Earlier this week, I represented the family at the Inquest into Victoria Harrison’s untimely death.
Victoria (26.10.94-16.08.12), who liked to be known as Tor, died aged 17 at Kettering General Hospital after an operation to remove her appendix. During the operation an artery was severed and repaired but, tragically Victoria bled again later and opportunities to detect and treat this were missed. There was a poor hand-over from Theatre staff to the Recovery Nurse and in turn to the Ward staff. Basic post-operative observations were not carried out and there was a further failure to carry out a formal observation after an injection of morphine was given for pain. Had these observations been done it is possible that the deterioration in Tor’s condition may have been recognised and her life saved.
Errors of judgement against a background of the six-month rotation of all Junior Doctors that occurs in every hospital in August and March meant the medics were not familiar with the hospital procedures or each other.
The simultaneous reconfiguration of the Ward Tor was on, had merged a medical assessment unit and a post-op surgical ward and the night nurses looking after Tor had no recent surgical experience. A recipe for disaster. And disaster occurred with Tor passing away in the early hours of 16th August and, by the time the alarm was raised and a resuscitation team arrived, her jaw was too stiff for an intubation tube to be inserted and attempts to revive her were futile.
Tor was much loved –the youngest of three children in a close-knit and loving family, popular, positive and her mother’s “best friend”.
What a complete waste of a young life. Or was it?
The Trust carried out an immediate and thorough investigation into what happened and prepared a report and recommendations to improve standards and systems to ensure these errors never happen again. More importantly, the senior nurse at Kettering General Hospital has worked closely with Tor’s mum and family to support them, listen to their concerns and kept them updated as the investigation continued. The Trust staff were open and honest about the errors that had been made and did not try and hide the truth from the family, ourselves or each other.
Staff involved have been retrained where necessary but all staff, whether involved or not, know about Victoria and the lessons that need to be learnt.
The 6 main problems identified by the investigation have been incorporated in a pocket sized booklet that has a page for ‘must do’ steps for post operative care but, also other areas where poor care can lead to avoidable harm such as pressure sore prevention. The clever thing about the booklet is, it fits in the nurses’ tunic pockets and, is made of hard laminated sheets so they are always aware of it being there and cannot forget.
All of this has been a huge comfort to her family and friends at a time of almost unbearable grief. They could see steps being taken to prevent another family suffering a similar loss. They were involved, empowered and listened to. They could help make a difference.
And they have and Tor’s tragic death has resulted in changes that will save others.
And this is Victoria’s Legacy.