The human cost of ignoring patient safety

27 September 2012

Tebussum Rashid’s sister-in-law died in labour along with her unborn baby. This tragedy was due to some serious failings in the care she received from her local hospital. Tebussum is now working with the hospital trust to try and improve the safety culture and build understanding of cultural difference. She tells us why this work is so important to her and what she hopes can be achieved.

Tell us what happened to your sister-in-law

Sareena was healthy, happy and so excited at the thought of being a mother. She’d had a normal pregnancy but was overdue, so was admitted to her local hospital to be routinely induced.

In the morning this seemed to be working, her contractions began and all seemed fine. As the day progressed however things went wrong, she began complaining of being cold and was in extreme pain. Her husband repeatedly tried to tell staff that something was wrong, but on every occasion his concerns were dismissed. The suggestion was that Sareena was being a drama queen.

Just after 8pm Sareena collapsed and went into cardiac arrest. Doctors carried out an emergency caesarean but her little girl was stillborn. Sareena had suffered a stroke and cardiac arrest and had severe internal bleeding. She died five days later.

Could their deaths have been avoided?

Looking back over the records it’s obvious that Sereena (pictured right) wasn’t properly monitored. She should have been examined for blood pressure, vital signs and baby movements on a regular basis.

We now know that at some point during the day her uterus had ruptured and the baby dropped in her womb. This is extremely rare, but nevertheless would have been picked up by regular checks or if her pleas had been heard.

Once staff did realise something was wrong they panicked and didn’t react as a team. There were also real problems with the resuscitation equipment (an oxygen mask was put on but it was Sareena’s husband who pointed out that it wasn’t connected to an oxygen supply).

Without these failures in care at least one of the two lives would have been saved. To me it seems obvious that the real cause of death was the failure of the system and some real deep-seated cultural problems within the trust. 

What was wrong with the organisational culture of the hospital?

It seems like the culture of care was ad-hoc, some staff demonstrated caring behaviours and others just didn’t. Their rudeness and arrogance was unacceptable. There was also a real lack of any personal responsibility from staff – an 'it’s not my problem or role' attitude which meant that no one tried to fix or flag up any safety issues.

All these issues had been allowed to fester and grow over time. It’s not that senior staff weren’t aware of the problems, they just weren’t being acted on. The trust didn’t follow through on complaints from patients and they didn’t pick up on the silos that had formed within teams that led to strange team cultures developing and a dismissive attitude to people from other cultures.

How much do you feel cultural difference played a part?

I think cultural ignorance played a key role in Sereena’s case. Staff seemed unaware of how childbirth is different for different cultures and faiths, and didn’t take into account cultural variations in how pain is expressed, how questions are asked, or people’s confidence to request things. Cultural differences between staff had also contributed to silo working.

The trust serves an increasingly diverse population, but hasn’t responded to its needs. Instead an organisational culture had developed which didn’t value difference, between both staff and patients.

Why did you feel you wanted to help improve patient safety at the trust?

Hospitals should be places where we know we will be safe. I felt such shock and disgust at what happened to Sereena, I wanted to draw attention to the systematic failures that caused her death and to prevent such an awful tragedy happening again. I also felt I could see the bigger picture, whereas internally, management seemed very focused on process and systems.

What impact do you think your involvement is having?

I’ve been working with the trust in small ways since January 2012. So far I’ve delivered training on the ‘Myths and Misconceptions of Islam’ and facilitated a workshop at their annual midwifery conference. I’m helping the education team think about cultural issues and would love to provide further training in managing cultural difference and see it included in staff induction.

It’s hard to tell what impact I’m having. Feedback from staff who attended my training was overwhelmingly positive. The strategic staff I’m meeting with say they find my input refreshing and useful, partly because of my passion to improve safety, but also because of my interest in diversity issues. I think it’s giving people lots of food for thought.

What else are you hoping to improve?

A lot more work needs to be done strategically in relation to both safety and diversity issues. At this stage it is very small steps.

For all round safety to be improved the trust needs to look at changing the attitudes and mindsets of staff, and improving how everyone communicates with patients and their families. It’s also vital that both patients and staff have confidence in the system and are able to express concerns without fear of being ‘black listed’.

Has being involved in this way helped you deal with the tragedy?

My main motivation is prevention. Getting involved with the trust doesn't help with the pain or help me understand why Sareena has gone. I wish it did.

I’ve gained some peace of mind that there is commitment from the top, and the intention is there to improve the safety culture. My worry though is that the momentum will slow as the trust is forced to make budget cuts.

Watch a BBC interview with Tebussum

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