Negligence/misconduct/murder

The Council has been receiving more and more reports from patients and their guardians of negligence and misconduct by nurses and midwives but also from staff about being ‘beaten’ at work. Each report is investigated by Nurses and Midwives Council staff who then report to the Investigations Committee, who eventually hand appropriate cases to the Disciplinary Committee.

Recently, because everyone is off planting up their fields, I became part of the “Investigations Team”, a job I didn’t want at all as I’ve seen more than enough bad practice here to last a lifetime but I thought that maybe being part of it might actually give me the chance to see what really happens when these things become ‘official’ rather than covered up or ignored.

Our first case was of a midwife who had been ‘assaulted’ by a guardian while on duty in a labour ward. The Midwife had apparently been beaten/slapped/hit by the relative of a woman who had the previous day given birth to a baby, that had then died 12 hours later. We were to interview The Midwife, two of her Colleagues, the Nursery Nurse who looked after the Baby and Matron.

Up first was meant to be The Midwife but she hadn’t thought it necessary to come in that day - so we moved on to her colleague. She reported that she had been alone on the labour ward that morning as no one else (including The Midwife) had come for their shift because they were sick/absent/couldn’t be arsed. She (The Colleague) reported the problem to The Matron and then set about admitting the women wriggling about on the bench in various stages of labour. She said that The Midwife eventually turned up for work and on her return from lunch break she was slapped by a woman who was crying and shouting, accusing her of being ‘satanic’. She helped remove this woman from the ward and then sent The Midwife home.

Next to spill the beans was another Colleague who described what had happened the day before. The Patient had been sat on the admitting bench, as she had been on 3 other occasions in the past couple of days, waiting to be sufficiently dilated enough to be allowed to hop into a bed and give birth. Her Relative was getting increasingly antsy about the whole thing and it was the last straw when they were again sent away (no doubt with a flea in their ear and a sharp sucking of the teeth). The Patient’s cervix did eventually reach the required 4cm stage and she was admitted to a labour room, accompanied by her Relative, to await the arrival of her baby. All was peaceful until The Colleague heard The Relative screaming for help, The Midwife leapt/moseyed into action and found the Patient standing, legs akimbo, with The Relative clutching the head end of the baby that was dangling, half in-half out. The Patient was heaved onto the bed where the rest of The Baby (and gubbins) was delivered.

Then came The Nursery Nurse who informed us that The Baby had been rushed from the post-natal ward to the nursery in the middle of the night – it was not breathing although it had a heart beat – so had been resuscitated, popped on oxygen and kept for monitoring. The Nursery Nurse said that she had noticed The Baby ‘twitching’ and it was hot, 40C hot, so it was taken out of the warmer (good idea) and the mother encouraged to feed it. A few hours later, it was 42C and its condition was ‘very poor’. A little while after that it was ‘critical’ and ‘there was nothing to be done – baby died, very sorry’.

Then came Matron2, she said she had read the reports of the beating and the death in the communication book but without talking to the Matron who had been on cover she didn’t know anymore than what was written.

So, with the interviews done, we looked at the incident reports, the labour notes and the Baby’s medical notes. It was then that we found the documentation barely had any useful information in it – the Baby’s in particular had no vital signs written down, no record of any drugs having been given and no signatures against any of the procedures that had been performed. No clinicians/doctors had been called to review The Baby. No one could provide any explanation as to why. The Nursery Nurse said she had dictated the notes to her colleague to write because she was too busy. Matron2 said that it was lucky we had the notes at all because the Relative had in fact taken them when the Baby died. Matron1 had apparently issued an order that the Baby was not to be released to the family unless they returned the notes – so without a choice the macabre trade off – notes for dead body – was done. Lucky indeed.

We had also requested additional information about the numbers of admissions, births, deaths and discharges so The Colleague was sent off to get the information. She returned, scrap of paper in her hand, and began to give us lists of numbers but it became clear that they did not tally with what we already knew – she showed us her paper, confusion furrowing her brow – she’d copied information from the previous week’s records despite having known the date (written on her incident form) and been reminded before she left the room.

So in summary, we had some pretty vague information from the interviews, some crap documentation and some incorrect record data – it was all going really well. My two fellow Investigators then took the opportunity to go off on a tangent and started giving Matron2 an ear-bashing about all sorts of other things. At this point, 5 hours into the whole thing, I felt tears pricking my eyes, it seemed so overwhelmingly pointless. I wanted to ask why a woman in labour had not had better explanations and care while she was waiting to be seen, why when imminently due to give birth she did not have a midwife there with her, why her baby had not been more closely monitored so that it didn’t end up being rushed to its death, why when it was ‘critical’ it was two hours between temperature readings, why no anti-fever measures were taken, why the family were treated with utter contempt once the baby had died, why no one was sorry for the family’s loss, in fact, just why?

Since The Midwife wasn’t available we couldn’t finish that case. So we moved on to no.2. This time it was of a 17 year old who had given birth but had had problems afterwards, she had been scheduled for a hysterectomy due to massive post-partum haemorrhaging but then it was thought the bleeding had stopped through uterine massage. It started again at some stage and she was for surgery again but before she got there she bled out and died. It was the same hospital, the same labour ward and on closer inspection, the same Midwife – I couldn’t believe it. We interviewed the Matron again about this case but she was as helpful as she’d been previously and we had to conclude that we couldn’t carry on.

Afterwards, at home, I really felt the lack of clinical supervision I have these days, someone professionally more experienced and capable of helping me think stuff like this through. I miss it a lot. I miss being clinical. I miss being there to help prevent things like this from happening. I miss teamwork. I miss having colleagues who I can depend on. I’m still happy being the person I have become in my role here and I want this programme to work with everything that I have, but I miss I miss being a proper nurse.

We’ll continue the investigations and see what happens – consequences of bad practice here are a slap on the wrist and your name in the paper, your licence might be removed but with the major shortage of nurses is it better that a crap one is on duty rather than not one at all?