The Airline Pilot Who Lost His Wife

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

 

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10 Responses to The Airline Pilot Who Lost His Wife

  1. Mike Leaf says:

    Unfortunate story. We really need to get to the point where the NHS can trully embrace the concept of learning from mistakes and systematising processes to minimise similar events happening.
    The Royal Colleges might be a place to start

  2. Yoav says:

    I have met Mr Bromiley on 2 occasions and he is a remarkable man.

    The first thing to say is that the incident took place in a private hospital, not an NHS one. This is not mentioned in your article.

    Secondly, rather than the typical “whistleblower” nature of your stories, the Royal College of Anaesthetists welcomed his input. Anaesthetists have always been at the forefront of patient safety and Mr Bromiley has contributed to many conferences and meetings on safety and has had a significant influence on practice in Anaesthesia in the UK.

    • Dear Yoav and Mike,

      Thank you for your comments. You are correct that the original incident happened in a private clinic, however the systemic problems that created the inappropriate response to Elaine’s emergency are generic to healthcare, whether private or NHS.

      The response of the RCoA has been very encouraging, and the anaesthetic community as a whole have really welcomed my input. This is at odds with the response from a couple of other Royal Colleges, who both talk about the importance of “clinical leadership”; but don’t appreciate that they can demonstrate leadership to their members by talking openly about safety issues.

  3. Daphne Havercroft says:

    Good news that the RCoA is responding constructively.

    Sadly at least one other college is not so helpful to the public. My opinion of the Royal College of Pathologists in relation to its involvement in the Bristol Histopathology Inquiry is that it is unwilling to openly acknowledge and deal with safety concerns about some of its members:

    http://www.whatdotheyknow.com/request/bristol_histopathology_inquiry_2#outgoing-132790

    “The Royal College of Pathologists will not release details of the
    pathologists who contributed to the review. The Royal College of
    Pathologists has judged that the sub-specialist reviewers it chose were
    sufficiently qualified and experienced to undertake the work of reporting
    the specific cases allocated to them; naming them does not add to the
    findings of the College report or to the final Inquiry report.”

    I think it would add considerably to the report because the public would know whether the college reviewers were national leads in their areas of specialist interest.

    It doesn’t seem to concern the College that some of its members (national leads in their specialist areas of interest), who raised concerns, were not given proper opportunity to provide all relevant material and information to the Inquiry, including chronology of events, to enable meaningful consideration of each case.

    Nor does the College seem concerned that, the Inquiry Report did not confirm which pathologists’ diagnoses were accepted for informing patients’ treatment plans. This is a matter of great public interest.

  4. Brian Dolan says:

    Over the last couple of years I’ve used the DVD ‘Just a routine operation’, kindly sent to me by the NHS Institute, during the session on patient safety, part of a course I’ve been running for nearly 2,000 charge nurses in New South Wales, funded by their Ministry of Health. When I ask at the end of the DVD, ‘could something like this happen where you work?’, the universal response is ‘yes’, irrespective whether they work in hospitals, community, rural or metro, or have experience in the private healthcare sector. It leads to many constructive discussions on what lessons health can learn from other industries, such as aviation.

    As someone who is proud to be a nurse for the last 30 years (mainly in the NHS), slowly we are beginning to recognise the magnitude of the challenge that is patient safety. It is not before time and we have so much still to do, however it is through the humility, great dignity and decency of Martin Bromiley that we can learn to see better and do better….and in doing so, Elaine Bromiley’s death will not have been in vain.

  5. My teachers may be cringing in their grave if they hear stories like this and I feel sad because these are the doctors who are helping the politicians and the managers and made us loose the human face of medicine.
    I worked in pediatrics for almost twenty years and must have intubated thousands of babies and sick children and am proud to say never failed to intubate but have seen how and why doctors fail to intubate.

    We cannot blame only the doctors because these people are earning a living using their post-graduate qualification acquired by reading books and passing examinations. If you can learn to work as a doctor and offer treatment based on what is written in the textbook and following a protocol, then we could have developed a computer to do our job better.

    Unfortunately doctors who speak the truth are shunned and people like you suffer in the hands of “incompetent doctors” because they have mastered the art of making you believe what they say is true.

    If this bunch of “Incompetent Anesthetists” labeled their incompetence as “Failed Intubation” and allowed Elaine to die, then I think they must stop working as Anesthetists. I gave up working in pediatric registrar and re-trained the day my vision started failing and I struggled to visualize the cords without my glasses.

    Why and how this happened in UK?

    In 1980s, senior doctors were monitoring every move junior doctors did in the wards. As seniors we used to keep an eye on things that went wrong, discussed and often criticized and made sure the doctor in training was clinically competent. Inserting a cannula, intubations and learning how to approach a problem (clinical acumen) was more important than the certificates, courses and degrees they acquired.

    In 1990s a new breed of doctors emerged because the Government planned to increase the number of consultants from three to seven or twenty-one. A doctor who had the membership of Royal Colleges was made to work as “Consultants”.

    I have known doctors who were working as research registrars and pharmaceutical companies suddenly became consultants in the hospitals. These consultants were academics and had not worked (on call every second or third day for 24 hours) as registrar or senior registrar for years. They were not allowed to work for more than eight hours shift and were on call once every seven to ten days.

    How can you master the art of medicine, intubation or resuscitation if you don’t get your hands dirty? These doctors are cashing in using their qualification and not based on the quality of work they do. Unfortunately its people like you who get hurt and we can only stand by and watch.

  6. Kim Holt says:

    This was a really interesting tale of an individual who wasn’t looking to blame but to learn; or more importantly to help the health team learn. There are some positives in there but also some areas of concern that has been pointed out raise issues for the broader NHS and Private health care.

    There is also an issue of investigations or reviews that are not fully comprehensive or are selective in the information gathered, or lets say not objective? There seems to be some of that going on from what I have read, and also personally experienced.

    Clinical leadership is also at the heart of this. Was one of the issues here that there was not a clear team leader in the emergency situation? Hard to assert oneself in the heat of the moment?
    Leadership is a very interesting phenomenon, it is not assigned by a title, its earned and team members need to be confident in the leader, and allow themselves to follow. If there is dissent then there is chaos.

  7. A crucial point here is to think about why the more junior staff were not able to speak up. Clinical governance requires not just that everyone knows WHEN to speak up but also that they know HOW to. The more senior staff also have to know how to listen.
    The point is often made that health care staff can learn from the airline industry. Crew Resource Mamagement, as it is called, puts all aircraft staff through training so that they know these things. The NHS does not do this anything like enough, and is still riddled with hierarchies that tend to prevent communication.
    Correcting these problems will remain very difficult if politicians keep reorganising so any kind of corporate memory and collective learning is constantly disrupted by moving all the deckchairs.
    The only way to make whistleblowing work is to give everyone a whistle and train them to use it.

  8. Robert Walker says:

    There’s a great book called ‘The Checklist Manifesto’ by Atul Gawande. He’s a surgeon who saw the adoption of good practice from other professions – such as airline piloting – as a way to reduce errors and fatalities in medical practise. The biggest hurdles he had to surmount to get his ideas accepted were those of ego, pride and hubris among those who thought they knew better.

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