Martin Bromiley doesn’t think he is a “whistle-blower”. He doesn’t believe he made great sacrifices and he didn’t have to fight anyone – he just wanted to help clinicians and the NHS do things safer. And he believes his journey has generally been supported by those he’s met, with a few exceptions.
His life changed on the 29th March 2005. Martin’s wife went in for a routine operation and problems had occurred, she was unconscious with a very real possibility of significant brain damage. 13 days later she was dead.
The clinicians involved had explained what had happened. It was “one of those things”; they’d “made all the right decisions but it just didn’t work out”. All Martin knew was that his wife was dead, and nothing would bring her back. He hoped that some lessons could be learnt so this wouldn’t happen to someone else? He says, “I now realise that what happened to Elaine is unbelievably common, it’s called normal human error. And through my background as an airline pilot I also know that developing systems and standardised procedures can give multiple opportunities to catch error before it becomes harm.”
In his moments as Elaine lay unconscious in her hospital bed he’d started to ask questions. He wanted to understand how her death would be investigated, just like accidents are in aviation, but was told it wouldn’t be, to paraphrase “that’s just not how things are done round here”. Martin wasn’t interested in blame, but also knew you can’t learn without proper, rigorous, expert investigation.
Martin persuaded an “outsider” to be brought in, Prof Michael Harmer who was then President of the Association of Anaesthetists of Great Britain and Ireland conducted a thorough review. This was followed by the Inquest. What was revealed was that Elaine; whose team was highly technically competent; died because of failings in teamwork, leadership and decision making, what in other “high risk industry” is referred to as “non-technical skills” or failings in “human factors”.
Elaine had been anaesthetised but for reasons still unknown it wasn’t possible to get air to her lungs, she started to turn blue and became “hypoxic”. Within a few minutes her anaesthetist and his assistant had started to attempt to “intubate”, in other words get a tube down her airway but their attempts met with failure. After 6 minutes, in response to a call for help others arrived in the Theatre, including another anaesthetist and the Surgeon waiting to perform the op. The three consultants continued attempts to intubate but soon this had degenerated to a situation known as “can’t intubate, can’t ventilate”, a recognised emergency in anaesthetics for which guidelines exist. These guidelines would suggest by this point (ideally sooner) that the best course of action would be surgical access to the airway, such as a tracheotomy. But, despite the Nursing staff around them trying to hint that this was the best course of action the consultants appear to have become fixated on intubation. Despite the ideal skill mix and equipment in the Theatre, Elaine died because they failed to bring the skills and knowledge available to the fore.
Martin believes strongly these weren’t bad clinicians, just clinicians unprepared for how their own normal human reactions might be inappropriate in such as stressful situation and with no systemic processes to help prepare or prevent such an emergency getting out of hand.
At this point Martin assumed that investigations such as Mike Harmers were fairly common, just as they are in aviation. So Martin went on line, he tried to find accident/incident investigation in healthcare, and found next to nothing. Maybe the NHS publishes internal reports so that clinical teams can learn? No.
Martin believes there are two problems. The first is that there are still very senior people who in his opinion don’t get it; they appear to regard safety failings as everyone else’s problem but their own. For example, they blame the European Working Time Directive as creating danger because it increases the number of handovers. This is true; but no one seems to have thought that maybe they should concentrate on developing systemic ways of making handovers safer in the first place. He was stunned at a meeting last year when someone raised the issue of junior staff struggling to speak up when they saw a problem. The president of one Royal College explained that it wasn’t a problem anymore, that it was only a problem in the old days! Martin felt he should tell that to the Nursing staff who watched Elaine dying yet didn’t know the words or have the confidence that would break through the mist of stress and get through to the Consultants.
And the second problem; that even today the NHS doesn’t seem to value proper investigation. In his opinion there are too many poor quality internal investigations which yield the same old “blame the individual” results. Often human behaviour is driven by the system in which you work. Martin believes you need fewer “high quality” reviews. Elaine’s death and subsequent investigation was published, by Martin, in an anonymous form in a number of places. A training DVD was also made. As a result of an investigation which cost maybe £5,000 and a DVD which cost £15,000 to make thousands of clinicians in the UK have learnt and changed their practice. Martin knows lives have been saved. But this process of learning has been down to individual passionate clinicians. The overall NHS “system” doesn’t quite know how to do this yet.
He still hopes that one day there will be a trial of a professionally staffed small organisation, perhaps called the “Medical Accident Investigation Board”. They will be asked to go in as independent investigators to help determine the cause of unexpected death. They will be trained as investigators in the same way as other professional accident investigation boards in other industries and will look not just at the individuals involved, but perhaps more importantly at the whole system. Martin believes that the vast majority of clinicians want to do a good job; but the system they work within is more like an old institution than a modern day safety critical industry. Ironically there’s a number of very forward thinking surgeons who support such a move. As one said, “It creates a win-win-win”. The patient’s relatives learn what happened, the NHS learn and change, and finally the other victims, the clinicians involved learn from what happened and hopefully will be able to move on in their lives, now better placed to make sure those lessons are passed on to the new generation through their own improved practice.
Martin Bromiley founded and runs a charity to promote an understanding of human behaviour in healthcare, it’s called the Clinical Human Factors Group, see www.chfg.org