‘Never let an aircraft take you where your brain didn’t get to five minutes earlier’ – this is a commonly understood concept amongst pilots.

While none of us can predict the future, the ability to anticipate problems that might arise given a particular set of circumstances is a basic requirement for many high risk jobs such as fire fighting, policing, armed combat and medicine. Doctors do have a licence to kill and they inadvertently use it when they can’t or don’t anticipate problems. Working backwards, if we don’t think the worst might happen, we don’t actively look for it and definitely don’t plan for it. Before we know it, it’s too late and the adverse outcome is inevitable.

Four days into it’s maiden voyage, the largest passenger liner of its time, the Titanic sank. It received six warnings of sea ice on 14 April 1912 but continued travelling near her maximum speed when her lookouts sighted an iceberg in its path. Unable to turn quickly enough, the ship suffered a killer blow and slowly sank over the early hours of 15^th April. 1635 of the 2224 people on board died.  The vast majority of the crew were not trained sailors but were either engineers, firemen, or stokers, responsible for looking after the engines or stewards and galley staff, responsible for the passengers. They were taken on at Southampton on short notice and had not had time to familiarise themselves with the ship. Knowing what we know now, is it surprising that the ship sank?

Saagar gave us warnings but we didn’t pick them up. Shouldn’t alarm bells be ringing nice and loud when a young man with a recent diagnosis of a mental illness is discharged in a hurry from Psychiatric services and he scores 27/27 on his PHQ-9? Whose responsibility is it to join up the dots?

When a plane goes down, the pilot goes down with it. When a patient dies, often nothing happens to anyone else. There is no black box. Tracks get covered, mothers over-react, things get forgotten and life goes on….