Last Line of Defence

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There have been references lately on LinkedIn to how useful, exemplary and positive it is to talk about one’s failures in terms of learning from mistakes. This demonstrates that success can follow failure, and indeed often does, if the lessons are sought, studied and used.

Admitting to error, however, is made more difficult in environments where there is a ‘blame’ culture, where an individual is made to ‘carry the can’ rather than the organisation taking the time to investigate, explore and think through all the contributors, all the causes, so that they can be remedied honestly and effectively.

But there are feared consequences to the latter approach. The organisation becomes vulnerable the more it becomes transparent, and in some situations where the public has to be faced, accountability must be accepted.

Nowhere is this truer than in the medical profession, illustrated by the recent sorry saga where the paediatrician, Dr Bawa-Garba, was hung out to dry by being struck off the medical register for having missed a diagnosis of sepsis in a child with Down syndrome. In fact, she was actually the last line of defence against an extremely difficult diagnosis that many, if not most, consultants will have missed at some time.

She had been coping with a high workload of other ill children, little or no senior support, agency staff, and a failed IT system. It’s no surprise that things went wrong. To her eternal credit, she immediately admitted to her own error of judgement. She admitted her failure. But instead of the profession, her seniors, investigating all the causes so that something could be done because lessons had been learned, she was dragged through the courts and to the General Medical Council.

Human error will always be with us and it is right that we should put our hands up when we fail. That should gain respect rather than total censure when usually there are many causal factors underlying the error. Medical practice, as with other skills and competencies, is a life-long learning curve. Error must be mitigated at all costs for the sake of the patients, but also for the sake of the practitioners who need to feel secure in admitting when things have gone wrong. Only then will they work in the ‘learning environment’ which healthcare should, must, be.

Young practitioners in any environment need to have confidence to own up to mistakes and come to an understanding of the subsequent remedies. They are the ones who, as they progress, carry the learning gleaned from the discovery of why that failure occurred. They can then support others from the basis of that knowledge.

Dr Bawa-Garba has eventually been allowed to continue her training. She and her learning from failure (which she admitted with dignity) would have been a loss to the medical profession and a bitter waste.

“Those who do not know or understand history are doomed to repeat it.”