble, I'm so sorry. Their letter sounds so final and you still don't have the answers and the reassurances you need. I wish I had something constructive to add.

I hate this bit

So patronising and I read it as "hey, we didn't actually promise to change anything."

I don't know where you are finding the strength but I hope you find a way forward. I hesitate to use the word 'closure' as it's so naff, and psycho-babbly but I hope you know what I mean. I wish they would just hold their hands up, admit they f*ed up and make the changes to ensure this can never happens again.

Bubble, That letter is very vague and sounds extremely inpersonal (sp?).
I'm so sorry you are going through all of this but if you have the strength, fight it til the bitter end.
So sad