And thank you for coming along. I’m going to share a story of an incident that happened to me in my clinical practise, and it might be, might provoke some emotions. So, if you do need to step out, that’s fine. We can pick up later. Claire’s going to keep an eye on everyone. So. 

We’ve had a catastrophe. The words that cut through the silent control room that’s normally buzzing during a procedure, are what struck me first. I just returned from a meeting, and I didn’t understand what was going on. The operation was supposed to be longer and yet as I looked into the theatre, everyone appeared to be finishing up. My eyes scanned across to the monitor where the eternal loop of the angiogram was playing, and in that moment, I felt cold, I felt numb, and I knew exactly what had happened. I looked into the theatre to find the lead consultant, but he wasn’t there. He was with the family where he needed to be to try and explain. But first I need to take you back, this was 2010, I was working at Great Ormond Street as the lead radiographer, and it was the best job that I’d ever had. I worked with the best team, we were pioneers, we were cohesive, we were dynamic, we were exciting, and I worked with the most expert clinicians and colleagues, and I still believe that. We took risks because the patients that came to us couldn’t be treated anywhere else. They’d been on long journeys, very complex and to be able to treat them, we had to take risks, but we manage those risks, and we learnt, and we worked through. We were together in our successes and celebrated and we held each other through the heartbreak of the cases that didn’t go so well, but we always learnt, and we always moved all on and we always strive to do better. So, when Francis came to see us, she’d had a journey already. She was a lively 8-year-old with a smile that lit up the room. She had a wonderful family, and she was well informed of her condition, of her health. She was involved in the decisions that we made. She wanted to be a doctor. And we all knew that we could help her. She had a complex arteriovenous malformation in her brain and in her face. And we treated her several times as a staged approach to reduce the abnormalities of the structures in her brain. We’d done a few procedures and they’ve gone well, and we welcomed her back each time. It was always a good day when we saw her name on the operating list, she was such a delight as she came into theatre and then there was that day, the 2nd of June, it was a Wednesday. We planned well. Her condition was progressing, and we knew we needed to treat more aggressively. So, we planned to treat both the internal malformations and some of the ones on her face and we made decisions based on that. The glue we’d use to embolize the arteries would normally be bright blue. It goes into the brain it connects with the blood and it, congeals and it closes off the arteries. But because we were treating her face, we didn’t want her to have blue staining under her skin, she was only 8, so we used an alternative product. it was clear. It would do all of the same care, but it wouldn’t be noticeable as she recovered. So, she came to theatre, started as any other case and as we started to go through, the anaesthetist noticed that she’d started to bleed in her airway. The condition was progressing, and the consultant wanted to do some more treatments to inject percutaneously as well as intra arterially. And little by little, the treatment progressed. But it didn’t stop the bleeding, and the anaesthetist made the decision that that was enough for today. We treated some, the rest could wait. Before we finish, we always want to do a completion angiogram, have a look, see what it’s like at the end of that treatment, so that we can plan the next treatment. And so, the consultant asked for one final syringe of contrast to inject into the brain to see where the bleeding was. The nurse handed over the syringe, not knowing that it had been contaminated with glue. That syringe was connected to the catheter injected into the intra internal carotid artery. and instead of the contrast flowing away harmlessly out of the body it stayed in the brain, an embolized half of her brain and that’s what I saw on that monitor. What started off as a normal angiogram and then stayed there, for eternity in her head. The aftermath was always going to be difficult, and in those days, we followed our RCA Plan. We had a team debrief; we had several team debriefs. We looked at what had gone wrong. All of those things we looked at human factors and how we could have changed our communication. We looked at why on earth we used colourless syringes for everything. Why did everything look the same? And we introduced coloured syringes, colour coded syringes, so we had red syringes for drugs and yellow for embolic materials. We worked with the family who were incredible throughout. And the compensation claim at the time was the largest ever medical negligence claim given at £24,000,000 which speaks of the damage that was given to Francis. And then we all moved on, and we led our lives and we took our careers in different ways and I took the path of becoming fanatical about safety and process. And I see that reflected in a lot of the ways I work still today, 14 years later. But it’s only been recently, as I’ve started to work with the Patient Safety Investigation Response Framework PSIRF. As we look to include families and work to a more restorative approach, that I’ve learned about restorative practise and having its origins in many tribal communities where they’ll often use storytelling such as this to work through an event that’s gone wrong and really explain what happened. What were you thinking at the time? How were you feeling? What’s happened since? Had anything happened before? How did that make you feel? And then what do you need? What do you need? From yourself, what do you need from those around you? What do you need from the family? From the other people that have been hurt? And how can you use that to move forwards? And so, I use today as one of my ways I hadn’t, really thought about it very much very deeply before it’s something that’s ever present, and every 2nd of June it becomes increasingly more present. But I recently returned to a reunion event, where several of my colleagues independently spoke about that case to me, to others. And so, I realised that we hadn’t addressed everything. We had had our debriefs. We’d had our after-action review, but we hadn’t really made our reconciliation. And so, I hope that the new ways of bringing restorative practise in can help that healing to start earlier. If we’d have started this 14 years ago, perhaps some of my colleagues would still be practising that have now given up. Perhaps we’d have had more communication with the family who have carried on their lives as well. And as I approach challenging situations, that perhaps aren’t hopefully as catastrophic as this one, I will continue to use those practises of questioning. What happened? What were you thinking? What were you feeling and what do you need? Thank you.