This is the text of the speech I gave to The Sixth National Conference on Current Issues in Midwifery organised by the British Journal of Midwifery yesterday. I have reproduced it here by popular request. I am not going to include the photographs of my family that I refer to, nor the medical charts, but the important information from these is in the text. The full version of the story is, of course, told in Friday's Child.
Good morning. My name is Ben Palmer, I am a father of two children, and a widower. I am also founding trustee and chairman of Jessica's Trust – a charity focused on raising awareness of childbed fever or puerperal sepsis, but more about that in a minute.
First, I'd like to introduce you to my family and give you a small and brief glimpse into our lives.
This is my wife, Jessica, and I just after we were married.
This is Jessica and our daughter Emily, just after she was born ... we didn't know she was a girl, so she's in her brothers hand me downs already.
It is one of only two photographs of the two of them together. Emily keeps it beside her bed wherever she stays.
Jessica died in June 2004 when Emily was just 6 days old, and three weeks after Harry's third birthday. She was 34.
This photograph is hanging in poster size on their bedroom wall, so that they will never forget her.
This is my family today.
Emily is a relatively carefree 4 year old still learning about who and what it is she has lost. Harry is a seven year old, unfairly burdened with the reality of maternal death. I'm less troubled than I have been, but a little greyer than I used to be.
This is a story that fills numerous files, but I'm going to condense it right down, hopefully retaining the salient information. Please remember that the small amount of medical knowledge I have now is 98% more than I had at the time.
I'm also going to illustrate the story with an early warning chart that I have filled in retrospectively from Jessica's notes. Unfortunately they were not being used at the time.
Emily was born at 6.26 on a Thursday evening after a complication free vaginal delivery. She was 9lb 13ozs. Jessica and I were ecstatic after the birth of our daughter - a sister for three year old Harry.
Jessica's temperature at delivery was normal, heartrate 78, BP 120/56.
After a sleepless night because of Emily's constant crying for milk, Jessica was shattered and wanted to go home, but her midwife was worried – Jessica was tachycardic.
At 9.40am Her BP had dropped to 80/40 and she was hot (although her temperature wasn't recorded anywhere that I can find it.) and her heart rate had increased to 90.
The SHO was bleeped just before 10am. Had the hospital been using this chart, these obs would have registered as a red score and should have made her a priority.
Through the day Jessica's heartrate rose to 100 - which would have registered as a yellow score - and with no sign of her, the SHO was bleeped again.
At 8pm the doctor at last visited Jessica without (Jessica told me) taking any fresh observations. Looking at the notes, it might appear that she re recorded the previous ones and then discharged her.
After supper that night, an hour or so later, Jessica was shivery and had blue lips.
I got her into bed and then took her temperature as she now looked flushed. It was 38.9C.
I could have called the hospital or, indeed, an ambulance, but two things occurred to us.
- that her previous symptoms - not that we fully understood them - had not been cause for concern, and
- that both of us had had high temperatures in the past with no ill effect.
I had no reason to think that Jessica was in any danger after a normal delivery. And anyway, as second time parents, we knew that the community midwife would be visiting the following day.
Jessica was tired and made it quite clear that she wanted to be left to sleep until the next feed.
Yes, the benefit of hindsight makes me uncomfortable about this. It was my missed opportunity.
Unfortunately, the midwife was too busy, with too many mothers, to visit the next day, but I told her on the telephone about Jessica's temperature and so she recommended paracetemol for the fever, should it return, and promised to visit the next day, Sunday.
Had the discharge form mentioned the problem or concerns in hospital, again with hindsight, I might have thought to mention it, but the 'Other problems' box was empty.
We were reassured and so got on with the business of looking after our young family.
Jessica came downstairs once over the weekend - in fact it was the only time she did in the three and a half days she was at home with us - and it wasn't for very long.
So, when the midwife visited on the Sunday, Jessica was in bed with Emily beside her.
She didn't have her thermometer with her, so just recorded that Jessica was feeling feverish.
She didn't know what Jessica's hot and red looking abdomen meant, so it was forgotten about. The midwife left Jessica after about 40 minutes and she carried on resting.
On Monday morning, Jessica was in a lot of pain in her lower back and so rang the GP's surgery. She was diagnosed as having sciatica and given Diclofenac. The medicine was great and made Jessica much more comfortable for the rest of the day, but the pills were obviously masking a worsening crisis.
By breakfast on Tuesday, Jessica was beside herself with pain and barely able to walk, and so I drove her around the corner to our GP. Jessica was seen immediately and referred back to the maternity ward by blue light ambulance.
On the way, her BP crashed and she was redirected to A&E. She was diagnosed with septicaemia and soon moved to Intensive care.
During the next twenty hours or so, I slept little, and shuttled between my home where my mother was looking after Harry and Emily, and Jessica's bedside.
She was given drugs for the infection and failing blood pressure in ever increasing strengths and dosages.
During the night she was put onto dialysis and a ventilator. I left her bedside at 6 in the morning to be at home when Harry woke up, but by eight in the morning, when I was called back to hospital after 40 minutes sleep, it was apparent that she was in very grave danger and deteriorating.
As a last ditch attempt to save her, Jessica was taken into theatre for a possible hysterectomy in the late morning. Almost immediately after the first incision, she went into cardiac arrest, and death was recorded just before midday.
Jessica died of multi organ failure caused by group A streptococcus.
I don't mean to judge or criticise - I just want to tell you what happened and why I'm here. Legally, the matter is closed after admissions of liability, but I hope there is something that everyone can learn from Jessica's case; parent, midwife and doctor.
I'd hate her death and our loss to be a wasted opportunity.
You don't need me to tell you:
- that puerperal sepsis is no longer a disease of dirty practitioners like in Semmelweiss' day when it was being spread from mother to mother in the wards;
- or to tell you that it is a community bacterium that many of us live with harmlessly - until it is given the opportunity to invade a body as in the case of a postpartum woman,
- or that it is still the cause of 14% of maternal deaths in this country.
In the grand scheme of things, 18 deaths between 2003 & 2005 may be a small statistic, but the human impact is not.
What I do want to tell you is what happens when you wake up as a single parent and a widower, with small and confused children.
When I got home, broken hearted and in shock, I had to go on and on breaking others' hearts. Jessica's parents, my parents, our friends and family and my son Harry's.
When I told him that the doctor's had tried really hard to mend mummy's sore tummy, but that she was too sick and now she was in heaven with God and the angels where her tummy couldn't hurt any more, he just looked at me.
He didn't say a word. He was three - how could he understand what I was also struggling with?
Thanks to my mother and sister, and subsequently a nanny, our day to day life carried on during the first few weeks: meals were cooked and our routine was followed, but we were crumbling inside.
Harry's fear and confusion usually manifested itself at bedtime. He wouldn't settle, would often wet the bed, and frequently woke me in the night to climb in to bed beside me, but it was the shouting, the screaming, that was most upsetting,
"I DON'T LIKE MUMMY ANYMORE" he yelled at me once after an extended tantrum. He was angry with her for deserting us. Another time, he thought that maybe she and I had had a fight and was now living somewhere else.
How could she not want to see him or live with him anymore?
I lost count of the number of times we'd go through this sequence, and I quickly ran out of answers. In the end he - and sometimes I - would fall asleep on his bed, him in my arms.
Every time I took him to a party or to a friends house there would be trouble at night. He couldn't express it to start with, but he was angry that other children had a mum; what had he done wrong that meant he couldn't.
My own reaction over time was not much better. Consumed by anger, isolation and despair, I sunk into depression. I was eventually diagnosed in 2006 as having agoraphobia, anhedonia, dysthymia, depression and an alcohol dependence. I was drinking, on average, two bottles of wine a night - over 120 units of alcohol a week.
My work - I was self employed - was too much for me, and my clients politely drifted away one by one. I just couldn't stay focused. I got to the point where I didn't care about anything, myself included, other than Harry and Emily.
After being diagnosed, I was lucky enough to have counselling and a long course of cognitive behaviour therapy, and I have now stopped awfulising.
Eventually, life does start to get easier every day, but we'll never be 'better' - bereavement isn't an illness and it never goes away, you just have to learn to live with it.
Emily has never kissed her Mum, she and Harry will never have their mother there on red letter days. On Emily's first day at school last month, in her new dress, she looked at me with a sadness and simply said, "I wish my mummy could see me today."
What will she say if she graduates, or gets married?
My point is that death never goes away once it has struck, but what I want to underline, through Jessica's Trust, is the vital importance of regular and continued observations, fast recognition of symptoms and of action. By the time sepsis is clinically obvious, it may already be too late.
That was where the mistake was made in Jessica's case – too many people passed off the increasing symptoms as anything but dangerous, and Jessica and I were reassured into accepting symptoms that now make me shudder when I think of them.
My focus is to raise awareness of childbed fever - I want all of us, midwife and parent together, to understand it and to talk about it. The last thing I want to do is to invoke terror, but childbed fever should still be feared as it once was. That way another mother's life may well be saved, or she may just be saved from a long recovery from organ damage or a hysterectomy.
I want to see early warning charts being used routinely, and they should go home as well, for the community midwife.
I'd like to see more midwives, so that no one is too busy again, and I'd like to see a maternity service that is as valued with funding as it is needed by us as parents.
I hope that you will remember my wife, our motherless children and all the others like them.