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Furness General Hospital  Safety of Maternity Services  June 2011
Introduction ,[object Object],[object Object]
Furness General Hospital (FGH) Maternity Services - 2008 ,[object Object],[object Object]
Known Serious Untoward Incidents (SUI's) before Joshua’s birth in 2008. ,[object Object],[object Object],[object Object],[object Object]
April 21st – Death of Niran Aukhaj and her baby ,[object Object],[object Object]
July 31st – Death of Nittaya and Chester Hendrickson ,[object Object],[object Object]
September 6th – Death of Baby Alex Brady ,[object Object],[object Object]
Dr Misra’s letter of 17th October 2008 regarding Alex’s death : ,[object Object],[object Object],[object Object]
Mr Smith said: ,[object Object]
Joshua’s Story 27/10/08 – 05/11/08 ‘ Our Little Fighter – Always Remembered ’
The Pregnancy   ,[object Object],[object Object],[object Object],[object Object]
Getting Closer….. ,[object Object],[object Object],[object Object]
The Days Before the Birth….. ,[object Object],[object Object],[object Object],[object Object],[object Object]
Pre-labour At the maternity unit, we told the midwife that Hoa was feeling unwell and described the symptoms clearly. We were very anxious about infection and we discussed these concerns with the midwife. Hoa was in tears and unable to speak and I did most of the talking. We were told that the illness was most likely a virus, and that there was “a lot going around”. After being checked over, we were given advice regarding monitoring temperature at home and to keep an eye on the colour of the fluids. Hoa was discharged about an hour later and told to return anytime after 10am the next day. With still no sign of labour, at about 11.30am on Sunday 26th, we returned to the hospital. We explained that Hoa was still feeling ill, tired and had a sore throat and headache.  At the hospital, Hoa was monitored for contractions (still none) and given blood pressure and temperature checks.  We were later discharged and told that if the contractions hadn’t started earlier to come back on Monday morning.
The Birth ,[object Object],[object Object],[object Object]
Hoa’s Collapse… ,[object Object],[object Object],[object Object]
Still in the Labour Room….. ,[object Object],[object Object],[object Object]
Postnatal Care ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
The First Photo… Emily meets her brother for the first time at just after 3pm on 27/10/08…….. We are all elated.
Still on the Postnatal Ward ,[object Object],[object Object],[object Object],[object Object]
After Joshua’s Collapse ,[object Object],[object Object],[object Object],[object Object]
Transfer to St Mary’s ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ECMO ,[object Object],[object Object],[object Object],[object Object]
At Newcastle ,[object Object],[object Object],[object Object],Joshua was very brave, he often opened his eyes when he heard our voices. He could squeeze a finger  when placed in his hand. Not being able to pick him up and cuddle him was heartbreaking. Joshua was being  given Hoa’s breast milk and it helped us to know we were doing something for him.
Joshua’s death ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
 
Getting home… ,[object Object],[object Object],[object Object]
The Cover up starts ,[object Object],[object Object],[object Object]
False Reassurances ,[object Object],[object Object],[object Object]
Refusal to share Information ,[object Object],[object Object],[object Object]
Misinformation ,[object Object],[object Object],[object Object]
1. Hoa’s Illness ,[object Object],[object Object]
2. Joshua’s lowest temperatures ,[object Object],[object Object]
Parliamentary and Health Service Ombudsman (PSHO) ,[object Object],[object Object],[object Object]
Care Quality Commission (CQC) ,[object Object],[object Object],[object Object]
Furness General Hospital – Maternity Services Update ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Furness General Hospital – Maternity Services Update cont…. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Fielding Report Secrecy ,[object Object],[object Object],[object Object],[object Object]
Inquest ,[object Object],[object Object],[object Object]
10 Failures ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Missing Medical Records ,[object Object],[object Object]
“Collusion” ,[object Object],[object Object]
‘ Every member of staff has taken this as a learning experience and been totally open, honest and fully co-operative with the investigation’ ‘ We have shared all of our information and findings with every agency in the spirit of openness and honesty in which we pride ourselves and operate as an organisation.’ –  Press statement from Tony Halsall, the North West Evening Mail – 15th January 2010.
“ Having discussed this with Dr Paul Gibson, his estimate of Joshua’s likelihood of survival if antibiotics were started at the same time as Hoa would be around 90%” The situation at FGH maternity unit that led to Joshua’s death must never be allowed to happen again.
Is it too late……? ,[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object]

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Joshua's story -_dr_amy2_-_2011

  • 1. Furness General Hospital Safety of Maternity Services June 2011
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  • 10. Joshua’s Story 27/10/08 – 05/11/08 ‘ Our Little Fighter – Always Remembered ’
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  • 14. Pre-labour At the maternity unit, we told the midwife that Hoa was feeling unwell and described the symptoms clearly. We were very anxious about infection and we discussed these concerns with the midwife. Hoa was in tears and unable to speak and I did most of the talking. We were told that the illness was most likely a virus, and that there was “a lot going around”. After being checked over, we were given advice regarding monitoring temperature at home and to keep an eye on the colour of the fluids. Hoa was discharged about an hour later and told to return anytime after 10am the next day. With still no sign of labour, at about 11.30am on Sunday 26th, we returned to the hospital. We explained that Hoa was still feeling ill, tired and had a sore throat and headache. At the hospital, Hoa was monitored for contractions (still none) and given blood pressure and temperature checks. We were later discharged and told that if the contractions hadn’t started earlier to come back on Monday morning.
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  • 19. The First Photo… Emily meets her brother for the first time at just after 3pm on 27/10/08…….. We are all elated.
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  • 44. ‘ Every member of staff has taken this as a learning experience and been totally open, honest and fully co-operative with the investigation’ ‘ We have shared all of our information and findings with every agency in the spirit of openness and honesty in which we pride ourselves and operate as an organisation.’ – Press statement from Tony Halsall, the North West Evening Mail – 15th January 2010.
  • 45. “ Having discussed this with Dr Paul Gibson, his estimate of Joshua’s likelihood of survival if antibiotics were started at the same time as Hoa would be around 90%” The situation at FGH maternity unit that led to Joshua’s death must never be allowed to happen again.
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