Kettering Hospital withholds death inquiry findings
A hospital where a girl bled to death has refused to publish the findings of its inquiry for fear of "endangering the mental health" of staff.
Victoria Harrison, 17, was found dead the day after an appendix operation at Kettering General Hospital, in 2012.
Coroner Ann Pember later criticised the hospital over missed opportunities.
The hospital subsequently conducted a serious incident investigation but has revealed it will not be making the full report public despite an FoI request.
It claimed putting some of its findings into the public domain would risk staff identifying colleagues, who would then be put under "additional stress and pressure in addition to that already experienced during the investigation and inquest".'Pain and bleeding'
The latest refusal was made in the hospital's response to a Freedom of Information (FoI) request by the BBC.
It was submitted after the hospital declined to comment on its action beyond a statement it released to the media after Miss Harrison's inquest last month.
The teenager, from Irthlingborough, had been an emergency referral by her GP on 14 August 2012, when she appeared to be suffering from appendicitis.
An artery was damaged during surgery, with the surgeon rectifying the issue.
But Miss Harrison texted her boyfriend from her hospital bed to say she was in pain and bleeding later that day.
Not all nursing staff were aware of the bleed and some did not routinely read medical notes and could not always decipher surgeons' handwriting, the inquest heard.
Her last written formal observations were taken at 20:15 BST on 15 August, nine hours before she was found by nursing staff.
Ms Pember criticised the poor handover from theatre staff to the recovery nurse and in turn to the ward staff and the failure to carry out post-operative observations.
"Windows of opportunity to treat Victoria were lost - had these been acted upon the outcome may have been different," said the coroner.
"I believe her chances of survival would have significantly increased."'Stress and pressure'
Kettering Hospital said at the time it had "strengthened guidance for hospital staff around post-operative care and observation/pain assessment" but would not comment further.
Asked under the Freedom of Information Act how many mistakes had happened, and when and where, it revealed 43 "care delivery problems" had been identified, six of which had a direct impact on the case.
It added: "The trust has undertaken a public interest test with regard to providing a chronology of events.
"It believes that Section 38 (1) (a) should be engaged as it is likely to endanger the mental health of individuals [staff] linked to the events leading up to the tragic death of Victoria Harrison, should the information be in the public domain.
"The reason for this is due to the risk of colleagues and peers being able to identify the individuals [staff] involved in the incident, and placing the individuals concerned under additional stress and pressure in addition to that already experienced during the investigation and inquest."
In response to a request for its investigation's recommendations, it said it had used the same section of the Act, for the same reason.
It also refused to reveal how many staff had been disciplined, or their rank, claiming individuals would be identified, but did reveal that no staff were dismissed.'Always be there'
Miss Harrison's mother Tracy Foskett told the BBC said she was still "depressed and angry" following her daughter's death and inquest.
Section 38 of the Freedom of Information Act provides an exemption if disclosure would endanger any individual's mental health or safety.
It is a qualified exemption, meaning a public authority is under a duty to consider whether disclosure should nevertheless be made in the public interest.
The Information Commissioner states there should be evidence of a "significant risk" to the physical or mental health or the safety of any individual.
Factors in favour of disclosure include allowing individuals, companies and other bodies to understand decisions made by public authorities affecting their lives.
Source: Information Commissioner's Office
"I do feel I forgive the hospital, mistakes are made, but it was a mistake that cost my daughter's future," she said.
"I think it [the report] should be out in the public domain, but obviously without names.
"It will make people more aware, if they know which mistakes were made."
Referring to the impact on staff, she said: "What stress are we going through? Our stress is never going to end.
"In a year's time, they [staff] could be moved on to another hospital and all of this will be forgotten, but we can't.
"It will always be there for us."
Corby Labour MP Andy Sawford, whose constituents use the hospital, said: "I'm concerned that information about what went wrong hasn't been made available to the public.
"It is important to be transparent when things go wrong, and I will be raising my concerns with the hospital."
Chief executive of Healthwatch Northamptonshire, Rosie Newbigging, said it was "sensitive to the impact for staff and noted the rationale from the trust".
She added: "The NHS has a duty to be transparent and accountable when things go wrong and we would encourage the trust to consider this responsibility to local patients and public, taking into account the wishes of Victoria's family."