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Mum’s agony leads to hospital changes
HOSPITAL rotas have been changed to provide better cover at weekends and holidays after parents’ concerns over the birth of twins at a city hospital.
Extra staff and better communication and pain management have been pledged after the parents wrote a report about their care last July and August.
Oxford University Hospitals NHS Trust executives said the case shows the big challenges of providing hospital cover 24/7.
The un-named mum gave birth to daughters by Caesarean section at the John Radcliffe Hospital in July and then spent a month in the hospital herself.
She developed a haematoma bowel obstruction and the twins were admitted to the special care baby unit with low birth weight.
A junior doctor “didn’t seem to grasp the severity of the situation,” according to her case, which was discussed by the trust’s board on Wednesday.
She said: “What we found was that when you went into the hospital at a weekend everything grinds to a halt.”
The mum, who was under care of the maternity unit, felt “in limbo land” about her condition and said her care “felt very inconsistent” as she was seen by different doctors.
She was discharged and re-admitted after going “really downhill” at home and was taken to the surgical emergency unit to remove the obstruction.
She said: “That is where we felt things got really sticky for us, because we fell between the gap”.
She was there for two weeks and wrote: “We were in three parts of the hospital and logistically it became really, really difficult for us.”
This led to problems breast feeding and a wait “for a very, very long time in agony” to get pain relief signed off after her epidural was removed.
She said she was later “absolutely tearing at the walls” to get out and see her family but her discharge was delayed allegedly due to “miscommunication and lack of senior doctors over the holiday periods”.
Director of clinical services Paul Brennan said the case was “quite unusual”.
He said holiday and weekend rotas have been revised while an action plan states that such cases must have a named doctor and midwife assigned to them.
Staff training around ensuring pain relief is ready and will take place, while more consultants and surgical nurse practitioners are planned by April.
A trust report adds: “Medical rosters should ensure adequate senior medical supervision is consistently available including during holiday periods.”
Medical director Prof Edward Baker added: “The weekends felt like wasted time for the family because a lot of routine things didn’t happen.
“I think that this is a real challenge to us as an organisation and to the culture of the NHS.”
Death rates at hospitals are the same at weekends as in the week, he said.
Chief executive Sir Jonathan Michael said OUHT is looking at the issue which was “complicated” by existing rota arrangements and staff terms and conditions.
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