James Titcombe is a name that is becoming increasingly familiar to many of you I suspect. James’s son died at Morecombe, and has been the subject of a number of investigations.

Last week the Parliamentary Health Service Ombudsman produced a report into the handling of the complaints about the death of James’s son. It’s a lengthy document, but well worth reading because of what it reveals about attitudes – attitudes that may exist in every one of us when someone ‘complains’.

At first glance it’s a very positive report that identifies failings and talks about ways to make things better in the future. It talks about the need to investigate properly, using Root Cause Analysis (RCA), but making sure that RCAs really get to the bottom of what happened. For example, it’s pointless saying that a person’s temperature was ‘low’, what you need to understand is exactly what that temperature was, or what gave the impression of it being ‘low’. RCAs need to be as specific as possible, whether about facts or impressions.

The report also talks about investigating using a human factors lens. It recommends that all curricula, training frameworks and continuing professional development should ensure that the workforce has the right values, skills and behaviours in relation to human factors principles and practices.

A good RCA will identify what exactly happened. An understanding of human factors gives us real insight into why people behaved as they did. When something bad happens, it’s usually the case that the people involved at the time thought they were doing the right thing. So why did it make sense to them at the time? Also remember that they themselves may not be able to understand or explain why it made sense at the time – this is where the skill and patience of an investigator, viewing the disaster through a human factors lens, is invaluable.

It’s also important to realise that without understanding human factors, we can make assumptions about what would and wouldn’t have been possible or obvious at the time the incident occurred. In my late wife’s case, it seems bizarre that a patient could have been on less than 40% oxygenation for over 20 minutes in the presence of three consultants, bizarre that the consultants couldn’t recall a nurse trying to raise concerns, bizarre that they didn’t resort to tried and tested methods to save the day. But stress alters our ability to perceive many things – confirmation bias, fixation, inattentional blindness – are all traits of being human, but traits we can ‘plan’ for when briefing and/or training to cope with emergencies

It would be tempting to not bother reading the rest of the report, but actually it’s a humbling experience and insight into what can happen when disaster strikes and you are one of those involved. ‘Off the cuff’ and emotional comments are made in a moment, but can lead to all sorts of consequences (the report quotes from emails used by the Trust regarding the complaint).

As you read the report (which also quotes from letters that James wrote to the Trust), you also get a deep sense of hurt, frustration, and anger. So was it the death of his son that created that, or the way in which ‘the system’ dealt with the aftermath?

There is also the claim of collusion in preparing the evidence, which the report did not uphold to be the case. It’s interesting that last week the police forces of England and Wales received new guidance stating that they are not allowed to compare notes prior to responding to a potential complaint against them. The official reason is that it’s been realised that this previously officially allowed collusion undermines public confidence. Although in James’s case that complaint wasn’t upheld, how often have you heard people say that professionals often ‘close ranks’?

Many years ago I witnessed an aeroplane accident, a mid-air collision in which remarkably no-one died. Yet as the minutes passed, it became clear how the conversations of my friends around me were starting to alter what had happened. Perception was influenced post-event. Immediately writing down recollections before inadvertent collusion happens is the only way to feel we’ve done our best to learn.

My overall feeling after reading the report is one of sadness. Sadness that such a tragic case – the loss of a young life – has become embroiled in the handling of the aftermath. If there is one thing to learn from this, it’s that when something terrible happens, it’s beholden on all professionals to be completely open and honest from their own individual perspective, and to do so with the hope of learning. It should be a core value. In the short term, it brings some sense of everyone working to ensure it never happens again. In the longer term, it gives the best chance of making sure it never happens again.

As professionals – wherever we work – that’s what working and living with integrity really means.

Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group, www.twitter.com/MartinBromiley

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