Patient Safety Commissioner: ‘Patients and families can be agents of improvement’

Summary

More than 20 years ago, Helen Haskell and her husband took their 15-year-old son Lewis to an American children’s hospital for elective thoracic surgery where he died unexpectedly.

Three years ago, a family on the other side of the Atlantic entered an NHS hospital for a more urgent reason. Martha Mills, like Lewis an active and healthy teenager, needed specialised treatment for a severe pancreatic injury. Like Lewis, Martha died unexpectedly in hospital. Martha's parents, Merope and Paul, were left horrified by a hospital system that had disregarded a family’s concerns while allowing a child to die. Merope’s and Paul’s eloquent campaign in the name of their daughter brought swift change in the form of the Martha’s Rule rapid review system for NHS hospitals.

Two decades earlier, Helen and her husband responded similarly and had worked to pass a law that gave families in our state of South Carolina the ability to summon help independently in hospital. Most English-speaking countries now have created policies for family escalation of care, almost all of them driven by the deaths of children. These campaigns have succeeded because of the poignancy of the stories, the continuing interest of the media, and the realisation on the part of all involved that such stories should never have to be told.

Yet ‘failure to rescue’ situations continue to occur in spite of years of advances in rapid response and patient monitoring, including sophisticated electronic systems. In this blog on the Patient Safety Commissioner's website, Helen discusses the reasons why.