How Do We End the Culture of Fear? Little Boy, Jack Adcock, Is Remain a Pipe Dream Until We Create a Dead

comment‘ There must be a better way to investigate deaths. One that examines human factors and systemic problems. ‘That commands confidence and honesty NO HOLDS BARRED Margaret McCartney How do we end the culture of fear? little boy, Jack Adcock, is remain a pipe dream until we create a dead. This is horrendous, culture where human error is seen as and accounts of the normal, inevitable, and as a source of background to the case important learning.” Aclearly show mistakes As Bawa-Garba’s reflective notes and shortcomings that could and were used as evidence against her in should have been avoided. But how? court, such a culture is unlikely any Jack’s treatment included clinical time soon. And the words of Mr Justice mistakes and numerous systemic Ouseley, giving the leading judgment ones, particularly regarding staff on the case in the High Court, are of absence and IT systems. This was particular concern: “There was no the “Swiss cheese” model writ large suggestion, unwelcome and stressful and fatal: the holes in the system aligned and let though the failings around her were, and with the tragedy happen. workload she had, that this was something she had The overwhelming feeling among many doctors not been trained to cope with or was something reading accounts of the case background is, “There wholly out of the ordinary for a year 6 trainee, not but for the grace of God go I.” There’s no suggestion far off consultancy, to have to cope with, without that Hadiza Bawa-Garba was doing anything except making such serious errors.” This seems to imply working hard in different circumstances. that doctors can be trained to have limitless Will striking her off the medical register ensure that capabilities. None of us can be. a death like Jack’s can’t happen again? I don’t believe There must be a better way to investigate deaths— so. Professional regulation and accountability one that examines human factors and systemic are vital. So, too, is patient safety. But the way we problems, which insists on evidence based change administer the two are often at odds. and can also command the confidence of bereaved The regulation of doctors is an adversarial families, as well as honesty from the medical system that seeks to deliver blame and sanctions profession. to individuals. Blame and sanctions clearly have A culture of fear is looming, but it needn’t be this their place. But it’s taken a long time for us to way. Doctors, patients, and families should be able regard human factors as the problem in many to work together to make systems safer. We need to medical errors and safer systems as the solution— move forwards, but this judgment risks taking us as well as outstanding efforts by people such as far back. Martin Bromiley, who founded the Clinical Human Margaret McCartney, general practitioner, Glasgow Factors Group, a charitable trust that promotes [email protected] best practice around human factors. As the group Follow Margaret on Twitter: @mgtmccartney says, “A safer, more reliable and efficient NHS will Cite this as: BMJ 2018;360:k443 the bmj | 3 February 2018 191 PERSONAL VIEW Helgi Johannsson and William Rook Avoiding blame and liability is vital to creating a safer NHS Medical law needs to be urgently reformed to allow doctors to reflect and to maximise learning from every mistake that is made ritish medicine has seen Written fatigue, and inadequate supervision much progress in the reflections are common contributory factors. development of an open can act as a and honest safety culture. sacrament of Overstretched system We report and investigate penance—an The death of Jack Adcock, for which Bincidents; develop action plans to Hadiza Bawa-Garba was convicted prevent repetition; and spread learning open, honest of gross negligence manslaughter, wider by discussion with colleagues, reflection in a is a tragedy. He received poor care not only within the hospital but at place of safety from Bawa-Garba. He also received conferences, in medical literature, poor care from an overstretched and even on social media. We include system that meant that Bawa-Garba our patients in this process—we are was covering for several colleagues, open with them, not only about what including the consultant in charge of happened, but also what we are doing the unit. She had to work in difficult to prevent it happening again. circumstances, with an IT failure Doctors are human and make and a junior team. There are enough mistakes. Preventing errors is at contributory factors to make any the forefront of our practice and doctor shudder and be thankful that reflecting on our mistakes makes it didn’t happen on their watch. us better doctors. When a mistake Medical training is rigorous and happens it is almost never because taxing—it attracts high performing of one person and there are always people who are constantly trying to circumstances that contribute to the do better and to learn. When we make error. Short staffing, high workload, mistakes, the pain of those mistakes ACUTE PERSPECTIVE David Oliver Should NHS doctors work in unsafe conditions? The case of Hadiza Bawa-Garba As is now well documented, Garba’s erasure, this case has far highlights a very specific issue with on the day that Jack Adcock died, reaching implications for an open no useful answer as yet. Bawa-Garba had just returned from reporting and learning culture. Where In 2016 the GMC made it clear in maternity leave and was working does this leave us? public advice that, if doctors believed in an unfamiliar unit, with an Commentaries on common law have that their workload, staffing, or off-site consultant. She was also suggested that system factors won’t supervision was unsafe, they had a covering staffing shortages, battling protect individuals from negligence professional obligation to report this IT systems, and supervising junior claims. The judgment in Bawa-Garba’s up the line and to have a clear paper However doctors new to paediatrics. appeal against her conviction and the trail of the concerns they had flagged. broken the The court decided, nonetheless, subsequent High Court ruling show But the GMC stopped short of system, that she (not her hospital or the wider that, however broken the system telling doctors to down tools if those doctors still NHS) was personally and criminally around doctors, they still risk being conditions put their patients’ or risk being held culpable. This led, after the GMC’s held personally culpable for failings. their own health at risk. The new personally decision to take its own Medical When Charlie Massey, GMC chief junior doctors’ contract, meanwhile, culpable for Practitioners Tribunal Service to executive, was confronted on the contains a clause that in “occasional failings the High Court, to Bawa-Garba Radio 4 Today programme about emergencies and exceptional (who had a previously unblemished whether doctors should refuse to circumstances” they may be asked record) being struck off the register. work in unsafe conditions, he evaded and expected to take on additional Whatever the rights and wrongs of the question. He spoke instead about duties and responsibilities. the criminal conviction and Bawa- their duty to flag any staffing and 192 3 February 2018 | the bmj can be unbearable. We search our Branch became operational last BMJ OPINION Richard Smith souls, blame ourselves, feel an year and its core mission is “to enormous sense of guilt. We talk to improve safety through effective and The continuing corruption colleagues as a form of counselling, independent investigations that don’t we reflect on what happened. Written apportion blame or liability.” of medical language reflections show our supervisors A doctor friend sends me a link and directors that we have learnt Conditions of work to a piece he has written for the from an incident, and also help us This is vital to learning from errors Guardian. I praise the simplicity come to terms with what happened. and creating a safer NHS, yet the law and clarity of the language and To a doctor, this process can act as and the GMC only look at a person’s suggest that, next time he sends a a sacrament of penance—an open, actions and do not take account of the piece to an academic journal, he honest reflection in a place of safety. conditions that person was practising uses the same language. “But will in. We feel that medical law has not the editors accept it?” he asks me. A step backwards undergone the same transformation I’d like to think that they’d prefer Bawa-Garba did exactly as the GMC as medical practice has regarding it, but I fear that his anxiety may be asks and reflected honestly on her liability and error. The law requires right. Why on earth should that be? performance. These reflections, urgent reform to prevent practitioners Almost everything, I believe, can be expressed in provided as evidence of learning from taking the full blame for system errors language that everybody can understand, and authors a critical incident, were then used and to allow us to maximise learning often use complex language because they don’t fully against her as proof of poor practice. from each incident. understand what they are trying to say. “Good prose,” This is concerning, and a step The death of Jack Adcock is a said George Orwell, “is like a window pane”: you see backwards for safety. Should doctors tragedy, but the way the investigation straight through it to what the author is trying to say. be fearful their reflections might be concentrated on individual failure, I accept that if writing for a technical audience then it used against them? Some may choose and used written reflections as makes sense to use their language.

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