There is only one time which no-one disputes, which no-one corrects or argues with and that is 6.19am. That has been recorded by the ambulance service as the time the emergency call was made. 6.19am. A fixed point in time.
But that’s the only time that no-one disputes in this grubby business. Every other time is worth arguing about, lying about and trying to fog up so that no-one, least of all us, will ever know the truth.
There was a time when I would have thought that anyone involved in my son’s death would want to make it their business to be very clear about time. Once even the word “time” wasn’t loaded with pain, with double dealing and twisted logic. But not now, for the guilty clutch at straws regardless of their outcome and it often felt both in the lead up to the inquest and during those 3 days in court as if the only people Southern Health were not concerned about were us.
But let’s talk about time.
One member of staff on waking night care duty checks each of the four disabled young people in his care every 20 minutes, in order to fall within the guidelines of Nico’s care.
Four young people who may all need considerable attention at various points throughout the night, one of them with severe epilepsy and prone to night seizures and all of them incontinent. When not checking every one of those young people every 20 minutes, that single waking night staff member must also clean and tidy the kitchen and living room, sort and iron the laundry and fill in paperwork. One thing not required though is to make a note of every time the young people are checked, so there’s no way to prove or disprove that everyone is seen every 20 minutes in order to keep them safe and well.
Or rather, there wasn’t until the night that Nico died. He died desperately calling out for help that never came and then lay there dead and unnoticed for over an hour, until it was far too late to save him.
The waking night staff made a statement which was presented as evidence at the inquest. According the statement, everyone was checked at 5.15am. Then at 5.35am the checking rounds began again. The first person checked needed a change of pad, but was left and onto the next person. They not only needed a pad change but their entire bedding and clothing needed changing as well and for one staff member alone, this took a while to do. Then onto the next person and they also needed a change. At 6.00pm it was Nico’s turn and he was found dead. The waking care staff ran upstairs to wake the nurse and they returned to Nico to start chest compressions and mouth to mouth resuscitation.
At 6.30am the nurse called to say Nico was having trouble breathing and we drove across country in that cold dawn, making a journey which normally took over an hour, in just 40 minutes. But while driving she rang us again at 7.07am to tell us to go straight to the John Radcliffe Hospital, as Nico was on his way there and if we hurried we might arrive at the same time as him. We changed course and drove to the hospital – still completely unaware that our son was dead. Nico had arrived there at 7.19am and was rushed to the emergency room for continuing CPR but when we arrived at the hospital at 7.32am, it was 2 minutes after the doctor asked the staff to cease CPR and declared Nico dead.
At the inquest the coroner questioned both the night staff very closely. He was puzzled as to what had happened between 6.00am and 6.19am. Why almost 20 minutes had passed between Nico being found and the ambulance being called. He was also unsure about the time of the initial check – was it at 5.15am? That couldn’t be proved as nothing was written down and seemingly it may have been closer to 5.00am. Over two days of intense questioning it became apparent that none of the times given were necessarily accurate. Both night staff claimed to have been the one who called the ambulance. The coroner asked how long it took to get from Nico’s room to the nurse’s room. In about 30 seconds, running.
The only fixed point which could not be disputed by neither the witnesses nor Southern Health’s barrister was the time the ambulance was called. All other times given by the care staff and suggested to them by Southern Health’s barrister (who was a very helpful man with the care staff, prompting them continually as they foraged around in their memories for the truth) moved and shifted back and forth over the days of the inquest.
By the time the coroner summed up at the end of the inquest what seemed most likely (but not definite as the care staff could not agree on the time line) is that Nico was checked at some point in the night which may have been 5.00am or may have been 5.15am. He was then checked again at some point which was probably 6.15am and not 6.00am as the witnesses and Southern Health’s barrister declared. After attempting CPR on Nico, one of them (difficult to say who it was, as they both claimed under oath it was the other one) called the ambulance at 6.19am and the manager of the home at 6.20am. Why they waited another 10 minutes before calling us we will probably never know.
At the inquest both the doctor from John Radcliffe Hospital who was treating Nico’s early morning vomiting and the emergency room doctor who had attempted to resuscitate Nico when the ambulance brought him in, declared that had he be found sooner, there was every chance that he could have been saved.
In Nico’s care plan it declared he must be checked every 20 minutes. Nico vomited that morning between 5.15am and 5.30am. If he had been checked 20 minutes after his 5.15am check, Nico would be alive.
It’s just a question of time……………..