In 2008, Julie Carman was involved in a road traffic accident whilst on a cycling holiday. She suffered injuries to her face, jaw and legs but made a good initial recovery and expected to be back at work within three months.Three years later she was still having treatment having experienced two further emergency admissions to hospital due to acute cellulitis and sepsis.In this short film Julie explains how a series of “everyday” communication failures conspired to create delays in her receiving effective treatment. These delays and the resultant risk to her life led to a slower physical and psychological recovery and in Julie’s view were very probably avoidable. Julie, a former NHS employee, speaks of her feelings of shame and concern at the level of avoidable harm in the healthcare system and appeals to healthcare professionals to take a long hard look at their practice as a result of listening to her story.
This powerful story clearly illustrates how inadvertent system errors can lead to serious harm to patients as well as significant added costs to the system. The story also points towards a more systemic and standardised approach to care and suggests that a better understanding of human factors could make a difference.
“Julie’s Story brought the real human impact of patient safety to the clinical staff in a way that no other medium could. Staff felt that the message was balanced and focused on learning rather than blame, whilst also showing quite clearly the gaps that occur in the care pathway when communication and teamwork fail.”
Dr Trisha Bain, Deputy Director of Quality Standards, The Rotherham Hospital NHS Foundation Trust
This film can be viewed alongside another short film entitled ‘Surviving Sepsis‘. Working with Dr Matt Inada-Kim and colleagues at Royal Hampshire County Hospital, part of Winchester and Eastleigh Healthcare NHS Trust, we’ve made a short film to document the innovative human factors-based approach that they have developed to tackle the identification and management of severe sepsis. Using a combination of audit, simulation training and practical tools to aid decision-making, the team have developed a comprehensive training and development package which they are currently spreading throughout South Central SHA.
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filkipo says
Should Julie ever read this, I want to thank her for sharing her story here – It’s a wonderful, if unfortunate, illustration of how systemic and cultural factors can lead to harm, more than it simply being down to one person to blame.
I’m a medical student, and although the day I graduate seems a little way off just yet, I shall certainly remember this story, and try to take away the lesson, that you don’t just need to agree a plan, but also be clear on who has responsibility for which parts of it – who is responsible for writing up the IVABS, who is responsible for communicating with nurses, or other teams etc. etc. etc.
So thank you – I hope that your story will in time make me a better doctor.
Julie Carman says
Thank you for posting a comment – it’s very helpful to get feedback. I feel you have really understood both my reasons for sharing my “patient story” and the messages within it. I am delighted and encouraged that you feel it will help you in your future practice. Being given the opportunity to tell my story has enabled me to turn what was a very “private pain and shame” into a “public purpose” and to have a positive impact on improving patient care by sharing my experience with health professionals.
If you haven’t already done so can I encourage you to look at the Surviving Sepsis film on the Patient Story website and perhaps share this with your colleagues and tutors. Many thanks, Julie
Clare Barter says
Hi Julie, I am a student nurse, watching your video as a learning tool. What an amazingly positive way to deal with such a dreadful ordeal. I have only been on 1 placement so far, but can see how easily assumption can cause such catastrophic outcomes. I wish you well and promise to consider your situation throughout my career.
Best Regards
Clare
Chris says
I am an FY2 doctor. The issues raised are things that i encounter on a regular basis. Sadly, on some occasions, even when you get a senior- i.e. a consultant review- there will be an excellent plan documented in the notes- however- ‘some’ cannot be bothered to actually prescribe the abx or the blood xfusion themselves. I have seen haematology consultants write in the notes- the patient needs a DNAR order- however- they have not bothered to write it themselves. When this is a consultant call, this means that it may be days before another consultant comes around to signing the order. Obviously, if a patient has an arrest in the meantime- a crash call is put out inappropriately- very distressing for pts families and using up valuable time and resources. It’s always important to ask yourself- if I don’t do this, who will?
Katie says
Thank you so much for sharing your story. We are a group of 4 student nurses, 3 student doctors and a student pharmacist who used this in our interprofessional education to discuss how communication between teams is essential to patient safety.
Philip Howard says
Excellent person story to highlight our current failings on treating sepsis quickly. Let’s use your story in a positive way to improve patient care with sepsis. I have tweeted this from @AntibioticLeeds
Juliet says
I am currently recovering from sepsis and cellulitis and would love to be able to talk about it. Recovery is taking much longer than I anticipated. I am finding making decisions difficult and do not know how long it will be before I can return to work. Who is it best to talk to? I didn’t have the same mistakes made with me but I have seen so many doctors and nurses , no one person knows about the whole picture of my health.
Julie Carman says
Please feel free to email me Juliet – Murray has forwarded you my Sepsis Trust email. Do take a look at the Sepsis Trust website too for more information, links to on line forum, Support Groups and “in touch” service. Not sure where you are located but if in the North West there is a UKST Support Group this Wednesday 24th Feb in Manchester. Julie
Pete Gordon says
Dear Julie,
Thank you for sharing your story.
We recently used it at two events focussing on reducing unnecessary waiting for patients and the harm associated with this. Your dreadful experience illustrated this more powerfully than we ever could.
https://twitter.com/ecistnetwork/status/807126019924750336
NHS Emergency Care Improvement Programme
MAUREEN OBIJIAKU says
Thank you, Julie, for sharing this story, it is a very good opportunity and lesson for us healthcare professionals to learn from and improve our communication skills in practice for improved healthcare standard for patients.
Jenny Hughes says
Yes, it’s so very shocking that the NHS wastes so very many resources: if they did it right first time loads of money would be saved and patients (& their families) would be protected from increased illness, disease, disability, loss of job/home etc. This has all been known for so very long (basics), I can’t believe patients are STILL being harmed in this way and that we’re STILL having to repeatedly tell docs/nurses+ how to do their (paid) jobs properly and safely.
In my own life NHS doctors have wasted so many appointments and have botched operations – too many to count; my GP decided not to write down my myriad of symptoms (after a very botched op which almost killed me) and refused to examine me or help me hold the guilty hospital to account – it was so very clear he was helping his colleagues at the hospital cover-up their wrongdoings but he stated this wasn’t the case: he lied to my face many times; this man continued to enjoy his NHS career (though ‘self-employed’?) while I lost not only my health but also my job, my home, and so much more = my life wrecked; but the NHS thought that was OK and even falsified my medical records to create ‘evidence’ that ‘nothing went wrong’ and so I was ‘delusional’ – they destroyed my reputation by passing their lies onto others – including my GP & an ‘independent’ psychotherapist they had contracted & briefed who then abused me more.
It’s now over 14 years later and I STILL haven’t been given the truth, too late for me because this delay has injured me far more and has cost so much in so many ways (including financial) – none of it can be undone. ‘The NHS will look after us from cradle to grave’? Nope, especially not if/when we are injured by the NHS/doctors.