we would like to thank you very much for all your hard work dealing with our case, it was very much appreciated. We were glad that we held out and not took the first offer - it was well worth the wait.

Help the Hospices

Why are mistakes repeated?

Once an adverse event has occurred, through human error or otherwise, why are mistakes often repeated? The most frustrating aspect of practicing clinical negligence is the number of similar cases that appear to be repeated over the years. Patients who have experienced something go wrong will always say they want to try to ensure that no one else goes through what they have whether they make a complaint or start litigation.

When something goes wrong, there is a sporadic reaction. There are a number of different ways in which incidents are acted upon:-

  • Internal investigations/Serious Untoward Incident (SUI) reports
  • External Investigations usually commissioned by the Strategic Health Authority
  • Complaints
  • Litigation
  • General Medical Council or other professional body
  • Health Care Commission (now superseded by the Care Quality Commission or CQC)

At what point does any one co-ordinate all of the information that the different forums hold?  The public costs of all these investigations are huge. The very least that needs to come out of these investigations is a central/focal record of the incidents and an ability for a statistical analysis of the same in an attempt to learn from disastrous events.

The NHS does not operate within a genuine market place. Internal mechanisms have been introduced to vary insurance premiums and monitor performance but the truth is that for competition to be effective it has to be genuine. Within our health service, there is no incentive to be better than the competition and whilst professional pride and the Hippocratic Oath drive practitioners to want to improve, clinicians are often constrained/hindered by the system in which they work.  In the commercial world, if an organisation, for example the aviation industry, makes a drastic mistake there is a rigorous overhaul of procedures in an attempt to learn from what went wrong with the obvious intent to limit danger to life but also to maintain a commercial reputation.

Nearly 10 years ago Robert Helmreich published an article in the BMJ urging the NHS to learn from the aviation industries approach to minimising risk and learning from mistakes.

> Comparisons with safety in the aviation industry