20 YEARS OF CS J
there is certainly still room for improvement.6 The National Patient Safety Agency (now sadly decommissioned) also introduced the concept of ‘never events’, producing a list of eight core never events in March 2009. The mindset towards safety saw a fundamental shift during this time. Discussion around the ‘culture’ in theatres also gained momentum – there was an increasing awareness that hierarchies can be a barrier to speaking up when things are going wrong. We now describe ‘incivility’ and ‘bullying behaviours’ as unsafe for patients, as well as being detrimental to the mental health of clinical teams. We know that temperamental and abusive behaviours are not an acceptable part of working in a stressful environment – even if it comes from the hospital’s most talented and skilled consultant. There is more work to be done, however. The 2021 NHS Staff Survey for England reported that almost 19% all NHS staff experienced at least one incident of harassment, bullying or abuse from their colleagues over the last 12 months.7
Learning from mistakes During my time as editor, I have interviewed a whole host of clinical experts, healthcare leaders and innovators in medical technologies. I have attended many healthcare conferences and exhibitions, and read numerous Government reports, inquiries and healthcare thought leadership papers. But if I was to choose one memorable moment, from a great many, that had a profound impact on me, it would be Clare Bowen speaking at a conference in 2009. Her brave and emotional testimony left a room full of perioperative practitioners – and myself – in floods of tears. Bethany, Clare Bowen’s daughter, tragically died during a routine operation in which a ‘pioneering new technology’ – a morcellator – was used for the first time by the surgeon, without proper training or experience, and without obtaining informed consent from her parents. Had Clare Bowen known about the additional risks on that day, she may well not have given consent. Human error was identified as the major cause of Bethany’s death, but
Safety issues have remained high on the agenda over the past two decades…
the Trust’s treatment of the bereaved family was also deeply shocking. Clare Bowen described what happened and the effects it had on her and her family. Reporting the tragedy at the time, The
Daily Mail headline read: ‘How gung-ho surgery by a trainee set off a chain of tragedy that destroyed a little girl’s family.’ (10 January 2009)8
documents containing gross inaccuracies relating to the family.9
Watching Clare Bowen
falter, holding back her emotion, and bravely continue on, to get her important message across, was deeply humbling. There were many lessons to be learned from her testimony on how to prevent incidents of this kind. The incident highlighted the importance of training and clear procedures when introducing new technologies into operating theatres. The doctor operating the morcellator on that day was a trainee and had never operated the tool before or heard of the procedure before that morning. The surgeon directly supervising him had never seen or operated the tool before either. Clare Bowen’s account also reminds us of
the importance of compassion and candour with families when things go wrong. The Trust failed to satisfactorily investigate the events surrounding Bethany’s death, and pursued a strategy of misinformation and obfuscation, including circulation of
There has been one major development that has helped surgery become much safer. The WHO safe surgery checklist (published in 2008) was mandated in the NHS in 2009, and use of the Checklist has been shown to reduce the rate of deaths and surgical complications by more than one-third.
NOVEMBER 2022
The family were also informed of her death by the surgical team, while on the ward in front of other patients and visitors, and were not taken somewhere private. Following disclosure of this devastating news, they were left to leave the ward and walk out of the hospital via the main entrance unaided and unsupported by any hospital staff. The hospital contacted the family the following day, and arranged for a bereavement services appointment, but the hospital later cancelled this visit, and offered no explanation. The family did not receive an apology other than in a letter from the Trust’s solicitors after the inquest, when they finally admitted liability – after a long and protracted fight for answers about the circumstances of Bethany’s death. I have read lengthy reports on some of the most disturbing healthcare scandals – from failures in care at the Mid-Staffordshire and Shrewsbury and Telford Trusts,10,11
to
scandals around medical devices – such as Poly Implant Prothèse (PIP)12 mesh implants,13
and pelvic which caused suffering
and trauma for many women. The Cumberledge report, First Do No Harm – The report of the Independent Medicines and Medical Devices Safety Review, (published in 2020) highlighted the fact that patients’ concerns – especially women’s – are not always listened to.14 Sharing the lessons learnt and
recommendations for change, over the years, has been a key focus of the journal. Hearing the experiences of patients and families touches us all and reminds us why ‘first do no harm’ is the first principle of delivering care. Raising awareness around human factors, safe cultures, and learning from mistakes remains as pertinent today. Human factors sessions at conferences
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