‘There’s plenty of evidence for a verdict of negligence.’
This is what Martin Bromiley was told by the coroner, on the first day of an inquest into the death of his wife.
Elaine was in hospital for a routine operation for sinus problems. She’d gone in at 8.30am comfortable, happy, a little nervous, of course, after kissing goodbye to her two kids.
She never woke up from the anaesthetic that put her down for an aborted operation, despite the best efforts of her medical team.
‘I said no, to the coroner’ was Mr Bromiley’s response. ‘By focusing on the individual or individuals, you fail to learn the lessons.’
It’s an astonishing response until you learn of this man’s profession. It’s a little astonishing still.
Mr Bromiley is a pilot, a captain for a major airline, and in his line of work most errors are traced to problems with ‘systems’ not people.
To understand why his wife died meant finding out what went wrong with the health system, not with the experienced anaesthetists, surgeon, technicians and nurses who failed to save her back in 2005.
Astonishing again, he calls them the ‘dream team’ for the emergency they faced when his wife turned blue and her oxygen saturation dropped to 40 per cent.
Today, the response of this husband in grief has a particular resonance with doctors as they consider the Bawa-Garba case.
Hadiza Bawa-Garba, a junior doctor, was convicted of manslaughter in 2015 following the death of a six-year-old boy. The Medical Practitioners Tribunal Service had given Dr Bawa-Garba a 12-month suspension, but this was successfully challenged by the GMC in the High Court, and the sanction was changed to erasure.
The case has rocked the medical profession, severely undermined their relationship with their regulator and left many in fear of their own careers.
‘I suspect, that was has really struck a chord over the Bawa-Garba case,’ Mr Bromiley told the BMA consultants conference in London last week, ‘is that whatever the rights and wrongs of the case, certain doctors identified with the clinician.’
Mr Bromiley campaigns, as the chair of the Clinical Human Factors Group, to make the NHS safer for patients without focusing blame on individuals for errors.
The group draws on lessons from the airline and other ‘safety-critical’ industries, such as nuclear, where mistakes can have catastrophic consequences.
Such industries must find ways to make it easier for its workers to ‘do the right thing’ and ‘difficult to do the wrong things’ by looking beyond technical skills, to those such as leadership, teamworking and decision-making.
He thinks the NHS has some way to go and a more complex challenge to improve safety than more simply structured industries like his own, where commands quickly pass down and are followed.
With so many agencies, commissioners, quangos, trusts and whatever else rubbing up against each other, the process of improvement will be a slow one in the NHS. It could take decades, he predicts.
Another trouble is that healthcare has ‘carried on and coped’ for some 30 years, Mr Bromiley says.
Doctors were and still are forced to work at risky speeds ‘not because you’re rash’ but because that’s how the job gets done in the NHS today.
‘We will have to influence all those national bodies to make the small changes which ultimately enable the frontline to do the right things and harder to do the wrong things,’ he says.
Doctors at the conference supported the idea of a ‘no-blame’ culture in the NHS. It’s an attitude they’ll hope NHS England, politicians and the GMC adopts too.
Given the experience of the airline industry and others where failures are tragic and catastrophic, it would be astonishing if they did not do so.
Keith Cooper is a senior staff writer at the BMA
This aviation industry model has been somewhat skewed to apply to medicine. Rather than being the passengers on the plane, who don't tend to know when the plane is about to go down, patients usually have a very good idea when their medical services/engineers are failing them, because in this analogy they are the plane itself. As such they supply their own early warning system of things going wrong or harms being done, but does anyone ever take any notice? The NHS only seems to take real notice after the plane has crashed.
Stop treating patients as adversaries, negating their concerns and stonewalling patient complaints, and we may all have a better health service. As for a 'no-blame' culture, what about the potential killers, paedophiles and abusers that lurk amongst NHS staff, as well as the generally bad apples? Like any other profession, (indeed like patients themselves), there are saints and sinners - saints who do their work well and go above and beyond, (probably in the majority, like all those altruistic patient ‘complainers’), and sinners who do their work badly and don't put in the effort they should, (comparable perhaps to those few patients who make vexatious complaints). Why should medics be exempted from any blame? No other profession would ask for this. The profession already fails to measure its own competence in failing to collect any meaningful data on misdiagnosis rates, and yet rushes to put any ‘medically unexplained symptoms’ (or as-yet-undiagnosed faults) down to the patient’s state of mind. Put that house in order and patients may be a little more willing to consider aspects of the aviation model. Go for a ‘no blame’ culture and from the patient’s point of view you may be destroying what little trust they have left.
Don't fly NHS.
Better not to fly at all.