Within an hour of the incident happening, I'd met with various clinicians. They'd
come to my bed, including the consultant anaesthetist who was on duty
But what was really a positive thing out of that situation was
I met with the anaesthetist who made the particular error
of not flushing the line. And he came to my bed and sat beside my bed and apologised and
you could tell he was really broken, really broken by it. And it had
definitely been a costly mistake for both of us. It was really important and
significant to have had that apology.
There was a chief surgical nurse, she
was on duty at the time of the incident, and came over to see, me and spent a lot
of time with me. And she gave me her mobile number and
explained the next steps and said there would be a 72-hour report. And that if I
ever wanted to find out more or understand what was going to happen next
then I could contact her through this mobile number, so that was really
helpful. So I knew I was leaving hospital knowing I had a source of contact
a source of direct contact. And I had also had an apology. And, yeah, so that was
I guess, probably as positive as it could be, in that moment for such a traumatic
incident I think. There was an openness from the moment it happened from the
bedside candour from the way that that was handled, it was a
very human response. I connected with the team then, you know I knew they were
dealing with a very serious incident. And I also had both the 72-hour report and
the serious investigation report as well, so had a copy of each that I could
read and digest and still come back and have questions. And that meant a lot to me
It was important for my own personal health and well-being and healing to see
You know, to not feel like this incident just got brushed under the
carpet. That everything seemingly came out into the light, it was seemingly
thoroughly investigated. That they were interested in positive
long-term change and that they took the opportunity to implement what feels like
significant changes before something even more catastrophic happened to someone.
When I received the report in September it was far more comprehensive
than I thought it was going to be. They talked about some of the learnings and
findings, and I could tell they were looking at the wider systemic failings so I knew
in that moment they weren't making a scapegoat of the anaesthetist. And so I
actually had a lot more respect for them and the leadership because they weren't
just hanging one person out to dry. And I I knew they were serious when they
invited me to be a part of that solution to help with speaking about it
in a training environment and to tell my story and give me time for that, as well
as producing reports, as important as that is as well.
What I went through didn't exasperate the trauma anymore, which was a positive
thing. The trust were very open and honest with me
and transparent and kept a clear line of communication. Yes there were things that
weren't always perfect or occasionally might have to chase, but I had a means to
do that and a contact person. And I knew that they were taking it all very
seriously.