Closure…

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1st July 2024

“So, what does closure look like to you?” my therapist has asked. We have visited this question several times over the last few years.

As a concept, closure has been difficult to visualise, and even harder to articulate. 

Throughout the last four years of the complaint process and subsequent litigation with the trust, the primary goal has always been to know that I mattered.  I also needed to know that the trust cared enough to review processes and ensure that what happened to me didn’t happen to others.

So why has this question in therapy been so hard to answer? 

I have been chasing an ideal.  In my head, it was always realistic and reasonable.  But over time I have realised that sadly the ideal is some distance from reality. 

Throughout this process, my concept of closure has therefore had to evolve. I have had to accept that ultimately I would have to settle for answers to questions…even if the answers were not those I hoped for.

Closure would be answered questions.

Closure, I guess, happened this week.

I first contacted a solicitor four years ago, six months post-cancer diagnosis and surgery, purely because I wasn’t getting answers to questions I put to the trust, regarding my care in the year leading up to that point.  I needed to understand what had happened.

How else was I to get those answers, given the difficulty, even I, as a healthcare professional, was having? 

It seemed the only way I could hope to get those answers, was to pursue a clinical negligence claim. 

Ridiculous, I know.

Earlier this year, the trust settled the claim, accepting liability for having missed the cancer on scan eleven months before diagnosis. 

While some questions were answered reluctantly during the complaint process, there was one question that remained unanswered throughout the four years.

Settlement didn’t bring me closure – how could it, when the goal had never been to get financial compensation, but to improve clinical care.

And that outstanding question? 

“Was the initial reporting radiologist ever informed that they had missed the diagnosis?”

A reasonable enough question to ask.

I need to make it absolutely clear.  This is not, and never has been, about pointing the finger of blame.  This has been about bringing into a clinician’s sphere of knowledge that a mistake has happened, so they can learn. 

I am a passionate medical educator.  I am a GP trainer, a GP training scheme programme director, and a medical student facilitator.  In each of these roles, I stress that we will all make mistakes throughout our careers.  

We are human, it is, therefore inevitable. 

The important thing is how we respond to, and learn from those mistakes.

If we don’t even know about a mistake, how can we ever hope to learn from it? 

During the complaint process, I was told simply that the initial reporting radiologist no longer worked for the trust, so could not be contacted for comment.  

This has always sat very uncomfortably with me. 

In primary care, complaints will follow you.  It doesn’t matter if you move practices, or even move countries.  You still have to comment, even if you no longer work for that organisation.  

Why would it, or should it, be any different in a hospital setting? 

Your heart sinks, and you feel physically sick when you are notified – we always strive to do our best – but it is an essential process to aid our learning and make us better doctors.

All doctors undergo annual appraisal. We must declare if we were named in any complaint over the last year.  We should reflect on any complaint.

I naively assumed that they would have eventually told the radiologist, given that the complaint had escalated to litigation.

This week, 6 months post settlement, and after repeated subsequent attempts to get a definitive answer to the question, I got the following response:

“When considering whether or not to inform a clinician about the outcome of reviews such as this, we aim to take a proportionate response.  There is an accepted and well-evidenced error rate within radiology and we would not routinely contact clinicians when such a discrepancy is identified”. 

It seems, that informing a clinician of a missed cancer diagnosis is not standard practice – to do so would not be deemed to be a “proportionate response” – regardless of whether they are still working in the trust.

So…

Closure.

I have it. Not how I hoped.

But the trust have finally answered the question.

Deep down I have known the answer.  The delay was telling enough. I guess I just needed to hear it. 

I had assumed, though, the trust hadn’t inform them because they left the organisation, I had not assumed that it was the trust’s standard policy. 

How very reassuring for us all…

How can that be right, but what else can I do?

So where do I go from here?  I need to move on.

The legal process has consumed so much of the last 4 years – not just for me but my family.  It has been impossible to envisage what life after this would look like.

In my first blog post back in March 2020, I said I was not a fighter or a survivor, never liking the labels of war associated with cancer.

Cancer recovery has been incredibly challenging, as this blog has charted.

However, it has been nothing, nothing, compared to the fight for answers and truth from the trust.

That has been my biggest battle. 

I am a fighter.

I am a survivor.

And I am certainly battle-weary.

I bear the scars of the last 4 years and will carry them always.  My 2-inch abdominal wound is the very least of them.   The process has made me feel so exposed and vulnerable, especially having to undergo a psychiatric evaluation to essentially validate my experience – my truth.

I have talked about carrying my box of emotional readiness for recurrence.   Occasionally, but not often, I have allowed myself to place it on the ground and give my arms a rest. 

I realise now that I have spent the last four years carrying two boxes, not one.  It has been utterly exhausting.  The litigation box has been sitting on top of the readiness box.  They’ve both been pretty big, and that top box has often obscured my view of the future.  It has been rammed full of potent, toxic emotions. 

It has carried a different grief process of its very own… “Denial?” Perhaps not, but certainly disbelief about what happened. “Anger” at the way the trust treated me, particularly in the context of the complaint and litigation.  “Bargaining” in the sense that I brought to their attention multiple failings but also gave them the opportunity to make good. “Depression”…where do I start?!

And finally “Acceptance”…

Here is what I now accept:

• The wider NHS is neither a “learning” nor a “transparent” organisation.  It shows little desire to be either of these things.  This is not a reflection of the clinicians providing care, but the system in which they work.
• The NHS does not look after its own.
• I don’t matter to the trust (but I do matter).
• Appraisal and revalidation are meaningless processes, as the organisations in which we work, fail to bring to our attention our shortcomings.
• I am never going to change the organisation.  The people who are in a position to change things for the better, often lack the motivation to do so.
• Hospital legal departments are the biggest barrier to true learning within the organisation.  It is an unfounded fear that an apology will lead to litigation. 

Patients want to know they matter, and that trusts learn from their mistakes.  Financial recompense is not the primary motivator, and genuine apologies would no doubt lead to less, not more litigation.

A sad reflection, perhaps, but the last four years have done nothing to dissuade me of the above.

But…

That complaint and litigation box is now empty.  

This week’s outcome is hugely disappointing. I am so sad…but my load is lighter.

So where do I go from here? 

Working in the same organisation, it is difficult to “leave it all behind me”.  I simply can’t do that.  The treatment I received continues to shape my practice –  I am scarred, untrusting, and sceptical.

But I still care – passionately – about what I do. 

I guess I have to keep my focus on who, and what, I can trust.

So I inch forward…

Step by tiny step, into the future.

Image credits:

albertideation.com, goodrx.com, fourteenfish.com, redbubble.com (The Weary Soldier, Tamara Bush), alamy.com