

What happened:
So what?
1. I will not retell the patient story, as it will not do justice to the event. You need to hear it for yourself. I will tell you this. The patient story of a routine operation alarms and horrifies me. It outlines a breakdown of basic communication yet highlights the impact of a hierarchical regime. The nurses did not question or were assertive however were able to in an instant identify the core of the issues at present. The failure: to intubate and ventilate resulting in catastrophic patient death. The nurses were able to identify a crisis yet felt restrained or were not assertive enough to to act. Despite regulations and procedures in place for this type of catastrophic event, they… Continue reading
What happened-
– today l heard and learnt about:
So what?
1. Lewis’s story is so distressing because I have seen this happen multiple times before. The ongoing saga of issues associated with this has lead to multiple reviews and recognisable changes in the healthcare system to provide a “safety net” for acceptable “parameters”. The issue with this is the evidence behind the decisions making processes. Lewis’s story has allowed me to reflect on issues I have observed in the past and the frustration I have experienced as both a junior and senior member of the nursing team. This story demonstrates multiple failures and, with the benefit of hindsight we are able to form a clear picture of the… Continue reading