During the age of the samurai, dishonoured warriors would perform “seppuku”, a form of ritual suicide.
It was part of their code of conduct.
Shame, cowardice and dishonesty meant that a samurai would fall on his sword rather than bring dishonour to his clan.
Samurai generally could carry out the act only with permission.
If he was samurai, he would have my permission.
You dishonour your profession.
Shame on you.
Shame on you.
“To see the right and not to do it is cowardice”….Confucius
A small snapshot of the 19 page report we received today:
Investigation into the care management of a neonatal death after a breech vaginal delivery at the RSCH
- Unit on divert to PRH because of workload. Elective procedures should have been postponed or cancelled in accordance with Maternity policy
- Prioritisation of elective over emergency cases by Registrar X and Consultant Y
- Registrar X categorised Nicky Swan as emergency (immediate threat to life of mother or baby), delivery should have taken place within 30 minutes of this decision.
- Difficulty contacting Consultant Y
- No review of Nicky Swan by Consultant Y despite requests from senior midwives
- Thorough review of Nicky Swan was not carried out by Registrar X, who reported Nicky Swan to have a normal CTG when this had not been carried out
- Ineffective communication between professionals at all levels
- Consultant Y and Registrar X did not acknowledge that Nicky Swan (being multi-parous and having ruptured membranes around her baby) was likely to labour rapidly and should have been prioritised over elective work. This was despite concerns raised by the midwife caring for her, two senior midwives and Consultant Anaesthetist
- Referral of Registrar X to her educational supervisor regarding decision making and communication
- Referral of Consultant Y to obstetric consultant lead regarding decision making and communication