Notes from local resolution meeting 14 August 2008.
Present:
Emily F - complainant
Karen M - Matron.
Voirrey F - ICAS advocate.
A&E
Voirrey F. outlined the complaint regarding A&E.Emily F . had told the reception worker when she arrived that she was miscarrying. She was asked to take a seat and waited one hour and had to return to reception to ask for urgent assistance.
Karen M . answered that it is normal practice to book in with reception place and A&E was very busy. The gynae team took a long time ad so the resident A&E doctor was called.
Viorrey F . asked weather reception did not prioritise certain cases such as miscarriage..
Karen M . agreed the wait was unacceptable and appoligised for this. Karen M has since spoken to reception staff and instructed them if a patient says that they are having a miscarriage , the reception MUST inform the nurse straight away that they are there.
Voirrey F. asked if this was now formalised as procedure
Karen M . replied that it was and would be a part of management of -A&E . Kare nM. aslo stated that plans are underway to provide a room in mccallum ward for women who are miscarrying which will provide a better environment and access to specialist doctors and nurses.
ACTION :Karen to confirm completion of plan to provide room in mccullum ward.
IMPROOVEMENTS AGREED: procedures in A&E reception.
Karen M. confirmed that the doctor who treated Emily was a gynae registrar. The doctor had been with the hospital 1 week.
The registar has denied saying "its only a miscarriage" when questioned.Karen M. agreed that this is not something that a nurse or doctor should say and she would hope that this would not be said to a patient .
Viorrey . stated that the registrars performancehad been so poor with regard to the specimen jar there was little confidence that the registrars performance had not also poor regarding this issue also.
Emily F . was adamant this was said to her.
Viorrey F . suggested that there are two differant accounts of thisand it is not possible therefore to resolve this issue. Karen.M. agreedthatit is not possible to resolve this.
Specimen Jar .
The registrar has stated that she did ive the jar to Emily because she did not know where else to put it. She acknowledged that this was a mistake and it has been made clear to the registrar that if she did not know what to do with the jar she should have found someone to keep the jar and its contents safe.
Karen suggested that the registrar was very distressed by the mistake she made but viorrey stated that this was not the concern of Emily. Karen gave a unconditional apology on behalf of the trust.
The nurse specialist for early pregnancy has gone to the maternity ward and the childrens ward to provide training and this issue has formed part of the training. Dr Ranjit has also brought this up at the doctors meeting.
Viorrey F . explained Emily has been traumatised by this incident and consideredand that the mistake made by the registrar was a serious mistake and should have been taken very seriously by the trust management.
Karen M . confirmed that the trust is unable to discipline a member of staff for a first mistake unless the mistake is serious enough to warrent a formal warning.She confirmed dr ranjit had spoken to the registrar during a poor performance interview (named a coouncelling session under the trusts disciplinary procedure) . The incident is recorded on the registrars personell file. Karen confirmed that the trust have taken this on board and will ensure that it never happens again to another woman.
Emily F. remains unsatisfied that the level of response from the trust towards the registrar was appropiate given the nature of this mistake made.
IMROVEMENTS: training for staff to raise awareness of this procedure.
The remains of the foetus.
Viorrey F asked how large the foetus would have been and karen replied it would have been the size of a thumb nail. The placenta would have looked as prescribed by Emilys partner.
Viorrey F. stated that that when Emily arrived at A&E she had not been clotting only bleeding.Emily is sure that the first time she passed anything significant was when she was on the comode.
The notes state that "the products passed at 19.14 whilst on toilet".
The laboratory report states that foetal parts were not present in the sample. It was agreed it was not known what happened to the foetus.
Voirrey stated that this was the most regrettable and that this is particularly distressing for Emily.
Karen M confirmed that the remains of the foetus/placenta would have been sent to the laboratory then kept for a month then a short religious service would have been performed and then the remains would have been sent for cremation. Karen confirmed this always happened
After the meeting i followed this up to be told that they have never recieved my remains.
Complaint.
Voirrey f . stated that the complaints process had not appeared to be helpful when Emily was making her complaint and that this has contributed to Emilys distress.
Emily confirmed that she had been put through to karen by PALS and that karen told Emily that she could not make a complaint.
Karen stated that she did not remember the phonecall and doesent have any notes about the phonecall.
Karen agreed to speak to cheryl about the initial log of the verbal complaint.
ACTION: Karen M. to speak to PALS about initial log of the complaint.
Notes taken by Voirrey F 14/08/08.