Mistakes were made: Part 1

February: Retrospective

I hate February. Every year for the last 3 years it has filled me with dread. The memories of it are traumatic and something I can’t get past. This is my attempt to. To get some stuff off my chest because it’s something I don’t think I’ve ever come to terms with and I’ve probably avoided talking about even through all my psychology sessions.

Photo memories are a wonderful thing sometimes. Sometimes they knock you sick. I love looking back at photos of Isla smiling and laughing, but more often than not I question how she was smiling despite everything that was happening to her.

This morning I looked back at my memories ‘on this day’ and saw the videos I took of Isla’s ecg in 2019. I genuinely don’t know why I was videoing it. How and why we were left on Orange Bay unattended I don’t know. It’s something I was fuming about at the time but I didn’t have the knowledge I do now. I was watching that video thinking stop videoing and push the emergency buzzer you absolute idiot. It was a complete mess. Non-sustained VT, R on Ts, pauses… pretty much everything you don’t want to see.

No Torsades on there but it’s a miracle there’s not, and I know already the next day there was. All while we were left abandoned with no one watching her monitor or even the central monitor. Scary. And when you see the picture of Isla that day, you could perhaps see why we were there. She’s fine and well, smiling and laughing, jumping around her cot. She should have been on ICU. What is on that video is not ok. 2022 Dave knows that. To some extent 2019 Dave knew that. I knew that it wasn’t ok. I knew what was happening on her ecg and I knew it was dangerous. I even remember us all being frustrated and angry at the time. I have a picture of me and Isla down in the play area because Isla had just had an episode of Torsades and no one came. I had to tell them it happened. No alarms went. No one cared. So I took Isla to the play area because at least if she died, she died with me in peace. Sorry… How fucking stupid and scary is that!? I shouldn’t have been allowed to feel like that, and that shouldn’t have been allowed to happen. I remember my mum arguing with the nurse in charge. She told her it felt like no one cared. And honestly that’s how it felt. Isla wasn’t as important as the other kids on the ward because she hadn’t just come out of surgery and she didn’t have chest drains or a structural heart issue. That remains a feeling to this day.

I do understand that there are insane pressures on bed spaces and ward managers are constantly pressed for space for step downs from HDU and ICU. I do appreciate that. Someone taking up a bed means someone is potentially missing out on their surgery because there’s not capacity in ICU because the ones who could be moved to wards, can’t be. Isla is usually on paper the one who can be moved to make space, because often she’s not in bed and can be running around the ward. In many ways I don’t have a problem with that because I wouldn’t want her to have to be bed ridden when she doesn’t need to be. However, the severity of her condition needs more recognition. I shouldn’t have been allowed to take her to the play area without any monitoring. She should have had telemetry and someone on hand to see what her rhythm was doing. I know this basically means she’s one to one while walking around the ward, but with how she was presenting, she should have been HDU/ICU so really she warranted that level of nursing or monitoring. She’d had a cardiac arrest and CPR at home 2 weeks earlier!

It honestly makes me feel really let down and angry. If anything had happened to Isla that day I would now be looking back at those videos and be inconsolable. I should have done something. Well, I say I, I shouldn’t, I’m her dad, not a nurse or doctor. Someone who could have, should have helped her. She should have had IV Magnesium, or IV Esmolol, IV Lidocaine… something to get her rhythm under control. Isn’t hindsight amazing? It took a 200 mile journey to London to see how that situation should have been dealt with, but even then, for the first few days/weeks; mistakes were made.