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.

Oh yes, I know about the varying abilities of locums. Both from my job and closer to home. My sister had locum registrar who told her the test for gestational diabetes was fine. At every appointment she queried this (she's a student nurse) but because he'd written that the test was negative in her notes, no-one bothered to check the test result. Which was positive. It was only at 32 weeks that a bright student midwife bothered to check the actual result. Which was positive. The guy couldn't even spell glucose, FFS! (English not his first language. And certainly not fluent) Fortunately baby was fine but the last weeks of her pregnancy and first week of baby's life were frightening and miserable.

Long-winded way of saying when you mentioned a locum I instantly recognised your point.

So, you want the hospital to give the senior midwife the power to over-ride locum docs (or staff docs if she's concerned about their decision) and the ability to do it by having her caseload reduced so she's available to oversee patient care? Sounds like the midwives are disempowered and unable to question poor decision-making by docs. Which is not uncommon.

And you made this point in your meeting and they've conveniently ignored it? A very rude word springs to mind. I would complain to the regulator, the Healthcare Commission. If they get the regulator breathing down their necks, they will have to respond. Commission went into that unit (west London? Can't remember) where 10 women had died and forced the hospital to change their policies and structures. Brought in staff from other hospitals to re-organise them.

I'm not up on current complaints procedures, but you may want to make these points to your MP (I'm sure you have, but MP needs to follow up this letter so remind her) and to make sure your formal complaint reaches the regulator. Looks like the hospital managers don't intend to address your substantive point so external pressure is the next step.

Healthcare Commission is here.