Day 602

Victoria and Adam are Elaine’s little kids. Her husband Martin is an airline pilot. In March 2005 Elaine went into hospital for a routine operation on her nasal sinuses. Unfortunately things didn’t go as planned and she died after 13 days due to an anaesthetic mishap. Just a routine operation turned into a tragedy for this lovely family.

The inquest brought out the fact that the anaesthetist was unable to establish a patent airway on her after anaesthesia was induced. He was helped by a surgeon and another anaesthetist and still they were unable to keep the oxygen levels in Elaine’s blood at a safely high level.

At the inquest it was also evident that in that situation the anaesthetist ‘lost control’ and it was unclear as to who was in charge. Awareness of time and seriousness of the situation were lost too. There was a clear breakdown in communication between team members. The decision making ability, situational awareness and ability to prioritise were all inadequate.

It was interesting to note that the nurses in attendance knew what the next step should be and they brought the appropriate kit into the room but they were not paid any attention by the doctors. There was a clear lack of assertiveness on the part of the nurses. The inability to listen and be open to suggestions on the part of the doctors possibly contributed a great deal to Elaine’s death.

Human factors are responsible for 75% of aviation accidents. If we were to look at the mortality caused by human factors in the medicine, it would be equivalent to 2 plane crashes per day.

“In short, human factors, not technical inability led to my late wife’s death” says Martin. He went on to set up the Clinical Human factors Group in 2011, working with health care professionals and managers to make healthcare safer.

Thanks to Martin, the awareness of human factors has come into the forefront of medical practise and training. I have huge respect for the man. Victoria and Adam will know that although their mother died, many others will live due to the lessons learnt.

 

 

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