Emerg Services Advice please - inquest found we could have done more

[Tim_Holgate]

Been really struggling the last few days. An inquest found that we could have done more to stop someone dying (which is kinda my KT event in the first place) and its just bowled me over. Anyone have any experience with this kind of thing, cos Im at a loss?

 

[FragileGlass]

I’m in the reverse position, I work on the security team in a hospital. I had to respond to a violent patient whom suffered dementia, had pace maker surgery that same day. Stitches opened, IV lines tore. Sadly I had to apply significant force on the patient because I was also badly injured in the altercation and at disadvantage once I had control and patient in compliance, he was doped up with sedatives to knock him out. The patient never fully recovered. Died four days later.

I was cleared of wrongdoing, however on the list of precipitating factors in patients death, the violent episode was recorded as a factor for unsuccessful recovery.

It’s was just enough room for a lot sadness and guilt to kick in.

My thoughts are with you!!

BTW - if you want to PM me feel free to do so. I’ll glad lend a supportive minds set and offer any advice and reassurance I can :)

 

[gealach]

I've been through an "informal" inquest, after an H2S exposure resulted in 3 fatalities; almost took out myself, my partner, and LEO's; my sup tried to stop us in the middle of a hot transport with an exposed patient, to take my cardiac monitor, which was in use and very much needed on said patient; I lost power in the back of the ambulance from a known and chronic but never fixed electrical issue because we're to f*cking cheap to fix these things; my O2 system went on the fritz and the patient drained every spare bottle of portable O2 in the unit; and there was no control of unaware civilians accidentally entering the effected area. It was a cluster-f*ck of epic proportions. Findings were found, policies were created or changed, and so on & so forth.

My point? Inquests are hindsight, and hindsight is always 20/20. They are designed to look back, pick everything apart in agonizing detail, and find places where policies, procedures, skills, etc. can be improved. They are designed to figure out what happened this time, with a view to learn for the next time. They're armchair quarterback's and backseat drivers. They aren't designed to find fault.

Even though you're triggered, you're not at fault. Even though you feel guilty, you're not at fault. If you can say that you did everything you reasonably could do, in the moment, you're not at fault (by that I mean, unless you intentionally and knowingly acted irresponsibly, knowing what the consequence to the patient would be).

And sometimes, it really doesn't matter if you move left, or if you move right, there is no perfect answer. Sometimes there's no right answer.

Sending you lots of support.

 

[hithere]

Really sorry you are going through this. I can't imagine it really. I have something kind of similar that I'm dealing with but dont want to put it on a public site... but the guilt and the hindsight... really sorry. it just sounds really hard what you had to deal with in the first place. I know this is totally different topic, but you should be paid more to have to be basically in the business of helping to save people's lives. As a random citizen Thank you for signing up for that job. If that was a dumb thing to say right now, I apologize for being stupid. Those are just the thoughts I had reading what you were faced with at the time.

 

[Freida]

Yep -- been there. 90 seconds to get an address, name, number, questions, code it and go. Doesn't always work out as you plan. Then someone else comes along and listens to the tape over and over to figure out what you did wrong in the 90 seconds you had. And then tells you -- you should have done this or that instead. You screwed it up.
Or you work your ass off to save someone and you lose them anyway - then some smuck who hasn't been in the field or on the floor in decades comes along and tells you that you didn't try hard enough.

I hated those. If I'm the one who screwed it up I have to live with it thank you very much - I don't need your input telling me how I suck. I can do that enough on my own.
If you are Monday morning quarterbacking me for some tiny thing that may have been possible if I hadn't been doing 900 other things then I'd like to see you do better in the same circumstances.

When it happens all I could do was ask myself---
Did I do the best I could?
Was my heart in the right place?
Either way -- you can only accept (or challenge) what they rate you on and then try to move on

If it is them micro managing then I have to let it go
If its my screw up then I have to learn from it
Either way I am so sorry you got stuck with this.

 

[blackemerald1]

inquest found that we could have done more to stop someone dying

What were the coroner's recommendations specifically? Were you called out specifically for actions you did or did not take? How much and in what way? You use the word 'we' ....there are a lot of factors and people all operating at the same time performing different functions. Is he talking about individuals or the organisation?

I can understand your feelings and I totally get how your thinking would be...having endured a catastrophic traumatic event now the system wants to f**k me all over again too??

Have you actually read the Coroner's finding's because I've never found them to be blaming or emotional knee jerk findings? In fact quite the reverse. They are quite cool and factual. Coroner's are very powerful people. The law pertaining to evidence is completely different to that of any other court. When they say there was a f*ck up...somebody's head will go on the chopping block or a law will be made or an organisation does an overhaul of procedures etc., because the Coroner has the power to send people/organisations for trial without further legal process for murder/manslaughter etc., etc., And they do this because that is what as a society we expect our Coroner's to do.

It would be a really stupid organisation having been called out by the Coroner as responsible or contributing to a death to not follow the Coroner's recommendation to the T.

'Could of done more'...as opposed 'did not do their duty', 'failed to follow recommended policy/procedure's' etc., etc., is completely different.

Coroner's are fed information from all available sources. Coroner's know that emergency response workers across the entire spectrum have to work in circumstances nobody wants to be in but somebody has to willingly go into. They know that seconds matter and response workers cannot use crystal balls.

Inquests are not intentionally held to find fault. They are held to find the facts surrounding and pertaining to a death that is not natural.

I think unless you have been found to be specifically negligent by a Coroner and are now facing the prospect of further litigation...you are reading too much into it.

This doesn't make it any less tragic or traumatic for you.

Inquests are not designed to help you they work for the dead and to provide explanations to the bereaved and society. If they decide someone is at fault..the Coroner will make that very clear. If they decided an organisation needs a kick up the backside same deal.

Yes...I am experienced in both sides of this.

 

[Tim_Holgate]

What were the coroner's recommendations specifically? Were you called out specifically for action...

We could have carried more oxygen, could have transported him out of the system faster and could have provided oxygen whilst we transported him out of the situation (but this would have killed him even faster as it was all below 6m) and that we if we hadnt been exhausted (700m sprint swim) we could have probably carried on CPR for a bit longer as he was hypothermic. Its mainly a go at the team but some other members are picked out for notable f*ck ups like being late
its not exactly blaming but it does throw us in the dirt

 

[blackemerald1]

So effectively...but for super, duper human effort and if all things unforeseen had actually been foreseen... the Coroner found that this rescue was still not going to be successful? And the person died as a result of (.....).

Coroner's can be critical of someone's f**k ups but still find they did not actually contribute to the death.

It is entirely understandable that you are feeling like this...it is just so tragic. I am not suggesting your feelings are invalid.

I do think you are setting an extremely high bar for yourself because.... Not every rescue is going to be successful regardless of what you do. Not everything is going to happen as you want it to or even expect it to. You cannot re-write history.

I know that these types of rescues are notoriously dangerous and now despite not all going to plan and a few people f**king up everything you could have humanly done, was done.

There are no winners in this.

But you are still a hero for bloody trying. :hug:

 

[FragileGlass]

The whole review process is so clinically surgical in its explanations, recommendations, how it applies faults to very specific actions.

When I was sitting in front of the review board accounting for my role with the patient, it sounded more like a sales meeting performance talk. I couldn’t get over how cold the whole process felt.

While I understand the goal of the review. They forget one critical factor in the process. The emotions of the people involved in the event. The board describes the event from words on a paper, we describe from visual, audible and some time physical memory.

They arrive at these findings, honestly I don’t think they understand scene management, scene obstacles, physical demands like trying revive or maintain during extreme physical exertion.

While I know this event has affected you and will for a time. Take the weekend to recall the many events where you’ve had successful patient recoveries or just any good stories as a result of your action and involvement.

I promise! You have done way more good than not. You’re a hero my friend!

I’m sorry the suits and paper pushers caused you doubt. From one uniform to another! Thank you for trying your best under really difficult circumstances.

 

[Freida]

s. The emotions of the people involved in the event.

This ^^^^ they forget about you because they are so focused on the case

"should have" doesn't take into account the living breathing people behind the rescue and their emotions. A review is necessary yes....but picking apart the people is not. Could you have done more? Sure. But that describes every action anyone will take. And doesn't take into account what you were already doing

Being told you could have done more is a huge blow...especially when you were already exhausted. It's unfair and doesn't take the reality of the situation into account

I agree with the others..you are still the hero in this

 

[gealach]

none of these are realistic or reasonable

We could have carried more oxygen

what size of tank? how many extra tanks? how many more rescuers would have been needed to carry those tanks? do you crack and put a reg on each one prior, or do you have 1 reg and move it between tanks as they run out? this is a recommendation from someone who has never carried multiple tanks into a scene, or had to change a reg on scene. Too much equipment weighs you down and frankly just gets in the way.

could have transported him out of the system faster

faster than what? faster then the team that was moving as fast as they could to save his life? did you guys stop for tea and crumpets on the way out? This wasn't an episode of CSI, you guys did what you could, as efficiently as you could, with the situation you were presented with. Rescues are dynamic, period.

could have provided oxygen whilst we transported him out of the situation (but this would have killed him even faster as it was all below 6m)

so he died because you didn't give him O2 in a situation that would have killed him faster if you gave him O2? so the inquest wanted you to kill him faster then? It sound like this inquest doesn't know their ass from a hole in the ground when it comes to underwater rescue at depth.

if we hadnt been exhausted (700m sprint swim) we could have probably carried on CPR for a bit longer

what an ignorant comment!!!!!!!!! what exactly is "a bit longer" (2 minutes? 10? 60?) exactly how many more minutes would have definitively brought the patient back? this is wishful thinking, not based on fact and knowledge of human physiology. And what are you supposed to be, super human? I have to point out the obvious, Superman and Batman weren't on this rescue, mere mortals were, and the human body fatigues, period. There's a reason why the compressor changes out after 2 minutes max. when doing cpr. Also, if the patient is asystole, they're done and you can do cpr until the next millennia, but you're not going to change that. Ditto for brain death.

notable f*ck ups like being late

this is the only finding that you mentioned in your post that might have any merit, but it's context absent, so it's hard to say. You can't save the patient if you aren't on scene, but why aren't you on scene? There's a difference between dragging one's ass and being late, versus having something legitimately interfere with one's ability to get on scene.


From your post, it sounds like you and your team worked a difficult rescue, in the best way you could. The patient died because he was already dead, not because of any f*ck ups on your part. Are there some things to be learned to make the next rescue more efficient? sure, because EVERY rescue is an opportunity for learning, but that doesn't ever write a guarantee for the next rescue. People die, it's just a fact.