Sepsis and Me

I have a very strange relationship with sepsis. Ultimately it is what caused the most devastating loss in our family. It is what robbed my first-born child of his life. I didn’t even know what it was and hadn’t even heard of it before William’s death certificate was presented to me. Now I know so much about it that it seems impossible that there was ever a time when I didn’t know that it existed or that it was an integral part of my life.

You would think that because sepsis stole the life my of one-year old baby that I would never want to let the word roll off my tongue again but it is what consumes my life on an almost daily basis. It is something that I cannot let go of. It is something that I have to speak about and it is always on my mind.

I work for the UK Sepsis Trust but to me it doesn’t feel like a job. If I didn’t work for them I would campaign, I would blog, I would educate the public and health professionals about sepsis and the reality of what it can do. Sepsis is an integral part of my life that is unavoidable, perhaps not as unavoidable as William’s death. William couldn’t avoid it and neither can I.

When I talk to health professionals about William’s death, about those horrifying moments that I found my lifeless child in his cot, rigor mortis having taken over his fragile little body, the words catch in my throat. Reliving it, retelling it and recounting every single painful moment is almost like a punishment, dipping myself back in to that moment. I invest so much emotionally when I talk. But it is not something that I can escape from. I could of course choose not to talk about it. I could choose not to revisit, but these thoughts and those memories live in my mind, they are part of my make-up. As much as William’s life is made up of the most wonderful memories, William’s death happened too. It is part of my life and it is what has redefined me.

I am always asked when I arrive at a talk or conference whether I get nervous. I don’t, not really. I don’t have butterflies in my stomach, I don’t have sweaty palms and I don’t feel any sense of anxiety. After all, the subject I talk about is my life, I can’t get it wrong. It’s not a test and no one is judging me. Something that every parent wants to do is talk about their children. Their pride and joy. I cannot talk about William’s latest achievements or what he’s up to. I have finite memories that I can recall, there will be no more memories to make. So, in order to talk about William, I talk about his death, because that is also part of his life.

Sometimes I get messages from people, saying that because of a talk that I’ve delivered, or a blog I’ve written or a video I’ve shared that they heeded my advice and due to that their loved one was diagnosed and treated successfully for sepsis. This warms my heart and for every story, every child, every life it still gives me goose bumps and it still makes me cry. I cannot help but feel that I wish there had been a ‘me’ several years ago when William was poorly.

I know that whatever I do William lives on in the hearts of the lives that he’s saved. I cannot bring him back, if I could, I would. I have not accepted William’s death, how can you accept something that is unacceptable, but what I have done is made peace with myself that one day I will be with him again. I don’t know how, I don’t know when, but I know that it is but one heartbeat and one breath away.

I haven’t just seen the devastation that happens when sepsis enters one’s life, I live it, I breathe it. It is what tore my family apart, it crept in to my son’s life and it was what stopped that golden heart from beating. I will not forgive it, I will not give in to it. I have embraced it, I implore it, I share it, sepsis forms every part of my way of being William’s mum. If I can help just one family from enduring the pain that we live in, then I’ll keep sharing, I’ll keep talking, I’ll keep telling sepsis that you might have won the battle but you most certainly have not won the war.

Love prevails. Always.


www.justgiving.com/williamoscarmead

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What do I think about the NHS?

In the immediate aftermath of losing William before we really understood the true consequences of how and why he died, I searched everywhere for the answers. When I received William’s post-mortem report a paediatrician came to visit me to explain the content. At best this was a summary – it didn’t really tell me what I wanted to know. I wanted to know how the pneumonia had taken hold, I wanted to know how long the abscess had been in William’s lung and which lobe it was in and how this might have affected his airway. I wanted to know the thickness of the fluid that had engulfed his tiny little chest. I wanted to know the strain of bacteria found in his lungs, ears, chest and blood. I wanted to know how that strain of bacteria affected his organs. I wanted to understand. I didn’t want to be placated with answers that were formed in such a way that they caused less hurt. Tasked with a job that no one would envy, what those who were in direct contact with me didn’t realise is that there is nothing you, or any report could ever say that could ever lessen the hurt. Carefully constructed sentences, they don’t work. Summarised reports, also don’t work. They do nothing to satisfy my desire to truly understand. It is not as though I have just taken my pet to the vets and a simple explanation regarding their illness will suffice. My child died; but one thing that must be understood is that bereaved parents do not need to be spoken to in a way that you might explain something to a child. Subsequently I called and spoke to the pathologist; it was my only choice. Did I want to speak to the man who had handled my child’s body in such a cold and brutal task; no. But regardless, he had seen William, he had understood, he was the man who was able to extract all the answers I needed.

When William died at home, we were taken to hospital by ambulance. An ambulance that had blocked our one car road. Traffic was queueing, but the paramedics didn’t move their ambulance. They did not rush us. They went at our pace. They allowed me to carry my baby in my arms out of his home for what would be the last time. As we reached the road, faces of the waiting motorists said it all. A subtle head shake as they bowed their heads in respect. The paramedic sat in the ambulance and cried with me. A man, a father, a real person, how did he feel? The worst, most tragic part of his job. When we arrived at hospital they waited until I was ready to carry my baby into resus. They stayed with us until we were ready for them to go. We weren’t a ‘job’ to them. William was carefully cradled by them, and treated with the dignity he deserved. Their demeanour our only solace of feeling secure in a situation that had completely shattered our world. They allowed me the space to lay next to William on his nursery floor and scream, beg and plead with him to wake up, knowing full well that he never would. They were human. They cared and their compassion will never be forgotten.

The process, which is the only word that can be used to describe what happens after a child dies is distant, impersonal and one that does not fill you with reassurance.

Once the initial ‘buzz’ has faded and you are left with nothing but a post-mortem report that explains how your child’s world ended is the time when the most support is needed. Simply put, you don’t get it, not unless you come to the attention of the mental health team – which I did. It shouldn’t take an attempt on a life to get the help you need. Losing William isn’t a one time event that slowly gets better over time. Every day deals another blow. Another day when the sun rises but no hope comes with it. It doesn’t get better with time, in time I suppose you just somehow live with ‘it’. You don’t learn how to live with it. You just ‘do’. What other choice do I have? For me, I wasn’t satisfied. I knew that William shouldn’t have died – his post-mortem confirmed that. But I would now have to wait another 5 months before the inquest would take place. 5 months. 5 months is a long time in an average life but not in the life of someone who counts every day, hour, minute and second, each of which plays out like an eternity. I couldn’t wait, and I wouldn’t wait. So my journey of investigation started.

I started by familiarising myself with NICE guidelines, which further progressed onto the British Medical Journals – which I had to pay for. I researched studies that took me around the globe and spoke to specialists from all walks of life. But I begun by weeding out the direct contact details of the leading paediatric respiratory specialist in the UK. Everything had to be dealt with objectively; this was the hardest part – I mean how do you stop writing, talking and generally acting in a way where you’re not falling apart. I still don’t have the answer to that. Everything had to be neutral, unbiased, constructive and without blame. I wanted the truth not a played down version to somehow make me feel ‘better’, I knew I would never feel better. When the responses from the specialists started arriving in my inbox or answer phone the story became alarmingly obvious, startlingly clear and horrifyingly obvious – William should never have died. Most importantly I spoke to paediatric respiratory, microbiology and sepsis specialists. Consultants that have spent years working in one specific area. Not a generalised approach. As the inquest approached I had the facts I had sought. In the meantime the doctor’s surgery who had ‘treated’ William had opened and closed a Serious Event Audit. Which we hadn’t been informed of until we were sat in the inquest. How can the general practitioners have a meeting and close an audit when they have not even discussed William’s care and concerns with us, his parents? I would find it very interesting to see the results of their initial SEA, which was closed after no failings were found, to compare that to the NHS England report that later detailed failing after failing. When I first heard news that a SEA had taken place but I’d heard nothing about it, I really sat down to think how I would approach this. Because clearly if I rolled over and took everything at face value I would get the duty of candour but I wouldn’t have answers.

Who, what, when and where is the easiest way to explain an inquest. Who died? What did they die of? When and where did they die. To assist with answering these questions they bring in a paediatrician. Not a specialised one, a general one. So, immediately I was concerned. How can a general paediatrician who has no experience of empyema and pleural effusions confidently ascertain and answer questions in relation to William’s death. Simply put – he couldn’t. An expert in his field, but an expert in the areas that contributed to William’s death he was not. He was able to conclude that had William had different treatment to what he received it was highly likely that William would have survived. That was all we needed for an NHS England investigation to be opened. Unless you bring your own specialists at your own cost, you get what you’re given. The paediatrician that we had come to Cornwall 3/4 times a year for a day. That’s how many days they allow for inquests into baby’s deaths in Cornwall. We were allotted 2 hours for William’s inquest – it lasted 8. How the family’s waiting behind us felt I will never know.

With my knowledge about how investigations are handled I suspected it wouldn’t be an easy ride – it wasn’t. However, throughout the investigation I was involved in every step. Perhaps because I was a constructive nuisance, I was persistent, and I wouldn’t accept answers that I felt were flawed or were not relied upon with justifiable evidence. Eventually after several hundred emails, multiple drafts of the report, and numerous meetings, the report was finalised in January – a report that I was satisfied with and reflected the truth accurately. A report that highlighted multiple failings in William’s care, from each GP we spoke to, the 111 help line and out of hours doctors. Ultimately if William’s chest infection had been diagnosed appropriately and not as a viral infection – he would have received much-needed antibiotics. If that chest infection had been treated the progression of pneumonia would not have happened, leading to a pleural effusion, lung abscess and the sepsis that would take his life.

I have lost count of the number of times I have been asked to point the finger, or blame, or speak in a manner that puts the spotlight on certain people involved. I have no desire to do that. Those involved have apologised, face to face and they have been held accountable for their mistakes – after all – unless they were living in a cave during the first part of this year, it was a bit hard to miss the media. I have met face to face with the GP that last saw William for what would be the last time, the doctor that should have sent William to hospital. I have looked in his eyes and told him how Paul and I feel. I have been asked if I will take our complaint to the GMC, phrases such as “shouldn’t he be struck off?” For me, to take such action, would be to prevent him from potentially saving another life. Those that went into work each time they saw William didn’t act in a malicious way, they didn’t allow William to die on purpose. They are aware of their mistakes and the systems that allowed for those mistakes to take place are being changed. I hope that those involved in William’s care will not make those same mistakes again. Their index of suspicion has changed, their threshold for prescribing antibiotics has lowered especially when it is clinically evident they are required. Their awareness of sepsis has been refreshed in the most devastating circumstances. I do not want my life to be consumed by hate, anger, and regret. To seek revenge on those involved would not honour William’s memory in the way that he deserves; and it would not bring William back – and that is all I want.

There are faults that lie within the NHS – some of which I have encountered. Those of which I have I’m sure, I could think of a better way they could operate. I’m sure many of them could be rectified with an endless pit of money – which the NHS simply does not have. But the NHS is built on foundations of compassion by those who go to work to do good, to do their best to help a patient to feel better, make their lives easier and with dignity. There are some of course who do not, there are always bad pennies, but thankfully they are far and few between. I have had my own negative experiences with my own treatment and miss-diagnosis in the past. But if it wasn’t for the NHS I wouldn’t be here – twice my life has been saved. If it wasn’t for the NHS, William wouldn’t have been born. The NHS did not cause my son to die – decisions of specific people did.


 An eBook of 50 illustrations donated by 50 world class illustrators has been created in William’s memory. The book includes a foreword by me and Ron Daniels CEO of the UK Sepsis Trust. There is also a little game that you have to find William painting within the book. The book costs no more than £1.49 with all proceeds being donated to the UK Sepsis Trust in William’s memory. Please support us and buy your copy here.

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Williams Just Giving Page

The best apology is changed behaviour…

Those days after William died, the day when I kissed William’s soft skin and whispered in his ear ‘please tell them what happened my darling boy’, the days spent waiting, wondering, hoping they would find something, something that would tell us what had happened to our beautiful little boy. As I would sit staring out of the window ruminating about my little boys broken body being transported up-country on his own to be operated on in a procedure that should be reserved for adults only. Wondering if he was ok, wondering whether they would look after him, wondering how the pathologist found the strength to do that job. I was told it would take a while for the post-mortem results to come back but just five days later William was returned home, and we were given preliminary results. Something we hadn’t anticipated, after all ‘SIDS?’ had been mentioned on William’s medical record. Something I later found out. But I knew, I knew that William didn’t just die. I was right.

In those five days I had pulled my hair out strand by strand and scratched my skin until it bled, anxiety winning the most debilitating war, whilst I waited. Can you imagine being in a position where you beg God, where you hope, where you wish that your child died of something so rare that no-one could have spotted it, that the 382 glorious days we were blessed with were borrowed time, that William would have been taken anyway. Can you imagine feeling that way? Toying with the possibilities in your head and deciding on one that somehow you might find easier to live with. But no, William didn’t ‘just die’, he didn’t die from something so ultra rare that he was no longer suffering from, William died from something common, sepsis.

When the pediatrician came and sat on my sofa, my pleading eyes, begging her to tell me something I could make peace with, but she didn’t. She told me that William died from something that doctors should be looking out for. Not long after, I spoke to the pathologist himself, he told me that William’s little chest was full of viscous, purulent fluid. Why didn’t the doctor pick this up? The one who listened to William’s chest just before he died. The one who told us his chest was entirely clear.

From the moment William was taken from us, from 08:47am on the 14th December 2014, from the moment the paramedic uttered those words “I’m sorry my love, but he’s gone” the questioning began. A constant reel of questions on repeat. In my head I would answer a question, but then immediately pick apart the answer and start the process again. That hasn’t stopped, what I do know is how William died, but what I will never be able to answer is why? Why William? William was well looked after, and loved beyond comprehension. I will never know why those doctors involved in William’s care made mistakes, I will never know why we, as parents weren’t listened to.

Very soon after William died it was obvious that things had gone desperately wrong with his care. Within a few weeks it was already apparent that the process after a child dies had flaws that are simply unacceptable. We were left to approach the doctor – the same doctor who had let William down – for help. Can someone help us? Is there someone I can talk to? Appointments that required us to dress, drive miles to the doctors, and sit in the very room where William was sent home rather than being referred to the hospital, and take advice from the very doctor who had examined William. We were offered 6 sessions of counselling. SIX. Of course it wouldn’t start tomorrow it would be at the earliest, next week. As I sat down for session number one, I was reminded that this would be the first of six sessions that lasted approximately 50 minutes. At this point I knew I was on my own.

We had what is called a ‘rapid response practitioner’ someone who you can liaise with. Someone who would tell you what was happening, what would happen next and what to expect. Any bereaved parent will tell you, this is virtually impossible, the waiting is excruciating. The not knowing is equally as painful as knowing, but the parental instincts inside me told me I had to know. So the journey begun. The journey of looking at William’s death objectively.

I’m not really sure what people think, those looking in, those not immediately involved with William, or indeed following our story about what it takes, but it is not a case of filling in a complaint form and sending it off to the NHS. I’ve not written a blog for a while. Mostly because once I sit down, I just want to be left alone with my own thoughts, not because I’m feeling better, I’m not. You see, what I’ve had to endure these last 520 days are something I do not wish upon my worst enemy. I have lost count of the meetings I have attended, conference calls I’ve dialled in to, I lost count of the emails I sent at around the 600 mark, the departments I’ve had to phone, chase, follow-up, push, and persist for them to do what they are supposed to do without me asking, the doctor’s surgery, SERCO, South Western Ambulance Service CEO, the Kernow Clinical Commissioning Group MD, the Child Death Overview Panel, the Coroner’s office, the pathologist, numerous pediatrician’s, rapid response practitioner’s, NHS England South, NHS South South West and that is not an exhaustive list; and that is before the inquest even begun in June 2015.

After the inquest, when the actual investigations into Williams death started was when the real journey started. I don’t think anybody really knows exactly what it has taken, just Paul. I have read through the transcript of the telephone calls I made to the health professionals in the days leading up to William’s death, I heard his little voice in the recordings, I’ve listened to the 999 call I made when William died, I’ve read and re-read William’s medical records and the witness statements, I have lost count of the amount of times I’ve printed and annotated William’s post-mortem report, I have analysed NICE guidelines, the British Medical Journals and I won’t even list the different Royal College guidelines, I have contacted and spoken to many highly respected medical consultants in microbiology, thoracic, cardiology, infectious diseases, pediatrics, and pathologists, oh and the genetics team. I have studied case-law and how this is applied to medico-legal reports. I have studied and learned medical terminology and what it means and how it is applied. I have liaised with the NHS 111 pathways team including the director, the Director of patient Safety for hospitals at the CQC, I have seen, used and experienced the algorithms used by NHS pathways, I have had to deal with the Judicial Conduct Investigations Office, the council and of course NHS England, I won’t continue.

What is the purpose of me telling you some of what is involved? I’m telling you this because when I set out to get William the justice he deserves I wanted to do one thing, and one thing only. I wanted to make sure that those involved in William’s care understood that my son’s life, William’s life is more important than any system. That despite the fact he couldn’t talk, his voice mattered and still does, and as William’s mum it was my job to ensure that his voice was heard. After 520 days we have finally received a full written apology from NHS England on behalf of those organisations involved in William’s care. We have had apologies from each party involved, and of course from the Government. I am exhausted, I am weak, I didn’t have any strength to begin with and I certainly don’t have any now, I am physically and emotionally spent. I have fought so damn hard, and although you might think I have succeeded, I don’t win anything, there is no reward, William doesn’t come back, he is still gone, and I am still left wondering why.

“The RCA panel / team are indebted to William’s parents for their persistence in ensuring that all of the facts were understood and that lessons would be learnt, and for their understanding approach in the context of devastating circumstances for them. The parents of William do want an apology from the parties and organisations concerned. SWASFT has already issued a formal apology to them. NHS England will give an overall apology to them on behalf of all the NHS organisations involved. The OOH doctor formally recorded his apology at the inquest. One of the GP’s from the practice has communicated in writing an apology to the parents and a private meeting between this GP and mum has also taken place…a final conclusion…the panel have concluded that if William’s parents had not been involved as openly and fully…the full extent of the contributory factors and learning would not have been identified…I want to offer this as a written apology on behalf of all of the NHS organisations involved in William’s care.”

Never underestimate the power that a mother’s love has. This is all driven by love, by William, by my darling little Grumpus.


www.justgiving.com/williamoscarmead

My Impact Statement

My sleepy boy

My sleepy boy


My dreamy boy

My dreamy boy

 
I have written down what I want to say so many times but none of it seems right and I’m sure there’ll be things I don’t say but wish I had, the truth is, there are no words adequate enough to describe the intensity of loving William and no words sufficient enough to capture the pain that we feel. William is loved beyond words and missed beyond measure. A pain that we shouldn’t be feeling, a cruel life sentence that should never have happened, today is day 178 of that life sentence. It doesn’t get easier, time doesn’t heal but only serves to widen the gap from when we last held our dear little boy.

We cannot cope missing William, knowing that we are never going to see William again is crippling. All I want is to be with my baby again, and there is only one way that is possible. I do not feel free, I cannot escape from my thoughts, what is now my reality. The clarity of mind that keeps reminding me that William is not part of the world I exist in today. The life that I am forced to be part of, I feel stuck, trapped and suffocated. The cruel joke of the world is that we are still here and William isn’t. It just feels like we are viewing life through a window, seeing it, hearing it but not actually in it. I no longer feel I belong anywhere without William, not even in my own life.

The magnitude of William’s absence is overwhelming and felt by all, even those who did not know him. From the moment we lost William, life has been split into the forever proverbial “before” and “after” William died. I don’t want to escape from this unbearable pain, I know that to feel this much pain is to know this much love. We are exhausted, physically, emotionally, and mentally, the anxiety and flashbacks are debilitating. Losing William has destroyed us, to lose him was to lose myself. In that moment, my soul died too and what’s left behind is a broken shell. We feel like we’re stuck in purgatory, somewhere between heaven and hell. Trying desperately to find another reason to forge through this intolerable pain, an impossible task. Paralysed by our love for William.

At 8:47am on the 14th December, the paramedic turned to me and said “I’m sorry my love, but he’s gone”, I didn’t understand why they couldn’t make him better and I didn’t understand why they stopped trying. William was gone, my little boy was gone. His lifeless body laid on the floor where we had given him CPR. He looked uncomfortable, he looked vulnerable, and he was stiff, I scooped him up and cradled him so close and I begged him to wake up, I pleaded with him to wake up, but he didn’t, he was gone. I knew he was gone, the moment I opened the curtains, William’s eyes staring straight through me, they cut me in half, it was with those eyes that William loved, I ached to hear the words “mummy, I love you” but he never got the chance. William expressed his love in everything he did, but his eyes said it all. Eyes that were so trusting. William trusted me, trusted me to feed him, trusted me to love him, trusted me to put him first, trusted me to be his everything as he is mine, trusted that he was safe with his mummy. The only thing I couldn’t do was make him better, If I could have, I would. That job I had no choice but to rely on the professionals, those that are trained to do so. As William’s mum it was my job to take him to the doctors when he was poorly, and I did, multiple times. I trusted that the examination and diagnosis at each visit was correct. Like William trusted me to look after him, I trusted them. We feel William was let down in the cruelest way possible, and William has paid the ultimate price. There were multiple opportunities to treat him, but we were always assured “it’s just a cough” “it’s just a cough” how can anyone be so wrong? Within 12 hours of speaking to a doctor, our little boy was dead. We were told not to worry, assured “it’s nothing grisly”, I don’t think you can get any more profoundly grisly than sepsis, how was this allowed to manifest, that is what makes this reality so hard to believe. Every morning we get up to the realisation that William is gone. He suffered so unnecessarily, he died in his bed, on his own with his little reindeer, in the place that he should have been safe. those last precious moments he was on his own, what was he thinking, my little baby, he knows what it feels like to die, how is that even possible. I so desperately want my little boy back, I need him back, I want what I can’t have, what has been taken away and that is wholly unacceptable.

In the 382 days that we were blessed with William he made more of an impact than most would in a lifetime.

William was born on my birthday, the most precious gift. After getting used to the idea that we wouldn’t be able to have our own children, William was just meant to be. We were like any first time parents, nervous and apprehensive but it soon became obvious we had nothing to worry about. William made it easy. Our little Grumpus defined me as a person, as his mother, he defined us. He was and always will remain the foundation of our family.

William was his own little person, such a happy, secure and most of all loving little boy. I would often sit and watch him in disbelief that he was actually mine. He was perfect, I can close my eyes and feel his delicate touch, to embrace him and feel his soft skin against my own, feel the weight of him in my arms and to breathe in his beautifully sweet smell when he would bury his head into our neck. When we put William to bed we couldn’t wait to be woken by his sweet little babbling, he would be all sleepy, not quite awake and wanting to snuggle. He’d grab his little reindeer, not wanting to leave him behind, he’d pop his thumb in his mouth, nuzzle into our neck and come into our bed for cuddles. We are crushed that we will never have this again.

You see, William was a clam, patient and content little boy. To sit with William and teach him shapes and colours, to then sit back and watch him learn, to watch him think, to watch him concentrating, to watch him working things out for himself, was a pleasure. Nothing was more fulfilling than to watch his confused little face turn to joy when he mastered something new, so pleased with himself. He would immediately turn to find you, his face lit up as it met yours, the happiness reciprocated, our pride encouraging him further. His infectious smile that would never fail to make you smile right back, a smile that injected happiness into any room. We were in awe of him. These treasured moments were priceless, memories that are irreplaceable. William filled us with a sense of freedom, taught us love with no boundaries, that’s limitless and endless. He was my one constant, we never knew love like this existed. William was our future, to hear his first words, to pick him up and dust him off when he fell over, to teach him to ride a bike, to watch his first nativity, to watch him fall in love, to be whatever he wanted to be, as long as he was happy, all of this is gone, William robbed of his future and us robbed of ours.

William’s death was so needless and unnecessary, nearly 26 weeks on, almost half his lifetime, we remain a family torn apart by grief, struggling to comprehend life in William’s absence. No-one knows a child better than his parents, no-one knew William better than us, a parents instinct should be listened to, we should have been listened to. We can only hope that no other family has to suffer the unrelenting agony of losing a child in these circumstances and that changes bought about by today’s outcome can prevent further deaths and improve the practice of all GP’s, 111 and out of hours services.

There is no outcome that can ease our pain, we have to live the rest of our lives knowing William’s life was taken from him, knowing that he should be with us and knowing that he won’t be coming back. William was a blessing and we are forever thankful that we can call him our son.