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Keogh review: A tale of warning signs missed or dismissed

14-May-2013 0:00
in General
by Dr. Jenny King

We note the findings of Professor Sir Bruce Keogh’s report with a mix of interest, sadness yet little real surprise. Once again it is a tale of warning signs missed or dismissed, from junior doctors right up through the NHS hospital hierarchy. I was reminded of the desperate case of Elaine Bromiley, brought into the public gaze in 2006 by her widower Martin Bromiley, a former airline pilot. Mrs Bromiley was a healthy 37 year old who died after endoscopic sinus surgery and septoplasty. One of the contributing factors was said to be a lack of assertiveness on the part of two nurses who apparently knew what needed to happen during the anaesthetic procedure when things started to go wrong. But they did not know how to broach the subject. It also brought to mind the recent downfall of George Entwhistle, former Head of the BBC whom the media commentators nicknamed “incurious George” for not asking enough, or the right questions about Jimmy Savile.  These two examples may seem unrelated but they are linked by the same theme – a culture in which the signs were there, but no-one spoke, no-one asked, no-one listened.  

The lessons from the Keogh review must not be confined only to those hospitals that are now the subject of special measures – all healthcare organisations need to be permanently vigilant, curious and often courageous in turning over the stones that may be covering a multitude of problems. Asking the awkward questions must become part of the culture, not alien to it.

In our experience there is no escape, ultimately, once risks to patients or to organisational governance are exposed. Finding the resources to support the appropriate routes to intervention is a major challenge, especially in the face of a growing NHS budget deficit. But as is so often said about the expense of recruitment “pay now – or pay later” or, in the case of the “do-it-yourself” organisations who field junior managers to sort out major dysfunction “pay cheap, pay dear”.

We are all paying dearly now.

Reference: Martin Bromiley “Everybody’s Business” conference at the Royal College of Surgeons England, 10 November 2006.
Click here to read Sir Bruce Keogh's report.


My opinions are my own and not necessarily those of Edgecumbe Group.

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