Know Yourself, Know Your Enemy Holby City

There's somebody from the Coroner's Office who wants to talk to me

-about Elaine Warren.

-The coma patient that died?

What do they want to know?

I can't operate this kit.

You wanted this to happen. You wanted Amira to fail.

I wanted you to stop it from happening.

I've forwarded an e-mail outlining the details for this year's

Junior Doctor Award and I'm asking all consultants

if they would kindly offer their services as supervisors.

You'll need to get your pitches in shape if you both want to impress.

Her name was Elaine Warren, not Lillian.

Sorry, who are you?

I'm her son, Jeremy.

And, er, what are you doing here?

Looking for answers.

Looks like I've found some.

Shouldn't you guys be in school?

Trick or treat!

All right.

One for you.

All right? Have a good day.

I'm not really sure about you encouraging truancy.

Nice wheels.

I know I should have gone into law.

My post-divorce mid-life crisis.

And how is Nigel?

Happily shacked up with his 25-year-old lap-dancer,

but you know me, I'm not bitter.

I thought she was his intern?

She is. I made the lap-dancer bit up.

OK, I might still be a tiny bit bitter.

So what are you doing here anyway?

I thought the hearing wasn't until this afternoon?

Another case. The morgue beckons.

Before you read me the riot act and throw away the key?

I shouldn't even be talking to you, never mind discussing your case.

Stop with the fishing, Ric.

You know, Louise, if I didn't know better, I'd think that

you enjoy putting us poor humble medics through the mill.

Well, someone's got to keep the wolf from the door.

-What have we got?

-RTC.

He's hypotensive and tachycardic with suspected internal bleeding.

Let's order an abdominal CT scan. Don't think we've got time for that.

Prep him for emergency exploratory laparotomy, please.

Here, I...want you to read this.

You want me to give you my opinion on your presentation?

No.

I was just giving you a heads up on the quality of your competition.

I'm sure it's an excellent read.

The successful treatment of pancreatic cancer has long been

the sought-after Holy Grail of modern medicine.

Indeed it has, so good luck with that.

So what have you got then?

Hanssen wants to go through the proposals today.

Yes, I'm well aware of that, thank you very much.

Then I look forward to your imminent downfall.

Well, as Fredrik apparently doesn't need my help, is there something

you want me to look over before your presentation?

No, not needed.

So what's this work of genius that you've been hiding?

It's more a work of fiction, to be honest.

I've got nothing

and every time I try to think of more ideas,

I come up with fewer and fewer.

-Creative block.

-Something like that.

Well, I need your help in theatre

so maybe we can come up with something together?

Maybe I should just give up on the whole thing.

No, no, no, that's not the attitude, Dominic, because

I don't think either of us could deal with Mr Johanssen's smugness.

Thanks. It felt weird picking up her things

after what happened last week. Sorry about that, by the way.

It's fine. You'd just lost your mum.

You know, not taking care of yourself,

you know it's not going to help anyone, right?

What's that supposed to mean?

I'm just saying, a bit of deodorant wouldn't go amiss.

Well, I guess I've let things get on top of me.

I'm sure your mum wouldn't want to see you like this,

-that's all I'm saying.

-Is this your bedside manner?

You know me. Caring and sharing at all times.

Well, thanks for the kick up the backside.

-I'll be sure to spruce myself up for the hearing.

-Good.

Then my work here is done. I'll see you later.

All this is a waste of time, isn't it?

You lot look after your own.

The Coroner's Court is there to find out if there was anything more

we could have done for your mum, if we missed anything.

And is there?

You need to understand that we do all we can for the patients here,

-but...

-But you're only human.

Yeah, it's OK. Don't worry, I get it.

How can I run a ward if I've got no-one to shout at?

So many nurses have gone bank to work sensible hours for better pay.

-Sounds like you're up a creek without a paddle.

-Care to join me?

-We can go over the waterfall together?

-You're on your own.

You need to understand that Darwin has a certain reputation

-for burning staff out.

-What's that supposed to mean?

If you ran your ship any tighter, you'd be popping rivets.

And you have a problem with that?

Spit it out, Fletch!

I've had three senior nurses refuse to work on your ward

since you've taken back control.

-You give them a choice?

-Or I could just watch them move to St James's.

Look, I know I've taken on a poison chalice here

but I am doing my best.

I just want someone senior with surgical experience

or I'm going to hang you out to dry!

Do you know what, mate, there was a time when just the sound

of your voice would send me borderline tachycardic.

Whereas now, your little rants I find amusing.

I think that new suit has gone to your head...mate.

Let me know when you're back in the real world.

The bleed is coming from somewhere in the pelvic area.

Blood pressure's dropping. Can we get some colloid in him, please?

He's going to bleed out before we can restore haemostasis.

I think we should pack the abdomen, go in again when he's more stable.

I agree. It will give us time for a CT angiogram.

Find out where this bleed's coming from and consider embolisation.

-My call, pack the patient.

-Your call?

-I just...

-Please don't spare my blushes, Mr Di Lucca.

Your patient, Mr Griffin.

-I will need you to cover my list this afternoon.

-Of course.

OK, let's get him stabilised.

Oh, I'm surprised to see you in today.

I thought that you'd be preparing for Coroner's Court.

What's there to prepare for? Turn up, say my piece and go.

-You're not worried?

-No, I've been there before.

I mean, the mere matter that it's gone this far...

Stop fretting. They always do this with a sudden death.

-I've never been to one before.

-You say that like it's a bad thing?

Must be really fascinating, you know,

going over the forensic details piece by piece.

-Donna?

-Hmm.

Do you think that maybe I could have a little look at the file, please?

Seriously?

It took me four hours just to write the statement.

-I'm just really curious.

-You're such a loser, you know that?

Here you go, Miss Marple, knock yourself out.

I will be on Tinder.

Jane Doe, collapsed at a food bank.

CT scan from the ED shows likely ischemia in the bowel

which we're about to see for ourselves.

Wow, certainly not her first time at the rodeo.

Colon is attached to the abdomen wall.

Large clamp, please. Thank you.

Right, let's start by mobilising the hepatic flexure, shall we?

Looks like she's had multiple bowel resections.

-Question is, what's causing them? Clamp, please.

-Possibly Crohn's?

Well, there's no sign of any ulceration.

Could be previous, I suppose.

-There's a perforation in the bowel just here.

-OK.

Scissors, please.

-What do we do next?

-A stoma would be standard procedure,

but she's so young that I would probably suggest removing

all the ischemic areas and then resetting again.

Good. How would you like to proceed?

Well, we need to cut the proximal part of the bowel

at the ileocecal junction,

then dissect up to the distal at the beginning of the transverse colon.

Excellent. I may yet be in the presence

of a winner of a Junior Doctor prize.

Come on. Something will grab you.

-So where's your mojo gone recently?

-I don't know.

Popped out for a pint of milk and never came back.

Are you missing a certain someone?

-What?

-Well, AAU's not far.

I think we're all missing Lofty these days.

-Ugh, no, not him.

-Who then?

All this talk of the Junior Doctor Prize...just makes me think

that Arthur would have been all over it, doing anything to win.

Guess I'm just trying to do it for him.

I know that sounds stupid.

The goal is to be able to go home knowing you've done

everything you can for the patient.

That's all we can ask for ourselves.

Take this girl, for example.

You could have gone for the easy option,

but you chose the harder route to give her a better quality of life.

How's he responding to the inotropes and clotting agents?

BP is low, but holding. Be good to have his notes?

Find out why that bleed was so heavy.

Well, let's take the guesswork out of it, shall we? Test results?

Scans and CT on order.

FBC have been delayed as the lab have only just received it.

Let's keep him on 15-minute obs.

And perhaps, Donna, you could use your legendary charm

to chase up the FBC results?

No need to ask. Already on it.

Bit bleary-eyed today. Heavy night, was it?

Amber was up all night with bad dreams, thank you very much.

-Feel guilty now, don't you?

-Ouch!

It's not the best prep for an inquiry.

-You've given your statement?

-Have you chucked him to the wolves?

Of course. You're so doomed!

In which case, Ms Jackson, I shall be taking you down with me!

SHE LAUGHS

-How many times is that now?

-In the Coroner's Court?

This will be the fifth time.

I've had two myself.

Stressful for you, even if you know you did everything that you could.

Necessary evil, Mr Di Lucca.

Weeds out the bad eggs.

Keep me posted on Mr Willis, please.

-Good morning.

-Amira, good to see you.

-To what do we owe the pleasure?

-Director of Nursing sent me.

I am the cavalry, apparently, here to save the day.

-You're serious? After last time?

-I'm the new and improved version.

Done my MIMS module and everything.

Dr Ford, would you mind showing Amira a locker, please?

It's OK, I'm good.

Which way's the staff room again?

Down the corridor.

-What are we going to do?

-Hope Jac didn't see and tell Fletch

we have a serious diplomatic incident on our hands.

-Good morning, Ms Naylor.

-What is she doing here?

Fletch's answer to our staffing problems, apparently.

-Batten down the hatches?

-Prepare for Def-Con 4.

Nurse Zafar. I didn't expect to find you on my ward.

I was hoping I'd speak to you before my shift started, Ms Naylor.

I want to reassure you that I'm up to speed

and I'm confident that I can do a job for you here.

Well, that remains to be seen.

I'm only asking for the opportunity and your support.

I'm not inclined to give you either.

I know I didn't exactly cover myself in glory, but...

I'll get that.

Elaine Warren died from the overwhelming spread of sepsis?

End of, as far as I can see from these notes.

Well done, Sherlock. Tell me something I don't know.

I mean, maybe the amputation could have happened sooner

if the CT angiogram had been done earlier,

but we're just talking about a few hours.

-And it's not Mr Griffin's fault.

-It's all in the file.

Radiography were snowed under after a major accident.

At that point, Elaine wasn't a priority,

as the sepsis hadn't shown up in her FBC.

No blame, no claim.

Did he ask for anti-coagulants to be administered to her?

What are you talking about?

Nothing, I mean...

It would just be standard practice, given her condition.

Well, then it must have been done.

There's no annotation of the drugs being prescribed.

It just would have improved her circulation,

stopped the sepsis from setting in so quickly.

Yeah, I'm sure there's a reason why.

An effect on the angiogram result or whatever.

-You know what, ignore me.

-Do you really think he might...

Who am I to question Mr Griffin? I'm sure he had his reasons.

I would perfectly understand if you took a leave of absence

until this matter is resolved.

You don't think that we're already over-stretched?

Your dedication is appreciated.

All the same, this inquest comes with unfortunate timing, doesn't it?

Your point being? The hospital is at a critical juncture.

Our every move is being examined and cross-examined.

We are under severe pressure to present this hospital

as a perfect NHS model.

-So that marks me as an embarrassment?

-No, no, not at all.

I consider you one of our finest.

but if we're to weather the oncoming storm,

then we're going to need all our key players.

-Duly noted.

-Mr Griffin, you have Holby's full support.

Representatives from management will be present at the Coroner's Court.

Let's hope that I don't need them.

-Are you stealing from patients now?

-There's nothing to steal.

Just this and some pocket change.

-Any idea who she is yet?

-Nope.

A search on that might give you a head start.

Let me save you some time.

It's Romanian for "Offer Me Peace".

How's that presentation prep going?

Now doesn't that silence speak volumes?

Don't you think you're letting your intuition get away with you

-a little bit?

-Not when my father's been enquiring

if and when you intend to hand your proposal in.

Have you managed to work your magic on the guys in the lab yet?

Batting eyelids, damsel in distress. You know the drill.

And the CT scan for the suspected peritonitis, bed four?

It's on order. He's also had pethidine and a drip

as he was severely dehydrated.

He's awaiting transfer to Keller and he's on hourly obs.

Well, when I checked on him, his temperature was up and his BP too.

Really?

Oh, er, I'll check on him again then.

I want him on 15-minute obs as of now.

It's a bit overkill, isn't it, if you don't mind me saying?

I do mind you saying.

PATIENT SHOUTS IN ROMANIAN

I'm sorry, I'm really...

-Just...

-What's going on?

Sorry, sorry!

I think we'll have to get a translator once we work out

-where she's from.

-She's Romanian.

-How do you know that?

Linguistics. It's one of my many skills.

Well, better get someone up from HR, OK?

-Can I leave her with you?

-Well, I was hoping...

I know. I know you want to do your research project

but I'm due in theatre and we still have a ward to run, OK?

-Then I guess I'm multitasking, aren't I?

-Thank you very much.

Hi, I'm Mr Copeland. I'm one of the doctors who operated on you today.

Now, I'm going to try and translate this conversation

using an app on my phone.

Now, don't you smell nice?!

Do you wear cologne for all the girls or is this especially for me?

Right, OK, so you do speak English?

You can speed up now. I'm quite fluent.

Why were you giving my boss such a hard time in your native tongue?

His hands were cold.

He very grimly and solemnly told me he had to remove some bowel.

Needs to improve his bedside manner.

So...

..when can we discuss how you're going to save my life, sexy man?

OK, there we go.

Ah, there you are. Are you sure that you're good to cover my list

while I'm at the inquiry?

Yeah, I just wanted to talk through Mr Willis's case before you go.

I managed to track down his file and get his daughter in.

She confirmed that he suffers from arterial fibrillation

and has had a TIA in the past.

-What medication is he on?

-Clopidogrel and aspirin.

That would explain the unusually heavy bleed.

Do you want me to take him off the anti-platelet agents?

No, I think the benefits outweigh the risk of a bleed.

His daughter's with him now if you've got time to see her?

Hello, I'm Mr Griffin.

I'm your father's consultant. I know who you are.

You do? Yeah, I looked you up on the internet.

One of this hospital's most respected and senior surgeons.

Your stats are amazing.

You do realise that your father is in a critical condition?

He's going to require further surgery.

He is going to live, isn't he?

So Amira's just going to get paid to sit in the staff room all day?

It's Fletch's problem, not mine. I've requested a replacement nurse.

OVER INTERCOM: Is this thing on?

Apologies for the interruption,

but this seems to be the only way I can get an audience.

We have a very busy list today, don't we, Mr Valentine?

-Nurse Zafar...

-You have my instructions.

I know she's not an ideal choice,

but you're fully aware that we're struggling

so we have to work with what we've got.

I told you I needed a competent, bomb-proof scrub nurse.

-She will be.

-Then she can stay, but she's not working under me.

-On what grounds?

-My authority is sufficient.

Don't you think you're making a rod for your own back

wasting a scarce resource like this?

Don't you think you're bringing a knife to a gun fight, Adrian?

I want to give you an opportunity to come to your senses,

because you will give her a chance today, and if you don't,

I'll report your behaviour to the powers-that-be.

Well...that went well.

So were you suitably evasive? Lots of contradictory evidence?

-What are you talking about?

-When you wrote your statement.

-Stitched up Mr Griffin.

-You're not even funny.

-Are you good?

-What if Ric did make a mistake?

I was there, Morven. Anticoagulants were never even mentioned.

-Are you sure?

-Pretty much, yeah.

Do you think I should bring it up with him

before he leaves for the hearing?

I think you'd be opening up a can of worms there.

You should just wait to see how it all pans out.

But what would happen to him if he didn't prescribe anticoagulants?

Mr Griffin knows what he's doing.

I'm sure there's nothing to worry about.

You've been neglecting me.

Apologies. I've had lives to save and you are no longer an emergency.

Anyway, I would like to take a detailed history from you,

just so I can try and work out why you've had so many operations.

I give you medical, but nothing personal.

Right, OK. What are you, some sort of international jewel thief?

-It's on my to-do list.

-Right, OK.

Well, then, for the record, I shall refer to you as "Patient A".

Really, though, why are you so secretive?

Hit woman.

I have my reasons.

OK, well, if it's anything to do with paying for your treatment,

then I can always speak to the Overseas Patient Officer.

They can talk you through a payment plan.

I have British citizenship.

Oh...I'm sorry. That's embarrassing.

-I just assumed.

-Never assume.

You just make an ass out of you and me.

So, what now?

You recover and you go home.

But I need you to find out what's wrong with me.

I'm assuming that you are undergoing treatment from other hospitals?

I've spent a lifetime being passed from one specialist to another

without a sniff of a diagnosis.

Have you any idea what that has done for me?

-How long have you been doing this?

-Eight years.

Well, look, if you would just give me your name

I can at least look for your medical history.

No, that would be a waste of time. All those quacks were wrong.

I want a different perspective from a new person.

OK.

Well, um, can you at least tell me things that I could rule out?

You're going to need a bigger notebook.

I don't understand. Why can't you just operate on him?

I'm sorry, Emily, until we can correct his clotting factors

any further surgery would be highly risky.

So what does that mean? You're going to do nothing?

He's stable and he's in the best place.

-We'll continue to monitor him...

-But how long can you keep him like this?

That's for the doctors to decide, not me.

-This is Mr Griffin's call?

-Hmm.

Watchful waiting is all we can do right now.

Are you OK?

Lost my mum not so long ago.

Don't look at me like that!

I spent the last two years with people going, "Ah, bless!"

OK. I'll, um, bear that in mind.

I'm sorry.

I shouldn't be having a pop at you.

So, what happened?

Went in for a routine op and died on the table.

I can understand why you must be worried.

Do you trust Mr Griffin?

I have worked with him for years.

He's a safe pair of hands.

-Is there anyone else I can call?

-It's just me and my Dad.

Right.

Well...

-Is Mr Griffin around?

-He's left for the hearing.

Is there nothing more we can do for Mr Willis?

-His daughter's very distressed.

-CT angiogram is inconclusive.

We simply don't know where the bleed's coming from

or if it's stopped.

I've seen patients like him who have been packed before and left.

It's finding a balance, Donna.

We go in too soon and he may well bleed out

if we don't find and fix it fast enough.

Yeah, but if you don't do anything, he'll die anyway.

Is the patient currently stable?

-Yes.

-Then get back to me if anything changes.

I'm trying to hold down the whole ward here.

We have emergencies coming in and there's only so much I can do.

Take it up with Mr Griffin when he gets back.

-You're in my spot.

-And?

I get 30 minutes a day to retune my chakra

and I'm not going to let you ruin it.

-The thought never crossed my mind.

-Right.

So you're prepared to play footy with me in no-man's-land, are you?

Pipes of Peace and all that?

Oh, come on, it was Christmas number one for weeks!

Never mind, I'll get my coat. Sit down, Fletch.

So, what you got?

I've developed a worrying addiction to Pulses' chicken salad.

Salt beef nudger man myself with optional crinkle cut crisps.

Bacon, obviously.

So how's life at the top?

If it wasn't for the money, I'd jack it all in tomorrow.

Well, I hear good things. Performing miracles with scant resources.

Have you settled your differences with Amira?

I'm musing on giving her a chance, as you so rudely requested.

Well, if you didn't have such a rod up your backside

you wouldn't have to...

-What's so funny?

-Thought you were going to have a stroke in theatre.

So did I!

Took me an hour to build up the courage to come in and say that.

Truce?

Truce.

So how's things at home?

Why do you ask?

It's just you've been a little bit tetchier than normal lately.

Well, Jonny's having to pull double shifts

because of the nursing shortage.

He's barely seen Emma these last two months.

I thought that would suit you. I'm practically a single parent.

Welcome to my world.

Not to mention trying to run a ward on a shoestring.

I'll say it again - welcome to my world.

Look, I've raised all your issues over staffing levels with the Trust.

Believe me, you're not on your own on this...

..and I'm sorry if I was a bit heavy-handed with you earlier.

It's been a very long time since someone spoke to me like that.

All I want is for you to make an effort to give Amira a chance.

You never know, she might surprise you.

Halvsies?

I'll pass.

Can you prep Ms Knight for theatre?

We need to get that appendix out ASAP.

Just give me two minutes.

If this is about Mr Willis, you've got 30 seconds. Thanks.

-When did you get all God complex on me?

-All right. One minute.

-Ceraclydin, Petumoledin or Chlorothropid?

-Sorry?

I worked on this case recently where a girl was packed just like Gareth

and I'm sure they used one of the three to...

If he's still stable, then this isn't urgent, is it?

I've got no-one else to speak to.

All right. Run the bloods past haematology.

Get their take on things ready for Mr Griffin's return.

-Progress! Thank you, Mr Di Lucca.

-Close the door.

So our Romanian speaks English, does she?

Indeed she does and she apologises for her earlier behaviour

but you had freaked her out a little bit.

What did I say?

She's had to have several emergency laparotomies for numerous reasons

over the past eight years and it seems every time she comes to

from surgery, that something else has been taken from her body.

Any idea what's wrong with her?

No, there's no triggers, no real rhyme nor reason for the attacks,

apart from the fact that that she's got elevated creatinine levels.

So that suggests a renal issue.

Well, yeah, but then there's the list of unrelated symptoms,

which is as long as your arm

and ranges from arthritic joint pain through to pleuritis.

So, your thoughts?

Maybe it could be an immune system issue where the white blood cells

are randomly attacking the host,

but I think it's probably more the case that it's systemic lupus.

I think someone has finally found their research project.

-You don't mind me working on this?

-No, not at all.

I haven't seen you this enthused for ages.

I think you've finally got your mojo back.

How's "Nursegate" going?

I'm guessing you're in full retreat given that she's still here?

Just put her to work, Mr Valentine.

Oh, I have and she's doing admirably so far.

Mr Bale, mitral valve regurgitation.

-Dr Ford has asked for a post-op chest X-ray.

-Thank you.

-Can I get you a coffee, Ms Naylor?

-I'm fine, thank you.

Oliver? It's Mr Valentine to you and you're not here to wait on us.

Just get that X-ray sorted.

I'm guessing your spat won't be over any time soon then?

I've just been up to haematology and they're looking into the drugs

I recommended for Mr Willis's clotting issue.

I thought Raf said just to get their take on things?

Well, yeah, I did, with a little input from me.

Do you think it's wise going over Mr Griffin's head like that?

-What harm is it doing?

-Donna.

I'm just trying to lighten the load before he returns.

Look, I was thinking about what you said

and he'd have read the case notes.

If he thought there was an issue, surely he would have spoken to me.

-Yeah, that's exactly where I'm coming from too.

-Good.

Well, I guess we just have to wait it out

and see what he says when he gets back.

I hope he's OK.

So we have established that the patient was admitted with

an ischemic leg which led to an amputation.

And that, during treatment, sepsis developed, leading to her death.

Do you agree, Mr Griffin?

I would.

And what started that chain?

A delayed angiogram.

The on-call radiologist that day was...

Was very stressed because she was very overworked.

Would you care to explain?

It was around 11am

when I placed the call to request a CT angiogram.

And her response to your request?

It wasn't considered a priority.

There'd been a MAJAX that day and so, if we wanted the angiogram done,

we were looking at a wait of several hours.

Leading you to reach the conclusion

that Mrs Warren was at insufficient risk

and that the CT angiogram can wait until later that day.

Did you take any further action?

Such as?

Run another doppler or prescribe a blood-thinning agent?

Yes, it's standard procedure to prescribe either heparin

or warfarin, so, yes.

Should that prescription have been put in

the patient's medical records. Of course.

Then why wasn't it in her notes?

I'll let you into a little secret

but if you tell anyone, I'll have to kill you.

I'm starting to believe that.

It's the accent. I sound like a Bond villain.

My name is Adina.

Well, I shall also let you in on a little secret.

My name used to be Darren but I changed it to Dominic,

although I've always really fancied being called Stefan.

Your secret's safe with me.

Pleased to meet you, Stefan.

So who's the gorgeous kid?

-My daughter. Take it you've been through my stuff?

-Absolutely.

I also drew on your face during surgery. Took some amazing selfies.

So, how do my insides look?

Like a patchwork quilt if I'm perfectly honest.

But you can fix me?

I'm not going back to die in front of my daughter.

She's young enough not to remember me

and well taken care of if push comes to shove.

So this is the interesting case study you've been hiding from me?

-Mr Levy seems to think you've backed a winner.

-Excuse me, Adina.

What do you think you're playing at? I haven't mentioned that to her.

Just curious to see what I'm up against as you've been so secretive.

Dominic!

OK, Fredrik, can you get someone from ENT up here, please,

to help cauterise this?

Thank you. Has this happened before?

Cathy, can we tell Mr Levy we might have a vascular issue here

and can I get an ANCA test and some cross match just in case

we need to go to theatre?

-What does all that mean?

-Just means that you're a big wuss.

Now keep your head tilted forward, OK?

Charging at 150. Stand clear.

Shocking.

-Still no output.

-OK, let's go with adrenaline.

Is sodium bicarbonates being administered through that cannula?

Right, OK. Keep up the compressions. I'll flush the cannula with saline.

Good catch.

Adrenaline and sodium bicarbonate don't play well together.

They form solid matter.

-That's right, isn't it?

-Indeed. Charging at 200.

Stand clear.

Shocking.

OK, he's back in sinus.

Good job someone knows what they're doing.

No, she got to the nub of it pretty quickly.

Do you think she's going after you?

She's just doing her job.

There's clearly an issue here

and she's just trying to get to the bottom of it.

The thing is, I had to be somewhere that day

and, because of the delay on the CT angiogram,

I made sure to order tests and anticoagulants before I left.

And can you remember who you asked?

Unfortunately, yes.

PHONE RINGS Excuse me.

Haematology.

Griffin.

-Are you OK?

-Not really, no.

Did they give you a hard time?

I had a call from haematology.

It's OK. There's no need to thank me. I'm happy to help.

What do you think you're doing speaking to them on my authority?

Petumoledin or any of the drugs you mentioned for that matter,

will not help Gareth Willis whatsoever.

-But I...

-Clopidogrel reduces platelet count

but it's not a blood thinner like warfarin.

Look, you know the protocol.

There's a chain of command and it's there for a reason.

I was trying to give you options.

So today of all days you decide to stick your neck out?

I really don't need this, Donna!

I don't think I've done anything that wrong.

I'm sorry. I'm sorry.

I just...

Sitting back isn't really an option for me,

you should know that by now.

It's not normally an option for you either.

Well...

..no harm done.

Except I told his daughter we might be able to help him.

I can fix that.

But there's something else that we need to discuss.

There he is. My saviour.

How long will I be nil by mouth? You're starving me to death here.

Well, we do need to let your bowel have a bit of time to heal.

Just teasing. Been here several times before, remember?

Could murder a big, fat, juicy T-bone, though!

No banter, sexy man? What's up with you?

-I think I know what's wrong with you.

-Are you serious?

OK, let's have it then.

Dominic, I'm not scared of dying.

I just really want to know what's killing me.

The ANCA test that we did today looks for a certain type of antibody

in the blood which is a marker for vasculitis.

Your test came back positive.

Now, that, in conjunction with what I know about your medical history,

leads me to believe that you are suffering with something known as

Wegener's granulomatosis,

which has now been more conveniently renamed GPA.

What does that all mean?

What it means is that your own immune system

is attacking small blood vessels all over the body.

On doing so, it causes inflammation

which then leads to blood not being able to get to certain other organs.

It's an extremely rare condition...

..and, in chronic cases, is incurable.

So that's it, no silver bullet?

We can manage it once we get it under control.

You'll still be probably looking at

a lifelong intensive treatment programme,

but survival rates have come a long way over the last few years.

I really don't think that you're going to be a million miles away

from leading a perfectly normal life.

The best bit?

It's not hereditary.

Hey...

..at least we now know what we're dealing with.

You have no idea what you've done for me today.

You've finally given me peace...

..Stefan.

I'm not going to lie to you.

Your body has been through a lot over the last few years,

so you're going to need some intensive monitoring.

Or we could just fly to Vegas, go nuts? I'm totally up for that.

On one condition.

That you would agree to be my case study for a research project?

-Can't get enough of me?

-Something like that.

You should expect a rough ride at the inquiry.

Your testimony is going to be key.

-Right.

-There's no easy way to ask you this.

Did you arrange for anticoagulants to be ordered as I instructed?

It's not in the notes.

As you instructed?

Donna.

Ric, you didn't order any.

It's all I've been able to think about all day.

So you knew there was a problem, but you didn't speak to me about it?

I know that I was in a hurry to get away that day,

but you KNOW me.

I would NEVER leave a patient in that condition and put them at risk

by NOT ordering an anticoagulant.

I simply don't make those kinds of mistakes.

Neither do I.

Well, as Mrs Warren's Consultant,

the buck stops with me.

So...what do I say?

Tell the truth as you see it.

You've spoken to Amira about this?

I thought I'd speak to you first, given the circumstances.

I ordered the chest X-ray over two hours ago.

-You've checked with Radiology?

-No receipt of request.

-The patient?

Currently stable, but wondering why he can't go home.

OK. Reorder the X-ray and get to Radiology pronto.

I'll head her off at the pass.

-Hi.

-Got anything for me?

-No news from the front.

Why would you lie to me?

-What?

-Mr Bale's overdue X-ray?

OK, look, there was no harm done. The patient's fine.

Jac...

..go easy on her.

So this Junior Doctor of the Year thing

seems to be pretty much in the bag.

Rare and exotic conditions do not attract investment

from pharmaceutical companies.

Why do you seem to think anybody in their right mind...

I'd like to thank my mum, my dad, my friends, Mr Hanssen...

Don't you think you're jumping the gun?

Apart from the fact I just need to type the presentation up...

..no.

-He's got nothing.

-I gave her a chance and now I want her gone.

I can see that the X-ray was purely precautionary.

What difference does that make? She's messed up here.

This time, I'm going to go through the proper chain of command.

I gave her every chance as you requested.

And how is me sacking her going to help anything?

What do you want? Do you want a full NMC enquiry?

Do you want her career ruined? Do you want her kicked out of nursing?

Did I not explain to you that we are running on fumes here

as far as staffing levels are concerned?

Amira...

..very proudly told me she stopped Mr Valentine from making

a catastrophic mistake that would have most certainly led to a fatality.

Please just sort this out for me.

Look, pull her up, by all means, OK?

Record it as an untoward incident,

but make it part of her learning curve.

I'm supposed to just chalk this up to no harm done, crack on?

Jac, I thought we had a truce? It's a two-way street, Fletch.

I can't believe she hasn't been diagnosed until now.

-How did she take the news?

-Adina's a happy soul.

-So is this what you've been working on?

-Yeah.

The best we can offer her at the moment is plasma exchange and drugs.

We're just not equipped to deal with GPA-related illnesses here at Holby

-at the moment.

-So what's the plan?

Well, there is a professor in Newcastle

who is currently studying various auto-immune diseases.

Particularly where auto-antibodies are produced

against neutrophil proteins

resulting in blood vessel walls being destroyed.

So it's the same type of tissue connectivity issue

-that your patient has with GPA?

-Yeah.

I'm hoping that he'll share his research

and work with me on my case study.

This is really good work, Dominic.

I just don't think that GPA is the right kind of subject matter

for your proposal.

I had a horrible feeling you were going to say that.

It just isn't Junior Doctor prize territory. It's too specialist.

So what do I do?

Just send her up north and kiss goodbye to the Junior Doctor prize?

I'm going to make it my mission in life

to find you a fabulously interesting bowel-related cancer.

Great. Guardians of the colon.

Oh, come on, you've been so passionate about this.

I thought you wanted to create a lasting legacy for Arthur?

How am I meant to do that at the 11th hour?

You've got to ask yourself what you've learnt today.

What was it specifically about her case that has inspired you?

So there is no miracle pill?

Sadly no, but Nurse Jackson was

acting with your father's best interests at heart.

It was only when she checked in with me that she realised her error.

However, I take full responsibility.

We do have a complaints procedure

if you wish to take the matter further.

No, she was just trying to help.

MONITOR BEEPS

We may have a problem here.

Blood pressure's dropping.

The bleeding's overwhelmed the packing.

-We need to get him into theatre.

-Can we get some hands in here, please?

Dad!

Dad! You have to save him!

I can't lose my dad too!

-Step back.

-Dad!

-Just let them do what they have to do, OK?

I must say,

I was extremely impressed by your choice of supervisor.

Nina chose me actually.

Chose you or the project?

The project wasn't on the table when she made her decision.

Should we continue?

I don't think Mr Copeland will be joining us.

KNOCK AT DOOR Come in.

I'm here. Sorry.

I got caught short with a burst appendix.

Shall we begin?

Thank you.

More suction, please.

Do we have cross match and clotting?

Eight units, but he's bleeding out fast.

Stand by with some Group O.

Make sure he's got platelets onboard

and he's had some tranexamic acid.

Where's it coming from?

There. There's a tear in the pelvic sidewall vein.

We're going to have to under-run the sacral vein. Clamp, please.

3-0 ready.

The sutures aren't holding.

We're going to have to use the staple gun.

Try and get some staples in the bone.

This is risky surgery, if you don't mind me saying.

Do you have an alternative plan?

Use a patch and hope it holds. Pack him again...

That's going to be a temporary fix at best,

plus he might not even make further surgery.

No. Sitting back is not an option for me, Mr Di Lucca.

So, in your opinion, you were happy with the care

Mrs Warren received throughout her stay on the ward?

She received the same level of care any patient would.

That's not quite what I asked you, Nurse Jackson.

Can we keep this specific to the case in question, please?

I was with Mrs Warren for the majority of her time on the ward

and I saw nothing untoward.

Nothing you would class as detrimental to her care?

I'd have spoken up if I had.

You would have questioned a doctor?

Even one as senior as Mr Griffin?

As a senior nurse, I take patient care very seriously.

If I'd have thought the patient was at risk, then...

I see from your statement that you and Mr Griffin are old colleagues?

That's correct.

And that you've recently returned to nursing

after an absence of six years.

I've had refresher training and consider myself competent,

if that's what you're getting at.

That's good to hear.

So you never felt under unnecessary pressure that day or was asked

to perform tasks or make decisions that you weren't qualified to do?

That's never been the case. We're a team, a unit.

Everyone knows their place and gets the job done.

But on occasion, mistakes are made?

Systems are in place to nullify such incidents, but...

..we're only human.

OK, I only have one further line of questioning.

BP is on the rise. Looks like you've got this.

Let's save the back-slapping for when he's awake in recovery.

I can close if there's somewhere that you need to be?

And leave you short-handed again?

It has been a bit of a learning curve

but I need to get used to the pressure down here again.

With great power...

..comes great responsibility.

I am really sorry that I didn't put Donna straight today.

If Emily decides to take things further, I'll come forward.

You'll do no such thing. He's my patient.

OK, well, at least let me close up and do the post-op care.

I believe you're needed elsewhere.

So having read your portfolios, yours albeit briefly, Mr Copeland,

I think I am now ready to give you my thoughts, for what they're worth.

Fredrik, your chosen subject matter

of Pancreatic Laser Ablation I find fascinating.

It is a technique that in the future could well extend

the lives of those with such an incurable cancer.

So you support my project?

That's not quite what I said.

Explain?

I believe it's a technique that has already been tested

so that it will support human trials.

I don't really see what contribution you could make

given the paltry sum available to you.

You're simply hitching your star to their wagon.

I want better than that for you.

If you wish to continue with the project, I will support it

but I would urge you to take this opportunity

of reconsidering your submission.

So...

..I suppose Mr Copeland here gets a gold star just because

some runaway happens to fall into his lap

with something rare and exotic?

Actually I'm investigating the study of bowel resection techniques and

the physiological and psychological effect it has on patients.

What about your dream patient?

She might have inspired the idea, but I very quickly realised

I was out of my depth with her case.

That takes a certain maturity, Mr Copeland.

Bowel resection techniques are hardly ground-breaking.

Yes, well, they might be mundane to you,

but think of the amount of people that it will help.

This isn't just about a prize for me.

This is about more than that. Mr Copeland...

All right, look, this might not be "sexy" medicine

but in my time here I have had the opportunity to work with

some of the best surgeons this hospital has to offer, or has ever

had to offer, and if there is one thing that I have learned, it's that

you support each other, you move forward together, always improving.

If you are looking to pan this project

because you believe there is a lack of imagination, then...

Mr Copeland, I was just going to say your soapbox is not needed.

Your portfolio itself was enough to convince me.

You have my full support.

In Mr Griffin's testimony, he has stated that he requested

anti-coagulants to help Mrs Warren's blood flow to her leg

whilst she waited for her CT angiogram.

Do you have any explanation as to why this was not in her records?

Nurse Jackson, it's a simple enough question.

As the senior nurse on duty that day,

do you recall blood thinners being asked for by Mr Griffin?

It was a busy day and requests were coming in thick and fast.

Either Mr Griffin didn't ask for the anti-coagulants

or his request was ignored.

So, I'll ask you again...

..do you recall Mr Griffin

prescribing Mrs Warren's blood thinners?

I have no recollection of Mr Griffin prescribing anti-coagulants

to Mrs Warren.

Thank you for your attendance, Nurse Jackson.

What's going on?

Ms Naylor's cancelled all her electives until further notice.

-Emergency cases only.

-Why?

She feels we have insufficient experienced staff to safely

-treat patients. So until that changes...

-Where is she?

-In her office. Left orders to not be disturbed.

-Good luck with that.

Amira.

Amira, hang on.

Amira?

What's Jac said to you?

More like what's she's done to the whole ward.

It's clear she blames me for what's happened with this missing X-ray.

-And who told you that?

-She doesn't have to.

I feel like I've let you down again, Mr Fletcher.

I...I won't be coming back.

Congratulations on your ground-breaking entry.

Bowel surgery - how nouveau.

Seriously, look, all joking and competitiveness aside,

do you not just think he was being genuine?

-You can still pursue it, you just need to find...

-Shut up!

Don't...

..patronise me.

Of course you'd agree with him.

Jac.

You're putting patients at risk.

You think by wasting bed space and theatre time,

that's actually helping the situation?

Someone had to make a stand.

Well, for the record, your stand has just cost this hospital a nurse.

She was never fit for purpose and you know it.

You know what, I expected a witch hunt about Amira,

and I always expect a battle from you, but...

A strike on electives?

That's just not like you.

You always put the patients first, so what's going on?

This can't all be about Jonny.

There's more to it, I know there is.

It's like you've given up.

And...

..why are you hiding in here?

I don't know.

Look, we've all been going through a pretty grim time of it recently.

And there were times in my life that I went to some very dark places.

If I didn't have a friendly ear or 12 to listen to,

I don't know what I would have done. So, look, Jac, you and me,

-we've got to stick together more than ever.

-No.

We're not friends.

-Jac, just hear me out...

-Just... This conversation is over.

Come on!

So you can't fix me but you know a man who can?

-Hopefully they can.

-Newcastle is so far away.

You're going to love it, it's a total party town.

Just no-one to party with.

Well, post-op recovery is all organised.

You shall be staying here at Hotel Holby for at least a week,

three square meals a day.

Stop it, I'm still nil by mouth. Starving!

I would quite like to phone your family, if I may.

I won't be a burden, life goes on.

OK, well, I guess that's your choice.

Come here, you've got a little something on your...

Anything?

Not even a tingle.

No point taking you to Vegas then!

I'm sorry.

You did what you had to do.

So where do we go from here?

Depends if Ms Mensall concludes that Elaine Warren's death was avoidable.

A first offence, what are we looking at? A slapped wrist, right?

I saw you talking with her son today.

Yeah, he came in...

Please, everyone, do take a seat.

I'd like to thank everyone involved in this inquiry

for your cooperation today.

The law states that unnatural deaths must be investigated...

..and that is why this inquiry is being heard.

You didn't kill her.

I didn't save her either.

Having taken into consideration all of the evidence given

over the day...

..I feel compelled to suspend this case...

..and refer the matter to the CPS in consideration of

criminal charges relating to gross negligence manslaughter.