I’m not sure where I read this, but in some intensive care facilities they adopt a very simple but effective strategy: if one member of the team has concerns, then all members of that team have to share that concern until it is demonstrated to be unfounded. In fact, I think this simple thing would probably have saved our baby’s life.
Like many modern ways of doing things, there are a lot of people involved in the care of one person. While this is good in the sense that diverse expertise can be called upon, it also creates serious co-ordination problems. This is a well known problem, and by way of example, it happened to us in the middle of the night in the middle of a bank holiday weekend.
During our baby’s birth, the midwife who was with us had serious concerns about what was going on. The CTG did not look good and progress had stalled. As things progressively deteriorated, our case was discussed by at least six different people, mostly her superiors. This was a lengthy process, during which the midwife’s concerns, and the overall perception of risk, was gradually played down by people who were not so involved. The result of this was a two hour delay in what should have been an emergency caesarean section, an ill-advised attempted assisted delivery which resulted in a probably fatal birth trauma, and a trip to the NICU upstairs with a profoundly depressed blood pH and breathing difficulties. He died there about nine hours later (much to NICU’s surprise) following another long period of similarly low perceived risk.
The point is that the midwife’s (and it seems the NICU nurses’) concerns were not taken seriously, investigated properly or transferred with our baby and he very likely died as a result. A policy of “one concerned, all concerned”, no matter who has those concerns, would have helped ensure that something as basic as this was impossible.
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