This article is from the source 'bbc' and was first published or seen on . It last changed over 40 days ago and won't be checked again for changes.

You can find the current article at its original source at http://www.bbc.co.uk/news/uk-england-northamptonshire-26681550

The article has changed 4 times. There is an RSS feed of changes available.

Version 1 Version 2
Kettering Hospital reveals Victoria Harrison death errors Kettering Hospital reveals Victoria Harrison death errors
(about 2 hours later)
A hospital where a girl bled to death has revealed a catalogue of errors, weeks after withholding details for fear of "putting staff under more stress".A hospital where a girl bled to death has revealed a catalogue of errors, weeks after withholding details for fear of "putting staff under more stress".
Victoria Harrison, 17, was found dead the day after an appendix operation at Kettering General Hospital in 2012.Victoria Harrison, 17, was found dead the day after an appendix operation at Kettering General Hospital in 2012.
An inquiry uncovered 43 errors, but bosses refused to release full details.An inquiry uncovered 43 errors, but bosses refused to release full details.
The BBC has now learned routine observations were discontinued and nurses' conduct was unprofessional.The BBC has now learned routine observations were discontinued and nurses' conduct was unprofessional.
'Stress and pressure''Stress and pressure'
Miss Harrison's mother, Tracy Foskett, who had seen the report, said all hospitals should publish details of their mistakes.Miss Harrison's mother, Tracy Foskett, who had seen the report, said all hospitals should publish details of their mistakes.
"I asked the hospital 'did my daughter die as a result of the NHS not providing funding?', and I was told 'no, it was human error'," she said."I asked the hospital 'did my daughter die as a result of the NHS not providing funding?', and I was told 'no, it was human error'," she said.
"So let the public know what that was - there needs to be more transparency.""So let the public know what that was - there needs to be more transparency."
The findings of the hospital's serious incident investigation were not published over fears that it would put staff under "additional stress and pressure in addition to that already experienced during the investigation and inquest". The findings of the hospital's serious incident investigation were not published over claims that it would put staff under "additional stress and pressure in addition to that already experienced during the investigation and inquest".
The BBC challenged the refusal under the Freedom of Information Act, with an internal panel agreeing that the mistakes, oversights and errors and recommendations were "in the public interest".The BBC challenged the refusal under the Freedom of Information Act, with an internal panel agreeing that the mistakes, oversights and errors and recommendations were "in the public interest".
The report - with names redacted - also reveals 10 members of staff were disciplined.The report - with names redacted - also reveals 10 members of staff were disciplined.
Among the 43 mistakes, oversights and errors were:Among the 43 mistakes, oversights and errors were:
The teenager, from Irthlingborough, was given an emergency referral by her GP on 14 August 2012, when she appeared to be suffering from appendicitis.The teenager, from Irthlingborough, was given 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.An artery was damaged during surgery, with the surgeon rectifying the issue.
'Spirit of openness'
But Miss Harrison texted her boyfriend from her hospital bed to say she was in pain and bleeding later that day.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, an inquest in December heard.Not all nursing staff were aware of the bleed and some did not routinely read medical notes and could not always decipher surgeons' handwriting, an inquest in December heard.
Her last written formal observations were taken at 20:15 BST on 15 August, nine hours before she was found unresponsive by nursing staff.Her last written formal observations were taken at 20:15 BST on 15 August, nine hours before she was found unresponsive by nursing staff.
Coroner Ann Pember criticised the hospital over missed opportunities and said, had these been acted upon, "the outcome may have been very different".Coroner Ann Pember criticised the hospital over missed opportunities and said, had these been acted upon, "the outcome may have been very different".
"I believe her chances of survival would have significantly increased," she said."I believe her chances of survival would have significantly increased," she said.
Peter Walsh, from the patient safety charity Action against Medical Accidents (AvMA), said the hospital's original decision to "suppress" the report "did not help public confidence".Peter Walsh, from the patient safety charity Action against Medical Accidents (AvMA), said the hospital's original decision to "suppress" the report "did not help public confidence".
"The trust's original decision to withhold the report was wrong in so many ways," he said."The trust's original decision to withhold the report was wrong in so many ways," he said.
"It runs against the spirit of openness and transparency when things go wrong, the need for which was made so apparent by the Mid Staffordshire scandal."It runs against the spirit of openness and transparency when things go wrong, the need for which was made so apparent by the Mid Staffordshire scandal.
"How could the public and bodies responsible for monitoring the trust know whether lessons really had been learnt and acted upon?""How could the public and bodies responsible for monitoring the trust know whether lessons really had been learnt and acted upon?"
Katherine Murphy, chief executive of the Patients Association, said: "It is vitally important that trusts disclose information about things that have gone wrong so that we can learn from mistakes.Katherine Murphy, chief executive of the Patients Association, said: "It is vitally important that trusts disclose information about things that have gone wrong so that we can learn from mistakes.
"The tragic death of 17-year-old Victoria Harrison is a clear example of lack of communication between staff leading to a catalogue of errors and unacceptable care."The tragic death of 17-year-old Victoria Harrison is a clear example of lack of communication between staff leading to a catalogue of errors and unacceptable care.
"It is essential that lessons are learnt and practices modified so that there is no repeat of such cases."It is essential that lessons are learnt and practices modified so that there is no repeat of such cases.
"It is the relatives who have to live with the consequences and the sad loss of a young life that could have been avoided.""It is the relatives who have to live with the consequences and the sad loss of a young life that could have been avoided."
'Vibrant young girl''Vibrant young girl'
Following the hospital's initial refusal to release its report, Ms Foskett set up a Facebook page to garner public opinion and was amazed at the support she received. Following the hospital's initial refusal to release its report, Ms Foskett set up a Facebook page to gauge public opinion and said she was amazed at the support she received.
"I know the hospital has put changes in place, but the public needs to be aware of what those are," she said."I know the hospital has put changes in place, but the public needs to be aware of what those are," she said.
"These changes have come about because of the death of my daughter, a vibrant young girl. They should have already been in place.""These changes have come about because of the death of my daughter, a vibrant young girl. They should have already been in place."
In January, the hospital's chief executive, Fiona Wise, said: "We have a right to withhold that information... where we feel it is appropriate to prevent further damage to individuals who have already been through a thorough investigation process."In January, the hospital's chief executive, Fiona Wise, said: "We have a right to withhold that information... where we feel it is appropriate to prevent further damage to individuals who have already been through a thorough investigation process."
It has set up a programme of improvement measures and, as a result of the BBC's request, has disclosed its detailed action plan relating to each of the 43 errors.It has set up a programme of improvement measures and, as a result of the BBC's request, has disclosed its detailed action plan relating to each of the 43 errors.
These include: