A newly qualified nurse describes what happened when she reported her first Datix for a serious incident.
I am an avid fan of the show, Silent Witness; pathologists trying to find out how someone was killed just from the body. The deceased is the only witness to what actually happened. So, by looking at the surroundings is the only way of determining what might have happened.
I also love watching 24 Hours in Police Custody. This is where they interview the person directly involved in the incident, the people around the time of the incident and the person who potentially did the crime: questioning, piecing together exactly what happened using statements, CCTV footage, verbal accounts of everyone involved. The art and science of investigation is clear. The experience and knowledge of the investigators is quite remarkable.
Investigation in healthcare doesn’t seem to work like this.
I am a newly qualified nurse. I have been qualified just over a year now. I reported my first Datix last month. I took over the care of a patient from a colleague. I was coming on to a night shift.
My patient looked very unwell. I took his observations. He was scoring a 9 on the NEWS2. I put a medical emergency call out. Everyone came, they got him a bit better. They decided he was not going to do well as he was frail and had many comorbidities, they decided to keep him on the ward and if he deteriorated further, he was for palliation.
I was pleased I had a plan for him, but I noticed that he didn’t have any observations taken for over 12 hours previously. So, I reported it as a Datix. I marked it as a serious incident. I was worried when I reported it as I didn’t know what to expect. When would someone from the investigation team come and see me? Would I have to write a statement? When would I get interviewed? Will I get into trouble?
I waited. The patient passed away peacefully. I forgot all about the report I had made.
Six weeks later I received an email. The investigation had taken place. But I wasn’t included. No one had asked me how I had found the problem, the circumstances around the problem or even asked me to be involved.
I’m not trained in investigation, but surely being directly involved in an incident I would be asked what had happened and be included in their investigation?
The email I received was to inform me of the outcome.
‘’Lessons learnt - Always follow the policies regarding the observation, statement taken from staff involved, practice educator involved with training.’’
I didn’t give a statement. The member of staff who didn’t do the observations made a statement, but not me. The investigation was also ‘downgraded’.
What does it take to be a serious incident? This man had no observations for over 12 hours while unwell in hospital. He deteriorated and it wasn’t recognised.
I think this is serious. Have others who have worked in healthcare become immune to the seriousness of incidents?
As for the lessons learned; what are these lessons? Telling people to do tasks isn’t good enough.
I can’t help thinking that healthcare hasn’t got this process right. Is this the same for other hospitals?