Robust NHS patient killed by disorganized and poorly-trained doctors

Elaine Bromiley kissed her husband Martin and their children Victoria, then six, and Adam, five. "Bye-ee," she called to them, waving as she was wheeled down the corridor towards the operating theatre. The otherwise healthy 37-year-old had suffered for years from chronic sinusitis, an inflammation of the nasal passages. Then, early in 2005, one of her eye sockets became infected. The threat of permanent damage to the optic nerve led her surgeon to recommend a minor operation to straighten the inside of the nose - a possible contributory factor.

Once they'd said their goodbyes, Martin and the children went home to wait for word that Elaine was awake and ready to see them all again. It never came. Two hours after she'd gone into theatre, Martin received a call from the Ear, Nose and Throat (ENT) surgeon to say Elaine was having difficulty waking up. Even then, Martin wasn't unduly worried. But when he arrived at the hospital, he was told Elaine was in intensive care, and, because she'd been deprived of oxygen during the operation, there was a risk of significant brain damage. The next few days were a blur as, numb with shock, Martin, with the help of friends, did his best to care for his family. Desperately anxious about his wife, he tried to maintain as normal a life as possible for the children, who continued going to school.

Meanwhile, Elaine was put into a medically-induced coma for three days to give her swollen brain a chance to recover. "I spent every minute I could with Elaine, holding her hand and telling her how much I loved her," says Martin. "The day after the operation was the 21st anniversary of our first date. I was told that the eventual outcome could be a full recovery, or that my wife could be alive but in a vegetative state - or any point between the two extremes. "My head was spinning. I couldn't grasp how life could change so quickly and in such a devastating way. I really couldn't see past the next day and had no idea what the future held for us."

Five days after the operation, a brain scan indicated little if any activity and Martin was told Elaine had suffered brain death. "It was like a TV screen covered in static: no shape, no texture, no colour to show that anything was working," he recalls. "Years ago, Elaine had told me that she did not wish to live as a vegetable. I made the decision that life support should be withdrawn and I prepared myself for a life without Elaine that I could not begin to imagine." Mrs Bromiley was observed for three days and then taken off life support. She survived for another four days, dying in the middle of the night when Martin was at home with the children. "I'd decided that they were the priority now," he says.

He had kept the children informed of their mother's progress, telling them "first that Mummy was going to be ill, just like Granny was when she had a stroke, but that she will get better". Then he had to explain that "Mummy wasn't going to wake up, she was going to die". Martin recalls those desolate days. "I just couldn't imagine how life would go on," he says. What Martin hung on to, he says, was his professional work ethic as a pilot. He took it for granted that - as is routine in aviation - an investigation would automatically be carried out. His hope was that at the very least lessons would be learnt to protect other patients in the future. He felt, if anything, comradeship with the operating team responsible. "I was 99.9 per cent sure that what had happened to Elaine could not have been predicted and that when the emergency occurred, the team did what they believed to be right but things just didn't work out."

When he discovered that no inquiry would be carried out unless he sued or made a complaint, he walked into the hospital chief executive's office to insist there was one. The subsequent investigation was headed by Professor Michael Harmer, a former president of the Association of Anaesthetists. The inquiry revealed that Elaine's operation was a textbook example of how surgery, carried out by technically proficient professionals, can go horribly wrong. The cause: human error. So much is made of the latest medical advances that it comes as something of a shock to learn that human error still figures significantly in modern healthcare.

Yet last month, the Chief Medical Officer, Sir Liam Donaldson, warned that the odds of dying as a result of clinical error in hospital are 33,000 times higher than those of dying in an air crash. "In the airline industry, the risk of death is one in 10 million. If you go into a hospital, the risk of death from a medical error is one in 300," he said. And yet it seems little is being done to improve those odds. Five years after chairing the inquiry into the deaths of 29 babies during heart surgery at Bristol Royal Infirmary, Sir Ian Kennedy, now chairman of the Health Commission, drew attention to the lack of progress. "It is almost as though avoidable deaths and injuries are accepted as part of the risk of care and treatment," he told a meeting of clinicians in London in July.

And it gets worse: the National Patient Safety Agency (NPSA), which was set up by the Government in response to the Bristol inquiry, with a brief to ensure that patient safety was a priority within the NHS, was recently described as "dysfunctional" by the National Audit Office. The agency has no idea how many people die each year as a result of medical error. It is currently under investigation, with a report on its future due out this week. The National Audit Office estimates that there may be up to 34,000 deaths annually as a result of patient safety incidents. But in reality the NHS simply does not know.

Contrast this with the approach taken by other high-risk industries. For years, businesses from motor racing to oil refining have recognised the dangers of human error, and the importance of communication and teamwork in dealing with emergencies. They have introduced what is known as Human Factors (HF) training, which teaches basic skills designed to promote safety. While much-prized technical skills are essential, they are not always enough in a fast-moving, high-risk situation. At critical moments, organisational and social skills are just as important. This means good communication and an ability to work together with each member of the team.

It appears that moments after being sedated, Elaine's airway collapsed, preventing adequate levels of oxygen from reaching her brain. Though potentially an emergency, the event is a recognised risk during an anaesthetic and, as such, should be manageable. Surgeons and anaesthetists are drilled to follow a series of steps at this point - beginning with a non-invasive attempt to get the patient breathing normally, and ending, as a last resort, with an emergency surgical procedure. This is usually a tracheotomy - where the surgeon cuts through the windpipe, inserting a tube directly into the airway through the throat.

At first the drill was followed impeccably. But then a problem arose: the surgical team tried to get a tube into the airway to help Elaine breathe, but encountered some kind of blockage. According to the drill, this was the time to consider doing a tracheotomy. Elaine, by this point, was turning blue in the face and one of the nurses fetched tracheotomy equipment. A second nurse phoned through to the intensive care unit to check there was a spare bed available.

But the three consultants appear to have made the sort of human error that is horribly common in crisis situations. They became fixated on what they were doing. The consultants also appear to have ignored the junior staff and remained intent on finding a way to insert a tube into the airway. The minutes ticked by. After 25 minutes, they were finally able to get a tube into her airway -but even then, the team failed to secure the tube and it was a full 35 minutes before adequate oxygen levels to the brain were restored.

At the inquest, held in October last year, the lead anaesthetist admitted that he had lost control and there was a dispute over exactly who was in charge of the procedure, making life-and-death decisions.

All of which could have been the end of the investigation. But Martin Bromiley had an unusual insight into the factors that led to his wife's death. He is both a pilot and a specialist in HF training, which has been mandatory for British pilots and crew since the mid-1990s. "Fixation is a normal reaction to stress. HF training teaches people that it's normal to carry on trying to take the usual action, even when it's clearly not working," he says. "But at some point, a decision has to be made to break out of that pattern of behaviour. The way to ensure that happens is for all members of the team to see it as their duty to speak out to keep the patient safe." There was no comfort in knowing that two of the nurses knew how to save his wife's life. "What they didn't know - and what HF would have taught them - is how to broach the subject with their bosses," he says.

"The same problem used to exist in aviation. It was common for the evidence from black boxes to show that junior members of staff had been aware that a mistake had been made and had either kept quiet or been ignored." Clinicians tended to view human error as a sign of weakness or the result of poor performance, says Martin. "Yet high-risk industries have shown that by accepting that it is normal to make mistakes, it becomes the team's responsibility to watch out for errors and catch them before they cause significant harm."

Martin began to ask questions and soon found that he was not the only person to be concerned about the risks of modern surgery. Indeed, for the past year the Royal College of Surgeons has been developing HF training courses in which surgeons have worked with experts from the aviation industry. Last month, it also organised a conference where leading doctors, nurses and managers heard speakers from the military, the oil industry and motor racing, among others, all described the dramatic impact on safety levels following the introduction of HF training. Martin himself also addressed the conference. "Patients want surgeons who can communicate well with them and effectively with members of the team,' says Tony Giddings, the Royal College of Surgeons council member responsible for patient safety issues and a former surgeon and trained pilot. "And there is a growing understanding of their importance within the profession. These skills are not unique to medicine; they are skills for life itself. They enable people to be confident and self-assured yet acknowledge they are not infallible. "Unless people have these skills intuitively, they need to be trained. Surgeons, anaesthetists, nurses and other members of the team can be trained together to develop these essential skills."

However, unless such training is mandatory, the surgeons who need it most won't participate, says Mr Giddings. It also needs funding. HF training could save thousands of lives every year, yet he says there is a reluctance at government level to commit resources to a scheme which could cost millions of pounds every year. "But however expensive mandatory training is, there is considerable evidence that human error in medicine is far more costly, both in human and financial terms." For Roger Goss, co-director of campaign group Patient Concern, there is no question that HF training must be implemented. "If the aviation industry uses this type of training, then that's good enough for me: flying is the safest mode of transport," he says. "Patient safety must become a priority in health care. It's not at the moment. Chief executives are constantly being criticised for failing to make it a priority, and instead focusing on keeping within their budget. The NHS has a moral obligation to do anything humanly possible to minimise the risks of surgery."

This week, Martin is meeting the Deputy Chief Medical Officer to discuss a number of initiatives. As he approaches a second Christmas without his wife, he is determined that his family's terrible experience will have a positive impact on the culture of surgery. "There is no question in my mind that Elaine's death will bring enormous change to clinical practice," he says with quiet determination

Source

***************************

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.

***************************