Two and a half years later....

Blimey! Two and a half years since I wrote anything. And yet, still I feel no further forward. It's been 3 years since a brilliant leading paediatrician with 40 years experience took a look at Jasmines records and answered my questions, and told me that in their medical opinion there is NO WAY Jasmine would have died had her care been appropriate. The catalogue of errors they identified were, guess what, pretty much all the errors that I identified and went to the two hospitals with after she died, only to be fobbed off by various means. Since then, experts from other disciplines involved in Jasmines care, have all said the same thing to me too.

The legal system has been in huge thorn in my side for all of these three years. The NHSLA states that they are there to rapidly settle those cases that should be settled and to defend those that are defendable. We are told there is a Duty of Candour and that all trusts are open and honest. Yet I am advised by my legal representatives that we must not provide the NHSLA with all of these expert opinions and all of our witness statements for them to consider, without getting their agreement to share the witness statements of the involved clinicians and their independent expert reports at the same time. My legal guys used to work for 'the other side'. They tell me that the clinicians involved will not willingly admit to their mistakes, and that I am dealing with one of the most famous children hospitals in the world, they will want to protect their reputation at all costs rather than admit any liability here. They tell me they would expect the other side to 'slightly alter' witness statements in an effort to make their actions look more acceptable if we just gave them all the damning evidence without receiving their clinicians accounts of what they did and why first. What about the Duty of Candour I ask? Pah! They say. Hmmmmm

In my world of ideals and morality, I would sit down and meet with the leading clinicians involved in Jasmines care, having given them all of our expert evidence to think about. I would take the experts with me to explain to those clinicians how they have come to believe that Jasmine would not have died but for her poor care. I would expect healthy, grown up, open and honest discussions and perhaps debate, discussing the issues and together reaching a conclusion. I would want opinions to be evidence based. I would want this because what is most important to me is to fully understand how Jasmine died. I believe I know the mechanisms by which her brain stem was so severely injured she could not survive, and I believe I know what the errors were that led to this. But what I also want to understand, from the people involved themselves, is why those errors were made. Why, on that day, it went wrong, when any other day it would likely have gone right? What human factors were at play. Those human factors are the key to safety. Once we all discuss, agree, conclude those things, Jasmines story can be used for teaching across the NHS to improve paediatric patient safety. This is what I want now, an opportunity to get out there and share Jasmines story with a national audience, for learning and improvement on a national scale. The things that went wrong for Jazzie are common themes, poor communication, lots of different teams not speaking to one another, assumptions, evening and weekend admissions, poor training, failure to recognise the deteriorating child, parents not being listened to.

So much good could come from openess and honesty and a willingness to learn from the two trusts. So much learning could be shared. I could finally feel free of this weight on my shoulders of feeling I have to get Justice in the form of truth for my girl. I could speak freely about what happened with the full support of those institutions involved. The paediatrician who gave me the answers I so desperately needed 3 years ago could write an article (co-authored by those involved if they were especially great) for a paediatric journal about this case for learning from a wider audience.

Why oh why do trusts behave in a way that means they are ticking the boxes and looking good, all the time covering up the truth. I'm not an idiot. It is crystal clear in my opinion that the two trusts involved knew exactly what really happened both before the inquest and during the time they carried out Root Cause Analyses (after the inquest occurred) All the bits that were 'missed out' from these two processes - it would seem too much of a coincidence that these were innocently glossed over to me.

I long for the day this ridiculous legal process ends and the real learning can begin - with or without the support of those that were involved. Perhaps they ought to consider how much better their reputation will be if I am speaking of their willingness to support me in sharing the learning from what happened than if I use their actions as an example to indicate why so much more has to be done to make the Duty of Candour ever make any real difference to families like us...