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Victoria’s Legacy

Victoria
The hospital has set up a programme of safety work in memory of a patient called Victoria.

Victoria Harrison tragically died at Kettering General Hospital in 2012 after an appendix operation led to internal bleeding which was not detected in time to save her.

As a result of her death – and in close co-operation with her family – we investigated what went wrong and set up a series of safety improvements.

This very important programme of work – outlined below – is in Victoria’s memory and, with the kind permission of her parents, has been called “Victoria’s Legacy”.

Being Open

Immediately after Victoria’s tragic death the hospital’s Director of Nursing contacted Victoria’s family to inform them that an investigation had commenced and to offer them support.


This contact continued and the Director of Nursing met on a regular basis with Victoria’s family to ensure that all of their questions were answered and that the investigation was transparent.


The investigation report was not processed by the hospital until Victoria’s parents had checked it and were satisfied with the content.


All other key agencies were informed at the time of the incident and were kept up to date on progress with the investigation and subsequent actions taken – these agencies included the Care Quality Commission, Clinical Commissioning Groups, Monitor and the Coroner’s Office.


A public inquest was held in early December 2013 where a full and very thorough account was given of the circumstances that led to Victoria’s death and the actions undertaken by the Trust to minimise the risk of this happening again.


What went wrong?

The key lessons the hospital learned from our investigation were:

  • We needed to make sure we were more consistent in monitoring patients’ vital signs – e.g. regular blood pressure, pulse, temperature checks and pain assessment– all completed on every occasion
  • We needed a well understood system that would enable staff to promptly spot any deterioration in a patient’s condition
  • We needed more exacting standards around how information about patients is passed on from theatre staff to ward staff.  


 

What actions have we taken? >