In September my Dad had a ‘funny turn’; an episode that lasted about 2 hours. I instantly felt he was having a stroke and took him straight to A&E. He couldn’t see (told me his vision had gone), was dizzy, confused and combative which was not like him at all.
I was allowed with him in triage and explained I believed he was having a mini-stroke/ TIA.
He was already on blood thinners for an unexplained blood clot in his lung that formed in July (this was the start of his health going down hill).
After triage, they took him through but would not allow me in with him to await the doctor due to ‘Covid regulations’. Dad was in no fit state to advocate for himself. After a few hours, during which time I sat outside on the bench, he still had not been seen. He began to feel better and text me to say so. I replied to say that mini strokes can resolve by themselves but still need investigating / treating to prevent a bigger one.
Eventually a doctor saw him and told him he probably just had a near faint. Putting the discharge paperwork through as near-syncope. I wholeheartedly disagreed but hadn’t been allowed in. No scan was conducted.
Followed up with GP as he was having other unexplained issues with movement and word blindness and they put through a non urgent referral to neurology.
The following month he had a major brain bleed and was found unresponsive. They couldn’t save him and we agreed to organ donation; ending his futile life support machine.
He was 65. Previously running about, working, bmi of 22, apparently ‘healthy’.
Ahead of the inquest, the hospital trust’s Patient Safety Team led a review of his case. I had the findings yesterday and they said they had no reason to believe that any neurological event took place the month before his major brain bleed and they stand by this, despite not having conducted any tests other than a general blood test in A&E.
I’m so saddened that they appear to be protecting their reputation rather than looking at genuinely making safety improvements for future patients. They clearly won’t learn from this. No reason for this post other than to offload and say how sad I’m feeling. Thanks for reading.
I am so very sorry this has happened. COVID did so many of us a bad turn. I wish things had not happened that way. Seems like you know what you know but have no way of proving it. It won’t bring him back knowing now, but it might have helped him for someone to have taken a better look at the time, or contacted you by phone while he was there to inquire. I doubt anyone was deliberately negligent, but the overlooking is very sad. He may have gone in insisting he was fine, not wanting to have to stay. I have done as much, ill advised as it was, and very many I know have done the same. I hope you will be able to remember all the good things you have shared together, and the good he gave to others upon his death. I can honestly say, having had a brain hemorrage that when it is my time to go, that is a relatively quick and painless route, and I would prefer it over most others. It hurts to know your pain. I hope something I have shared will somehow ease it for a bit.
I am so sorry for your loss. Hopefully sharing your thoughts and venting your frustrations on here will be cathartic and will enable you to focus on your good memories of your Dad.
Death causes heartache that no one can heal
Love creates memories that no one can steal
Sending best wishes to you and your family.
Regards Sue
Thank you all for your replies. I know it’s not healthy to focus on this and I’ve made progress with my grief (having lost Dad towards the end of last year). It just angered me that they reviewed his case internally at the request of the coroner, and still decided that there was no learning the hospital could make to prevent future tragedies.
The outcome I had wanted was for them to say that in future anyone attending with neurological issues alongside a current/ recent blood clot gets some kind of screening for a stroke/ brain bleed; likewise for those on blood thinners. I also believe they should allow someone in that confused state to be accompanied when the doctor attends. It’s not like we’re in 2020.
Thanks everyone; you have helped me and you’re all amazing. I’ve read some of your posts and am in awe of your strength. Thank you again for taking time to comfort me despite what you go through day to day.
I think your desired outcome from proper in inverted commas investigation was noble, correct and worthy .
There is an American professor, I think at Harvard - named Amy Edmondson who about 20 years ago observed that the hospitals with the best performance were paradoxically the ones that reported the most mistakes. Over the years her statistics, investigation and thus conclusions led to the hypothesis that they weren’t the ones that made the most mistakes they were the ones that acknowledged all their mistakes and discussed them and then avoided them. the others that didn’t report so many were hiding and repeating.
A whole genre called psychological safety as evolved out of the topic. It rather obscures the particular issue here. In brief it says people need to feel safe in the workplace in order to talk about mistakes and thus instigate a culture of learning from experience. There is more but it’s not so relevant
I hesitate slightly to mention it but maybe your father’s outcome was not the beginning but the middle of a cycle where previously made mistakes were repeated and are still not being recognised and acted upon?
You’re grieving process is the most important thing. That allows you to put this chapter behind you. You may thus wish to leave it closed when you can close it. However you might continue to pursue the quest to help them engage virtuous circles in the future in the way that you suggested. It does sound as if they’re in denial at present
@BereavedDaughter so sorry for your loss. Covid has a lot to answer for & it’s a shame you weren’t allowed to stay with your dad at that time.
In my experience hospitals will usually stand by their original decisions. There may be very good reasons for that but of course it doesn’t help when you’re the one that’s grieving.
It’s very difficult to challenge what happened as you have to prove that the outcome would have been different if they’d had the different treatment.
I don’t know if you get the right of reply to their report but you could maybe raise it with the coroner. They might dictate that the hospital has to learn those lessons.
Sending my very best wishes & so sorry again that you have lost your dad xxx
Although not the same situation, I went through something similar when my dad died. Briefly, he had a terminal illness and was on his GP’s palliative care register. When he entered the last phase of his illness, the palliative care didn’t kick in and I felt he was poorly treated mainly due to his GP practice overlooking his needs.
I tell you this because I decided to complain, initially to the CCG (as they were at the time). When they didn’t respond to my satisfaction (they refused to apologise) I then took my complaint to the Ombudsman. This was a lengthy and sometimes gruelling process, but they upheld my complaint. Not only did the GP practice apologise, they also explained a new procedure they had put in place that should prevent this from happening again.
As you can imagine, I got some closure from this and although it couldn’t change what happened to my dad, I felt that it might help prevent someone else from being in this situation.
I’m enraged to read your story.
It’s useless that I pretend to have something good to say.
You had more an idea of what was going on than anyone did in A&E.
I feel you were close to saving him, at least your instincts were spot on
then, very likely, almost everybody feels insecure, because generally, people hate admitting they’ve gone wrong and do everything to cover their behind (the CYA technique)
@pando
And so In part hence the psychological safety meme that has carried Amy edmundston’s career for the last 20 years .
She has a clinical background and observed the need for the phenomenon in hospitals with a&E departments. It’s an important apparent non-sequitur that makes perfect sense when explained
She has since tried to generalise the idea to all corporations and her lack of experience in other business cultures shows to a degree.
Unfortunately the idea of psychological safety has grown wings and been popularised and has resulted in codes of conduct being rife without understanding of what it takes to implement as a cultural shift the need for behaviours that recognise and encourage diversity. It looks as though this thread is exposing that short-term protection of reputation over long-term gaining of truly impressive reputation - such a shame
I listened to your 50 min youtube clip, Simon. Very good.
In a civilized and educated world I would imagine the mechanism you talk about takes place beautifully, and naturally, following unspoken decency and traditions. In today’s world it’s more like each one for himself.
Anyway, I probably miss the point. They say English is such a maleable language, and can be used in many different ways. But there’s so much diversity in the UK which is why there’s so much confusion.
I tried to think how musicians perform and stick to certain groups and styles (whether playing or just listening). In music there are many good interpretations of the same piece possible. Some are not elegant, some renderings are nonsense, some are called in “bad taste”. I discard those, but update my thoughts to understand why I don’t like certain accounts of a work. Certain conductors I respect, but chose not to follow. Those styles that I click with I add to my way of thinking. Life is too short to focus on all ideas. I have plenty of performers and styles left that are out-of-this-world and I’m very happy listening to. I look up to those.
Speak soon, and thanks for the talk on youTube,
ciao, Roland