The First part of the Investigation Revealed
So after our mini break away our little family got back to reality again, things started travelling along nicely for us and we were comfortable and happy for a couple of weeks, until I received an email from the hospital in the first days of October telling me that the RCA on Liam had been completed and they looked forward to meeting with Ryan and myself in the next day or so. Ryan and I met with them on Wednesday October the 3rd at 2pm. Ryan came from work and I drove in from home and we met together outside the hospital. I walked past the spot where our car had been parked when we had gone to hospital 3months previous, arriving with hope/excitement and anticipation to have Liam, and I looked up at the hospital and hated it, I hated the smell, I hated the feel of it and I didn’t want to step a foot inside. When we walked in, there were about 3 or 4 mums of newborns with all their presents and flowers preparing for their first trip home in the car and it made me feel sick down to the guts.
We were ushered into an office and had a meeting with ‘Jenny’ the director of maternity and ‘Michael’ some sort of big wig in the hospital. Michael’s first words to us were “I’m sorry that we even have to have this meeting, it is the culmination of a terrible event that has been distressing to us all, but it is nothing like to us, what it is to you and we recognise that. I’m an obstetrician by background but not practicing anymore, but I do understand the terrible time that you have been through, and I understand that you had 4 miscarriages before you finally got pregnant, carried it and then this happened and I suppose it is your worst nightmare, probably one of the worst nightmares you can ever have……..we are trying to make something positive out of this in trying to reduce the probability of this ever happening again, that is something that we strive to do always when things go wrong and fortunately it doesn’t happen very often, particularly an event like this, so it is not something that we deal with every month or even every year, but it is that sort of terrible event that happens sometimes and it is just really terrible that it happened with you. We acknowledge that and we are sorry that this has happened to you.” He then went on to mention that he was going to share with us what they were putting into the department for public health for the RCA, and he stated that RCA’s take a long time to happen because it takes a long time to get people together particularly Drs. He explained that an RCA is a route cause analysis and it was something that they do when there has been a catastrophic event and they needed to report it to the department. He likened the RCA to the TV show air crash investigations in how long it takes to get one ready. They both then fluffed around telling us how much time and effort had gone into the investigation and it was then that Ryan tried to move them on a little faster and asked “Well what did you find?” We had been waiting so long for them to tell us, that this little banter before the findings were told to us seemed unimportant, however now looking back at what Michael said at the beginning it already shows me that he realised that the hospital contributed to some critical errors that contributed to Liam’s death, he had already acknowledged that they wanted to reduce the chances of this ever happening again. I felt a little frustrated that he had mentioned my miscarriages at the beginning, it made me feel like he was adding that in as a way of saying that something within me may have caused Liam not to survive and I had also felt frustrated that he had called Liam ‘it’.
Michael then said “what I would like to do is share with you is what is going in, and it is going in this afternoon, so you have the opportunity to see it before it goes in, now it doesn’t look very long or impressive but that is the format that is required’ and he showed Ryan and I one A4 piece of paper (my whole baby’s birth and death came down to one piece of paper) “to change it now would be a serious problem, it all sounds a bit impersonal but it has to be written in that style, there are no names there because it is confidential and I know that sounds a bit clinical, but we realise that Liam was a much wanted baby, this is not a clinical issue as far as you are concerned, it is a catastrophe.” For those who haven’t seen an RCA it starts off with a causal statement, and this statement went through the background of what happened, it stated that I was 39 weeks and 4 days gestations, Group B strep positive with a history of 4 miscarriages. I had used Clexane until 20 weeks of pregnancy and was then commenced on aspirin. I presented to delivery with spontaneous rupture of membranes, cervix 2cm dilated and in early labour. A CTG was applied and showed an abnormal trace. The OB was notified of the abnormal trace and came to the hospital immediately. The clinical decision to perform an emergency caesarean section was made but not flagged as category one by the admitting OB. This together with the fact that theatre staff were not on site, led to a discussion between the OB and anaesthetist, resulting in the decision by the OB to request an epidural analgesia which probably further delayed transfer to the OT and knife to skin time. After a long period of infant resuscitation and discussion between the clinical staff and the parents a decision was taken to cease resuscitation. The cause of the abnormal CTG trace was unknown, An autopsy on the baby was declined by the parents.
It then goes onto Contributing factors:
- Continued CTG monitoring during transport from delivery suite to OT could have underlined to medical staff the need for an immediate caesarean section and hence the need to proceed to general anaesthetic.
- From the time of the request to the ADON for OT team to be called for an emergency caesarean section, staff were on site within 30mins. The anaesthetist was available on site at the time of the request for a caesarean section, having already been called in to attend another patient.
- The emergency C section was called for foetal distress but was not given a category.
After that come the recommendations which I will get to later, but just from looking at the top part I was already a little disappointed. They had pointed out all my faults, that I had the miscarriages, that I had group B strep that I had used Clexane, that we had declined an autopsy, they had pointed out all their “positives” they had theatres on site within 30mins of the call, they had the anaesthetist already onsite, but NO WHERE in the document had they stated how long it took to get Liam out, yes theatres was on site within 30mins of the call, but that didn’t mean the OP happened within 30mins, the OP had taken from our recollection 90mins but from the notes point of view 75mins to occur, why had they not mentioned this. They had also stated that a Category had not been given, so even though my OB had classed me as a Cat 1 it had not been ‘flagged’ as Cat 1, that appeared to be their argument as to why things went so horribly wrong, none of the staff realised how serious it was because my OB hadn’t said “Category 1 everyone”…..I’m sorry but an emergency C section called for at 130am and calling in theatres screams Cat 1 to me, that is a given, I wouldn’t think it needs someone running all over the hospital yelling out Category 1 everyone for that to be obvious!
Anyway, after reading the 1 page document, Ryan’s first question was that the RCA had written in it that staff were on site within 30mins, how did they come up with that number because that was not the time in which Liam was born, and Michaels response was “that’s right, I understand it took a lot more time and the reasons are there, there are a number of reasons, but it wasn’t related to the response times by the staff or the obstetrician or by the anaesthetist it was about the decision making process that occurred” so basically he was saying it was no one persons’ fault, not the hospital, not the staff not the specialists just overall poor decision making.
So I then asked ‘Was there miscommunication between the OB and the staff, because my OB told me he classified me as a Cat 1’ to which Michael responded with ‘that did not occur’ and Jenny said to us ‘On that night an emergency was called but no category was given, and that is what we have reflected in here, your OB never mentioned a Category, we have worked a lot with him with this RCA and he actually backs that up as well’ and I said to them both that he had written to me via email and had stated that although a formal category wasn’t given I was classified as a Cat 1 and therefore the baby should have been out within 30mins which would have been 144am not 244am’ and Michaels response to this was “Well you will need to talk to him about that” This statement has baffled me for a long time, after their extensive investigation, an investigation which proved I should have been a Cat 1, my OB had classed me as a Cat 1 subsequent to the event, why then would I need to go back and talk to him about this, this is what was stated, this was the facts.
I then asked “wouldn’t, if you called an emergency C section classify all of them?” and this question was never answered instead Michael stated that in a Cat 1 you certainly wouldn’t discuss an epidural, and epidural is right out of the question for a number of reasons to which I responded with “I can’t understand why he has written to me telling me I was a Category 1 C section and therefore the baby should have been out within 30mins, do you need me to forward that email to you to show you that, that is what he has said?” to which they responded with “you can, but what we are reporting is what he said to us, I think you need to take it up with him” and I told them that I had already taken it up with him and that he had said that the baby should have been out within 30mins, and the reasons that it didn’t happen included that theatres were not on site and that they had to be called in and that the anaesthetist had chosen to do the epidural rather than the general, and that was the anaesthetists choice, not his choice and the anaesthetist believed it was the quicker choice to do rather than the general as theatres were not yet on site. This comment was brushed off my Michael who stated that “we are happy that this RCA reflects as clearly as possible the results of our investigation”
Ryan then asked if it was entirely on the OB to call the category, were there not a series of guidelines that would force a category to be called, and Michael stated that it was the OBs responsibility alone to call the category. Ryan also said that we were wheeled around to delivery a little after 2am and waited a long time for things to get ready in the OT (which Michael agreed with) and Michael stated that the response time should be 30mins or less from the time the Category was called to the time the baby is out to which Jenny added “and from when it was called the theatre staff were here in that time frame and we did confirm that with swipe entry and all that sort of thing” so it either was or wasn’t called they were saying that the Category wasn’t called yet in the next breath they could justify their hospitals arrival time from when it was called, sorry I don’t understand that one.
We then went through the recommendations from the RCA with Michael and Jenny which included
- The hospital considers a change if policy to allow midwives to call a Category 1 Caesarean section and obtain urgent obstetrician review
- The protocol for calling in staff for a category 1 C section is defined more fully and, further, that medical staff clearly state the category
- The hospital considers a checklist for all theatre emergency procedures
- The hospital reviews its 24hr ability to undertake a category one caesarean section within 30minutes
- The hospital considers having on call operating theatre staff present on site, as decisions regarding clinical management can be influenced by resources available at the time
Ryan and I then asked why monitoring of Liam ceased just after 2am and he had no monitoring between then and when he was born at 244am, if baby was in distress shouldn’t continuing monitoring occur? And Michael said that normally it would occur and he wasn’t sure why this didn’t happen, to which Jenny interjected and said “I will explain that. CTG monitoring was taken off to insert the epidural and that is common practice because you need to get access to your back, I believe that after the epidural was inserted your OB was there, and he and the anaesthetist wheeled you straight around to theatre, the midwife did try to put the Doppler back on but was very much instructed by your obstetrician just to get you round to theatre, they wanted to get you there as quickly as possible, you then went into that area where you said you waited for a little bit and we have confirmed that there was a wait there, and your midwife again tried to take foetal heart but the OB and the anaesthetist directed her to go straight into theatre, so that ability from the midwives point of view was taken away from her by the physicians, and that was to get you to theatre quick, they were just trying to get you in there” to which Ryan then responded with ‘yes but unfortunately 210am to 244am is not quick’ which she agreed with.
We then had a long discussion on the timeline of how fast/slow everything occurred. Jenny was saying that the OB didn’t arrive at the hospital thill 130am and his decision to do a C section was made after that however Ryan and I specifically remember him arriving just after 1am, making the decision to do the C section at 115am, but she kept refuting this saying she was going on documentation and he didn’t get there till 130am and the decision was made after then and he wrote in the notes at 2am. Ryan and I were both happy to go off their ‘fantastic’ documentation system and I stated to them that I had read in the notes that the nurse documented at 130am that the OB was inserting a cannula and prepping me for theatre and if he was doing this at 130am then the decision to do a C section had to have come before 130am as he was already prepping me at 130am according to their ‘documentation’! We bantered on this issue for quite some time, they told me they had read my notes over and over and there was no point arguing with them, so I thought we could settle this by having the notes in front of us, so they were retrieved and as I had previously told Ryan exactly where that statement was written in the notes he went to it straight away (he was sitting next to Jenny who had the notes on her lap) to which there was very little response to, so they kept telling us they could only go off documentation, we showed them how it was documented but then that point was ignored? We were told ‘We know what the sequence of events was even if it doesn’t reflect your timeline’ BUT the time was EVERYTHING how could they just want to dismiss this?
I asked why the Category wasn’t called for us, and Michael told us that he couldn’t answer that question, Ryan then asked if you had to call a category when you called for a C section and quick as a wink they both said yes, but Michael told us that you can’t compel an OB to do anything, that the hospitals responsibility was to provide an environment to practice the best possible medicine, the rest was up to the OB.
Jenny then told us that they had phone records for when the ADON (After hours director of nursing) was called to ask for her to contact operating theatre staff to come into hospital and that call didn’t occur until 152am, and I said to them if they were prepping me for theatre at 130am (which the notes clearly said) why wasn’t theatre called in for another 22mins, there was 22 out of 30 of my precious minutes that was already gone and theatres weren’t even called in, to which they just both agreed and told me that I should bring these things up with my OB, wasn’t that their job, wasn’t that why they had spent weeks and weeks preparing this inadequate 1 page document, if I could point all these things out on a whim after just being told shouldn’t these ‘specialists’ in their own field have thought about that, shouldn’t they have asked him these hard questions, why should it be up to me to go back to him and ask, this should have been worked out already and I told them that everytime I talked to him he told me that he did everything as quickly as he could, as quickly as he could 90mins later was not very quick from my point of view. Michael told me that I was asking for more specifics than ‘as quickly as he could’ because that statement was a broad statement and that was why they had spent so much time putting together the RCA to come to a conclusion, but no one was 100% right there may be a flaw in their investigation, the RCA was not a legal document it was simply a description of the best of their knowledge as to what had happened.
Michael then told us that nurses would soon be able to call the category at their hospital, that they would be able to overcall rather than under call a category from now on, and I pointed out that, that was standard protocol in lots of public hospitals already, they have been able to call a category 1 for years, and Michael told me that it was not the protocol in private hospitals and so I said ‘are you saying that public hospitals are better than private hospitals?’ and he said that no the results in private hospitals speak for themselves (well not in our case they didn’t) Michael tried to point out that private hospitals were better than public hospitals, that their OBs had provisions to view a patients’ CTG at home before coming to hospital, good in theory but when I asked the obvious question, our OB had not looked at the CTG at home before coming into hospital, so good in theory but in practice not actually used.
I said ‘how can you compare a public hospital who can have a baby out in 7-20mins after they have called the category to a private hospital that took 90mins, we were probably your 1 really urgent Cat 1 C section for the year and it didn’t happen in 30mins, yes there are other Cat 1 C sections that you deal with and you get the baby out and everything is fine, and for some of those if the baby was out in 40min, 50mins it wouldn’t matter, we were that 1 that needed to be out as soon as possible and it didn’t happen, how can you justify 90mins?’ and the response from Michael was “in retrospect absolutely, this is a tragedy, a tragedy and looking back there are things that could have been done differently to prevent this and why was it you, I don’t know the answer to that”
The whole time we were in there, we had long, awkward silences always with the tick of a loud clock in the room, it was clinical, it was tense and it was not where either Ryan or I wanted to be, but we were there to fight for our little boy, we were there to stand up for him, because everyone else seemed to be covering up, or passing the buck from one to the other, we were Liam’s mum and dad, we were not nice in that meeting, we were confrontational, we wanted answers, but all we got were more questions, how had they not thought of some of the questions that we had, why didn’t they have the timeline correct, why did it take 22mins before the OB called the ADON to get theatres in, why was an epidural given, and why did it take so long after removing the CTG to get Liam out, and whether the OB or the anaesthetist wanted it or not, Liam had a right to be monitored, it should not have been our job to have to go back to our OB and bring up all these issues, it was the hospitals duty to investigate thoroughly. Just before the completion of the meeting we were given a summation, where they told us that our OB had failed to call the category, it had been his choice not the anaesthetists choice to insert an epidural rather than give a general anaesthetic, and on 3 separate occasions my midwife had tried to monitor Liam after the CTG machine had been removed but had been instructed by my OB not to. Their summation of what happened clearly blamed my OB, the doctor whom I had defended to everyone for the past 14 weeks, the doctor whom I had a rapport with, had been a patient with for over 4 years, they had told us that the blame lay with him, and he had told us that the blame had laid with them, who were we to believe?
- Posted in: The First Weeks