Sarah Bellamy has been a qualified nurse for 26 years.
She has been a widow for a year.
Her husband Stuart was taken into hospital after collapsing at home. As things took a turn for the worse, she had a clearer view than most of how things might have been done differently.
She has been working with the Royal Sussex County Hospital on a checklist for clinical staff to help prevent avoidable deaths in future.
A short but powerful film in which she set out her experiences was shown to a board meeting of the Brighton and Sussex University Hospitals NHS Trust.
It has been shown to doctors and nurses.
And it will be shown to Brighton and Sussex Medical School students before they are asked to make life or death decisions for real.
Here is what she said: “A&E was pretty busy. It was handover time so Stuart was on a trolIey for a while, admitted and assessed quite speedily.”
It was during the snow in January last year and doctors were unsure whether Stuart might have a blood clot on his lung or a kidney stone.
She said: “They needed to keep him in for observation. Stuart was then transferred to an orthopaedic ward under the care of the urology team.
“Clearly there was a bed crisis going on at the time.
“I went to bed that night quite confident.
“I got a panicky call from Stuart at about half past ten in the morning. (He said) they’re taking me to theatre. He sounded absolutely terrified. I went and spoke to the ward sister.
“She was unaware that the urology team had reviewed him that morning.
“She was very concerned that his breathlessness was still quite pronounced. He was on continuous oxygen and had been since the ambulancemen arrived at the house.
“(He) clearly wasn’t in a fit state for theatre and hadn’t been seen by an anaesthetist.
“I asked the ward sister if she would get the urology registrar to come back and speak to me which she did. The urology registrar came back. I outlined my concerns about his breathing.
“He sort of slightly brushed it off and said, oh well, we won’t bother then. I was just going to stent him and send him home but perhaps not.
“By this time Stuart had had a CT scan which seemed to indicate that there might be stones but Stuart didn’t have any more pain. He didn’t have any sign of infection.
“Between the three of us we agreed that if theatre was optional, then perhaps we’d opt out at this time.
“But he was still struggling with breathlessness. It was painful to watch him.
“I had a very different feeling on that second evening. I just felt I couldn’t settle. I felt worried. In fact I didn’t sleep the whole night through.
“I still didn’t feel that he’d properly had a review. I didn’t feel that we were really getting to the bottom of why he was breathless.
“This is a man who’s never smoked, didn’t have any underlying respiratory conditions and, as far as we knew, nothing wrong with his heart.
“So I was struggling to work out what was going on and I felt that people weren’t asking the right questions or that in fact his care was being not so much shared but passed about from one individual to another.
“I never felt that anybody had the overall picture of what was going on. I felt that we’d lost the plot really.
“I got a call at half past six in the morning from the ward to say that I needed to come into the hospital. Stuart had taken a turn for the worse.
“I’ve been a qualified nurse for 26 years. I know what that means.
“I drove down past the train station, down Trafalgar Street, couldn’t have gone a worse way, slipping and sliding and panicking.
“And at that point I knew that he’d died. I don’t know why I knew but I knew.
“As I walked on to the ward I saw a figure at the end of the corridor, a young woman, and I didn’t recognise her and I assumed that if she was there waiting for me then that was because there was really no point waiting with him.
“She said we need to sit down somewhere and have a chat. I said we really don’t. You need to just tell me that he’s died because I know that he has.
“At that point she started to cry and I gave her a hug and said it’s all right.
“And it obviously wasn’t all right. We’d been married for 23 and a half years and I felt that we had a lot of years left in us.
“He was the love of my life. And my children at 16 and 18 were really not ready to lose their dad.
“But there we are. That’s what happened.
“From then on it just became a blur really. But the truth was hard to hear that he had died of bilateral PE (pulmonary embolism).
“His mum had had a PE at 50 and so there was a proven family history which obviously the medical teams were aware of.
“Stuart was very high risk for a PE. It was all there really. The information was there. It was just buried in the notes and buried in the minds of the people who were managing him.
“And I suppose I couldn’t help feeling that if we’d all sat down, well not necessarily me as a next of kin or a relative, but if the medics had all sat down and actually said let’s just look at this for a moment, let’s just think about this for a moment, whether we wouldn’t have come to the conclusion that PE was the top of the list.“This was possibly an avoidable death and there will be more avoidable deaths that come through your hands and I suppose working on the project to look at the checklist and to look at how we can talk to each other as health professionals … how we can just take that moment to stop and think, have we really asked all the salient questions? Have we really looked at the important factors here? … Rather than leaping to a conclusion and then trying to make the loose ends tie in.”
“I believe that a checklist is the way forward. I believe that it’s vital for the way that we are in medicine in the 21st century.
“I believe it protects staff. I believe it protects patients.
“And I believe that if we don’t do it, we will have to answer for that.
“I would rather justify doing something that might slow us up slightly on our travels, or might seem repetitive, might seem a little bit of overkill perhaps.
“I would rather have to justify that to colleagues than have to justify not using something which could save somebody’s life.”
The film ends with the stark words: “Stuart died of massive pulmonary embolism. He was 46. He didn’t even receive VTE prophylaxis (clot busting drugs). Stuart never did have a kidney stone.”
