Our Last Hospital Meeting Re Zak

We had a meeting on Thursday with some people from the first hospital I went to (in NSW) when I couldn’t feel Zak.  This was the hospital were all the fun started and I went into labor.  They also were the first ones to say Zak needed to come out.
The reason for our meeting was to talk about the findings of the RCA (Root Cause Analysis) that was done at that hospital in regards to our time there.
(What is RCA?  RCA is a process analysis method, which can be used to identify the factors that cause adverse events. The RCA process is a critical feature of any safety management system because it enables answers to be found to the questions posed by high risk, high impact events—notably, what happened, why it occurred, and what can be done to prevent it from happening again)
I have always said I was happy with my treatment at this hospital so I guess I was a little shocked when they actually admitted that events on the day (at their end) contributed to the overall event.  These events were not events that any one person at the hospital can be accountable for but more policies that should have been implemented when in fact they didn’t even exist.
Their findings ranged from – lack of senior staff being involved in my care when it was obvious the situation was to serious for junior staff to deal with, NETS not being contacted from the start even though that is the recommended practice, time delays getting in contact with QLD hospitals due to lack of phone numbers,  to me being transferred by road when I should have been transferred by air to get me to a hospital that could cope with the birth of a 32 week gestation bub faster.
It was also found that NETS (NETS is the statewide emergency service for medical retrieval of critically ill newborns, infants and children in New South Wales (NSW), Australia) did not have ANY contact numbers for QLD hospitals on hand when finally contacted even though most transfers are North (QLD) rather than South.
There are a few more. That is just a quick summary of what they found. 
There have been some major hospital policy changes at this hospital following the RCA.  Some of these are – senior staff are to be brought in right away when there is a critical situation, senior staff have 15 minutes to find a hospital and then it MUST be passed on to NETS.  (This will cut down on time wasted by Dr’s trying to ring 5 different hospitals to find a bed plus from what I can work out having NETS find you a bed lets the hospitals know just how serious the situation is).  NETS State Director has also held meetings with nursing staff and Dr’s to go over their mistakes.  They have also now got all phone numbers on hand.  As has the hospital in question.  The hospital now has all hospitals, Dr and specialists phone numbers on the wall in all birthing and maternity rooms for easy access.  (My understanding is this is to be implemented in all Northern Rivers Hospitals)
There has also been a Flow Chart for urgent transfers of maternity patients that lists who is in charge of what decision.  This is to stop junior Dr’s and nurses being made to make decisions that senior Dr’s should be making.  They found that junior staff and nurses sometimes take on jobs/decision that are beyond their experience because senior staff tell them to.  Junior staff and nurses tend to do as they are told by senior staff just because they are senior.  The flow chart must be followed.
All in all it doesn’t change anything for us.  It wont bring Zak back but it just might help someone else in our situation.  This should be the end to all meetings we have with the hospitals involved in the care of myself and Zak.  I’m tired now and need to get my head in a better place.  Dealing with the hospitals and re living the events is hard work.  I’m glad it has now come to an end.

2 Responses

  1. That must have been such a tough day Brenda. I guess on the positive side at least the hospital had done something proactive to remedy what sounds like a clear lack of protocols. I’m just so sorry that wasn’t in place for Zak.

  2. Months, later and you are still a warrior. I know how hard it is to relive all this, but I know a part of you is better for knowing the truth and for seeing that true changes are coming out of this. God knows how many others in the future these new changes will help. You and your husband must be so mentally drained from having to relive all this, but I hope it can provide some closure. Also, draw strength from knowing that this aspect of your experience with Zachary is now over.

    I can relate, we sat down with so many doctors, nurses, specialists and finally geneticists (spelling). Only to hear over and over again why my baby did not have a chance in hell to make it. But the end finally came and I knew that my last visit, was my LAST visit indeed in reference to her death. Knowing all I could know ended that aspect of our suffering (the whys and hows), now I could truly mourn my baby.

    I wish you peace in your findings and happiness in your memories of your precious son. Every time i see his picture it just kills me-so precious.

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