Thursday, 15 November 2012

Learning from "mistakes"

In my last post I spoke about the investigation carried out by the hospital, into the care that I received during my labour and birth of Harry.

I was really unsure about how I would feel about this meeting, but now as I have had to visit "The Centre for Women's Health" so frequently since having Harry, it wasn't the visiting the hospital that I was unsure about. Thankfully, I had taken wise advice and left super early so I could park easily as my appointment was in visiting hours, and I know from previous experience that parking at this time can be impossible. I was already relaxed from this, and felt fine going into the hospital. The security man on the desk was really smiley and happy and made me feel at ease, instead of the blank, unfriendly faces usually greeting your arrival. I waited in the lobby area watching all the pregnant ladies coming to be scanned, or those visiting newborns and their proud parents. I saw one man whose wife was on the labour ward. He was off to get a meal from the cafe and the nervousness and excitement was all over his face. Bless him, I thought. He has no idea of what lies ahead, I wonder how he would cope if things went wrong. I hate that I think like this now. But I can't seem to help it.

I was meeting the senior midwife and the "governance lead" at the hospital, and we held our meeting in the midwife's office, on the pre and post labour ward. The same part of the hospital that I spent the night on after having Wills, where I had stayed when I had a dreadful stomach bug early in my pregnancy with Harry and also where we stayed during Harry's short life. I wasn't saddened by where we held the meeting, as I felt like whilst this place holds a variety of memories for me, it is also where I need to come to have any future babies and the place where I can try to make a difference within.

Anyway, I had met with the senior midwife before to discuss my complaint letter, and while I hadn't met the governance lead, we had held several telephone conversations and emails. Immediately, I felt at ease as they were really friendly and smiley and was offered a cup of tea. They told me that this meeting was to be led by me and any questions that I had. We talked about the report and how I had found it hard to learn about the number of issues raised. I spoke about how I think it is a huge step for the hospital to be so open and honest about where they feel they have fallen down and to willingly address areas for improvement.

We spoke about each point of failing by the team caring for me, and spoke about the steps being taken to resolve these. In the main, it appears the hospital are refining their existing policies and procedures inline with the care I received to improve care offered to other mothers, in labour. For example, as I was left without being monitored for four hours... it says in their  policies "a mother's vaginal loss should be monitored regularly" - now they have made a change which now say "a mother's vaginal loss should be monitored regularly, at least every 30 mins, especially when the mother had an epidural fitted". So that reassures me. Likewise for the placenta being examined. The policy says that "a placenta should be examined after birth" it doesn't give a time frame. But now it does and explains it should be checked so that the infant can receive "applicable care for example in the case of vasa previa". Seeing those words in their policy document made me proud to see, knowing that Harry's little life was now improving the care received by other mothers and babies. The other points where policies are already in place, but weren't adhered to, staff have been reminded of their responsibilities in newsletters, and in training environments. 

We then went on to talk about those who cared for me, and how they had been scrutinising their actions, as to whether they had anything to learn from this case, and have been given applicable supervision where necessary.

We talked about the work of the Trust and our donation to the Neonatal Unit, and how wonderful the doctors were. We also talked about the support group I had set up and how I wanted to help other mothers not feel so alone as I had done. We spoke about the National Screening Committee and how we are working together to change the way vasa previa is screened for.

I felt good leaving the meeting as I felt that all I could ask to be done was being done and that the hospital were trying to learn from their mistakes and things seemed to be going in the right direction.

I walked out the office and began to walk out towards the exit. There coming down the corridor was a mother in a bed being wheeled to the post natal ward. She looked ecstatic. I felt hugely envious. Behind her was the same Dad who I had seen in the lobby, pushing the tiny cot with their new baby in it. I felt like I had been punched when I looked down at this dear little baby boy. A beautiful baby. I smiled at the proud father, as I struggled to keep it together. I can't wait to be that mother being wheeled back to the ward with our newborn baby. I hate that the last time I was wheeled back from the theatre I was in total shock, after being told our baby may not survive. But as I said, this place holds lots of memories for me, good and bad. But it is now about making sure that Harry's short time makes a big difference to others, and I need to be strong to make sure that happens.


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