Friday, July 02, 2010

Airline pilot vowed to improve NHS safety culture after his wife's death

Articles at Wales Today by Madeleine Brindle of the Western Mail, on 28 June 2010

Airline pilot Martin Bromiley is now helping the NHS in Wales to put patient safety at the forefront of everything it does and prevent future fatal mistakes after his wife Elaine died because of clinical errors in her hospital care.

Elaine, aged 37 was admitted for a routine sinus operation, but never regained consciousness and died 13 days later.

After her death, Mr Bromiley was told by the ENT surgeon that they couldn’t have foreseen the complication and that they’d made all the right decisions, but that "it just didn’t work out." But when he realised the death would not be investigated unless he decided to sue he reflected on the aviation industry where all accidents are considered avoidable and investigations are thorough and routine, not to place blame, but so we can learn to ensure it doesn’t happen again.

He persuaded the director of the hospital unit where his wife died that an investigation was necessary. This showed that two minutes into the procedure his wife had turned blue and was struggling to breathe. Four minutes in and she was taking in only 40% oxygen. Six minutes in the team tried to put a tube down her throat. After 10 minutes in they still couldn’t get the tube in.

Guidelines stated this was an emergency, but the theatre staff continued with their attempts to intubate. This was a very experienced team, "In many ways they were the dream team to deal with something going wrong. So why didn’t they?"

The communication process seemed to have dried up. The lead anaesthetist lost control. Many of the nursing staff seemed to know what needed to be done but were ignored.

Mr Bromiley believes that inadvertent human error caused Elaine’s death and that systems need to be developed and people trained to reduce harm.

He said the NHS needs to look at how humans behave in the system and manage the structure around them to make it as easy as possible for the best service to be delivered.

“In aviation we accept that error is normal – it’s not poor performance and it’s not weakness. If you accept this then you can start to catch error; not hide and deny it. Then you can make a difference.

“If you work in healthcare and you feel something is going wrong you have to speak up. If the team in Elaine’s case had taken a minute to get as many views as possible from the team present, maybe it would have helped. Maybe she would still be here. We will never know.”

Mr Bromiley is now involved in the "1,000 Lives Plus campaign" which is involving patients to ensure that NHS Wales is working together to deliver a safe, quality, productive service.

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