Jenni Dewhurst
I have spent my working life as a Health Care Professional in the NHS – training as a Therapeutic Radiographer and spending my last 20 years as Clinical Head and Manager of Therapeutic Radiography in S.E. London.
In this specialty, because of the delivery of large doses of Radiation, we had a culture of following strict policies and protocols and double-checking everything possible in order to ensure correct treatment. All errors and potential errors were recorded, analysed and acted upon. Because we were a relatively small profession (around 60 centres) we also learnt lessons from incidents at other centres and changed practice as necessary. I believe we were always open and honest with our patients and offered immediate help and support when an error did occur.
My personal experience relates to my father who was admitted to an acute ward with pneumonia and heart failure (not picked up by his GP). He had excellent care and treatment on this ward for 10 weeks. He recovered well and plans were in place for his discharge. However prior to this he was transferred to the Rehabilitation Unit for extra Physiotherapy. Sadly, there was no continuity of care. My father was now under a completely new Consultant instead of those who had looked after him for several years. After a week, my father was no longer given his diuretics and died 6 days later. As well as grieving for my father I felt guilty that I had ‘taken my eye off the ball’
Although an incident report was completed and the Consultant I saw at the time told me it was a Medication Error, the enquiry I requested decided that discontinuing his diuretics had been intentional. When I queried this, further investigation revealed that they could not be sure whether it was intentional or not.
I then involved the Health Care Commission who investigated and produced their recommendations, but although I requested it, I have seen no evidence that these have been implemented.
At the time I was concerned that if all this was proving so difficult for me, having worked in the NHS, then how would other members of the public cope? All I wanted following my father’s death were straight answers and an assurance that this could not happen again.
I am therefore delighted and grateful to have an opportunity to work in partnership with Health Care Professionals and Policy Makers to ensure improvements are made which will prevent avoidable harm and lead to safe healthcare for all patients.