by Martin Bromiley OBE

I’ve no doubt that our supporters will be aware of the tragic death of 6 year old Jack Adcock, the subsequent Court case and the more recent GMC ruling related to Dr Hadiza Bawa-Garba.

The CHFG have been looked to for our thoughts on the recent GMC ruling and the wider implications for a future learning and just culture in the NHS. Given the debate going on at the moment we feel it’s important to be clear about what experts believe a just culture might look like.

Despite my own loss, I simply cannot imagine the tragedy of the loss of a young life, compounded by complex investigations followed by the current and very public debate. This must be heart-breaking beyond most people’s imagination for Jack’s family.

When harm occurs and it is subsequently discovered to be – as far as can be determined – preventable, it is critical in our view that the principles of a just culture apply. The first priority must be to support all those affected. More generally, it is necessary to learn about all the causal systemic and human factors issues involved and to share the lessons widely to minimise the risk of further loss of life. Once that is done, it may be necessary through separate processes to consider if it is appropriate to take disciplinary or legal action against individuals or organisations.

It is absolutely right that gross negligence and reckless behaviour must not be tolerated and is deserving of sanction. It is also absolutely right that inadvertent human errors and systemic or contextual issues are learnt from without sanction. Honest disclosure of all aspects of adverse events must be encouraged to ensure future patients are safe. Ultimately, feeling safe to reflect and
report honestly is most likely to result in a safer system for all.

In my own field of aviation, when accidents occur, international best practice suggests there should be protocols and practices existing between Coroners (or equivalents), the Police, investigators and the judiciary. These ensure that the right people have primacy at the right time and that anything that could prejudice future learning, such as the admissibility of certain evidence, is considered very thoughtfully. These practices do not prevent prosecution for gross negligence occurring, but they ensure that a considered approach is taken. Throughout the industry there is a common understanding of rules, practices and behaviours that are required to ensure a just culture exists, to ensure future safety for all.

We welcome the review announced by the Secretary of State for Health. We hope that the review will take the views of all those affected by harm, including patients, families and staff, inclusive of those most marginalised, vulnerable or harmed. Bringing together organisations and individuals from both within and outside healthcare, including the Police, Coroners and judiciary would be a start to consider how we ensure future learning is not prejudiced using the development of appropriate protocols similar to that in aviation. If there is any hope to come from this tragic case it is that we might be able to move closer to a just and learning culture that is right for all.

In order to promote an HFE approach to maximise patient safety, CHFG has met with numerous individuals and organisations both in and outside of healthcare and we will continue to do so where appropriate.






Martin Bromiley OBE