PROFILE


Accidents will happen “


Adam Campbell learns how personal tragedy led airline pilot Martin Bromiley to found a charity dedicated to reducing the incidence of human error in healthcare


IT WAS the worst thing anyone would want to hear,” says Martin Bromiley, recounting the moment he was told his


wife, Elaine, was in intensive care. Only a few hours earlier he had dropped her off at a private hospital for a routine sinus operation. An airline pilot, Martin says that aſter the initial shock he very quickly went into “pilot mode”. “I thought the important thing now is


that Elaine’s life is saved. My focus for three or four days was very much about being there and doing the best I could to make sure that whatever could be done was done,” says the 52-year-old. It was 29 March 2005. Earlier that


morning, at 8.35am, Elaine had been anaesthetised in preparation for the operation. Almost immediately things started to go wrong. Increased tone in her jaw muscles was preventing insertion of the laryngeal mask airway. Four minutes later her oxygen saturation had deteriorated to 40 per cent and attempts to ventilate her lungs continued to be unsuccessful. Te consultant anaesthetist tried a tracheal intubation but this too failed. By this time there were two anaesthetists,


an ENT surgeon and at least three nurses in the room. Shocked at Elaine’s vital signs and colour, one nurse went out and booked an intensive care bed. Another asked her colleague to fetch a tracheostomy set. Both of these measures were considered over-reactions by the consultants as they continued to attempt intubation. Te bed was cancelled, the tracheostomy set unused. When an intubating laryngeal mask was finally inserted at 9am, Elaine had already gone 20 minutes with severe oxygen starvation. At 11am, Martin got the call to say


Elaine had been admitted to intensive care at a nearby NHS hospital. On arrival he was told she might have significant brain damage. A few days later, confronted by the reality of her situation, the decision was made to switch off her life support.


14 What happened next – a journey that


would lead to the setting up of the Clinical Human Factors Group (CHFG), a charity dedicated to reducing the incidence of human error in healthcare – was entirely unplanned but had much to do with Martin’s training as a pilot.


Not about blame First there was his discovery that there was no plan to investigate the incident. Te very idea was anathema to someone from the aviation industry. So he pressed the case, while making clear to the director of the private clinic: “this is about learning; it’s not about trying to blame anybody. My thought at the time was that the clinicians did absolutely everything they could and that there might be some small lessons that could be learned”. Te investigation and the subsequent


inquest, however, highlighted numerous areas where things should have been done differently. Generally, there had been a loss of awareness of time, of the seriousness of the situation, a breakdown in the decision- making processes and in communication among the consultants. Te nurses said they knew what was supposed to happen but they didn’t know how to broach the subject. Clearly, thought Martin, there were some


rather large lessons that needed to be learned. “I recognised that here were failings that had to do with human factors and non-technical skills,” he says – human factors being all the things that make people different from logical, predictable machines. As a pilot, he was used to an industry


where technical skills were rarely taught without an element of the non-technical. So that when pilots are taught about a new piece of equipment, for example, there will also be a discussion regarding why they might choose not to use it in an emergency, and how colleagues can help to make sure it is used effectively. “I suddenly realised that here was a safety-critical environment which doesn’t seem to work in the way that


other safety-critical environments work.”


Spreading the message With two small children to look aſter on his own, Martin decided to cut his flying time by 50 per cent. Tis meant he had the odd aſternoon here and there, and he kept coming back to this question of human factors in healthcare. So he began talking to people about it – academics, policymakers, clinicians. “I didn’t really have a plan but over two


years I built up a picture of some really good work going on in health. But these were really tiny pockets of work, and they weren’t connected.” He’d seen a human factors group


involving policymakers, academics and pilots develop in aviation in the 1990s, starting almost as a hobby, and eventually become part of the Royal Aeronautical Society, so he decided to organise a meeting in London. Perhaps testament to his powers of persuasion, 45 people from his list of 80 names turned up. Aſter that first meeting, it was suggested


that if they were to keep it up they would need some kind of capacity for booking meeting rooms, paying expenses, and that


SUMMONS


PHOTOGRAPH: GRAHAM TURNER/THE GUARDIAN


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