Birth Injury, Disabling Families & Enabling Human Factors

Transcription

1 + Accidents Recovery Resilience Reliability Michael Benson age 9 Birth Injury, Disabling Families & Enabling Human Factors Dr Dawn Benson

2 + Why parents pursue litigation on behalf of their children who had been avoidably injured at birth

3 What Parents Wanted From Litigation Wanting answers about what had happened; finding out the truth - parents saw through inconsistencies and often sensed a cover up Lessons to be learned make sure it does not happen again Wanted resolution - often felt professionals and organisations were dismissive, that the child was not worth an investigation that litigation would help them gain closure and recover Gaining financial independence of the state for support services

4 + We ve never been given a specific answer and that s one of my biggest regrets because actually that s one of my reasons for pursuing the clinical negligence claim, was that we could get some answers, firstly what happened and secondly to stop it happening again. I don t feel we achieved anything in that respect. We insured her future with the claim, we ensured she s got money to provide for whatever she needs for the rest of her life but I don t think we made any progress in getting any answers or changing anything for anyone else, which I had hoped maybe naively Just a bit of a nutcase now really. Susan Interview data

5 + Parents took the research into Patient Safety Organisational Psychology Human Factors

6 + Parents Wanted to make sense of what had happened challenged & rejected any idea that the injury was an accident philosophised about why what happened was not an accident

7 + Accident Waiting to happen It was an accident waiting to happen, they knew if was likely to happen cos the same thing had happened before and nothing had changed to prevent it happening again, in fact the team had become dysfunctional because of the past events Victoria Interview data

8 + Asking why & how things went so wrong Because the right people were not in the right place doing the right thing at the right time.

9 + First time might be an accident Perhaps an Act of God or Meaningless Coincidence

10 +Accidents Failures of Risk Management

11 + I don't blame the registrar, he made the decision to take one of the other ladies first and me second and the third lady third. I don't believe he made the wrong decision because I think had he taken me first, there was a good chance that if number one went second, she would be sat where I am. It was a Sunday night, the delivery suite was full to overflowing and three of us needed an emergency section. This is where the cost-cutting comes in because when I said why not have the obstetric theatre staffed every day? They turned round and said, it's not cost-effective. I kind of just lost the will to live at that point. It had got to be more cost effective to provide the staff than pay for litigation. The obstetric unit wasn't in use because they don't use it on a Sunday evening [to be cost-effective]. Susan - Interview Data

12 + Communication Hierarchies Team Work Situation Awareness Decision Making Leadership Managing Stress Coping with Fatigue Non Technical Skills

13 Mindful infrastructure for High Reliability Organisations Track small failures Resist oversimplification Be sensitive to operations Maintain capabilities for resilience Mindfulness Capability to Discover & Manage Unexpected Events Reliability Take advantage of shifting locations of expertise Adapted from Weick et al, (1999)

14 + Recipe for Disaster what parents said went wrong Fixated behaviours conditioned to follow propaganda of public health priorities rather then thinking holistically and independently Communication Barriers to effective communication were usually influenced by other elements Arrogance/hierarchies instinct to protect professional supremacy Resources - out-of-hours Teamwork disorganised, dysfunctional lack clear leadership, or a local lack of a team or leadership Decisions/actions decisions made under circumstances governed by the above elements

15 + High Reliability Parents Thank you

16 + Learning Accidents Trade Offs What We Don t Know About Incidents We Are Not Safe People hold the system together.