An inquest in December was told that Kettering Standard Hospital had uncovered 43 blunders in the teenager’s treatment method.
But the Northamptonshire hospital insisted that publishing specifics of the blunders could ‘endanger the mental health’ of their workers.
It launched the inner report to Victoria’s devastated father Andrew Harrison, 57, and mom Tracy Foskett, 42, but mentioned it had a appropriate to withhold info from the public. Details had been released – with personnel names redacted – after the BBC appealed underneath the Freedom of Details Act towards the hospital’s refusal to release its findings.
An internal panel agreed it was in the public curiosity to reveal the blunders and the report’s suggestions.
The report says personnel did not check out Miss Harrison’s abdomen, regimen observations had been discontinued, there was no formal discomfort evaluation, there was inaccurate recording of her resuscitation, the wrong surgeon was named on documentation and nurses’ conduct was unprofessional. It reveals that 10 employees had been disciplined, but none dismissed.
The case comes right after recent assurances from Wellness Secretary Jeremy Hunt that whistleblowers will be protected as component of efforts to produce a culture of ‘openness and transparency’ in the NHS, which the minister explained was important to prevent a repeat of the Mid Staffordshire scandal in which up to 1,200 individuals died needlessly.
Mrs Foskett, from Irthlingborough, Northamptonshire, named on all hospitals to publish this kind of data to help avoid other tragedies from happening.
She mentioned the hospital had initially told her “it would be greater to preserve the report private” and that publication of elements of the report would compromise her daughter’s dignity.
“Victoria hasn’t received any dignity now,” she mentioned. “She’s dead, they took all that away from her. What about my psychological health? I have misplaced my shadow, my youngest daughter.
“The public have the right to know what took place. My daughter must not die in vain.”
Victoria was provided an emergency referral by her GP, who suspected appendicitis, in August 2012 . The surgeon realised he had broken an artery during surgery and rectified the situation but Miss Harrison misplaced much more than half a pint of blood. She texted her boyfriend with the picture to say she was bleeding later on that day, but not all nursing staff have been aware of the bleed and some did not routinely go through health-related notes.
Regardless of complaining of currently being in ache nurses gave her morphine until she suffered heart failure and died. Northamptonshire Coroner Ann Pember’s narrative verdict criticised the hospital more than missed opportunities and mentioned, had these been acted on, “the end result could have been quite different.”
Peter Walsh, from the patient safety charity Action towards Medical Accidents, stated the hospital’s unique choice to suppress the report did not support public self confidence and ran against the necessity for spirit of openness and transparency highlighted by the Mid Staffordshire scandal.
The hospital has disclosed an action program relating to each of the 43 mistakes.
But a Freedom of Details Request uncovered the complete scale of the mistakes.
– The wrong surgeon was named on hospital paperwork
– Inconsistency in respiratory rate recordings
– Uncertainty of blood reduction
– Inconsistency in handovers in between nursing teams
– Inaccurate recording of healthcare administration
– No formal discomfort assessment
– Issues with overnight monitoring
– Essential indicators not monitored following painkillers
– Lack of piped oxygen in bed spaces 3 and four
– Advisor not advised of bleed
– Member of personnel did not check Miss Harrison’s abdomen
– Inaccurate recording of attempted resuscitation
– No record of discussions with the loved ones