I have recently re-read Malcom Gladwell’s excellent book, "Outliers". Like all good books there is always more to understand second time around.
His analysis of the Three Mile Island Accident of 1979 is worth repeating in full…
"…there was a relatively routine blockage in what is called the plant’s "polisher" - a kind of giant water filter. The blockage caused moisture to leak into the plant’s air system, inadvertently tripping two valves and shutting down the flow of cold water into the plant’s steam generator. Like all nuclear reactors, Three Mile Island had a backup cooling system for precisely this situation. But on that particular day, for reasons that no one really understands, the valves for the backup system weren’t open. Someone had closed them, and an indicator in the control room showing they were closed was blocked by a repair tag hanging from a switch above it. That left the reactor dependent on another backup system, a special sort of relief valve. But, as luck would have it, the relief valve wasn’t working properly that day either. It stuck open when it was supposed to close, and, to make matters even worse, a gauge in the control room that should have told the operators that the relief valve wasn’t working was itself not working."
The operators were unable to break out of a cycle of assumptions that conflicted with what their instruments were telling them. It was not until a fresh shift came in who did not have the mind-set of the first set of operators that the problem was correctly diagnosed. But by then, major damage had occurred.
As clinical negligence lawyers we often see, with the benefit of perfect hindsight, what could have been done and when. Afer a serious injury or death internal reports are required to be commisioned by the NHS. Some comfort can be taken by injured parties and families when a Serious Untoward Incident Report is prepared. They feel that their case is being taken seriously by "the powers that be."
The SUI report is designed to address systemic or individual weakness and prevent future negligent acts. In the past week, one of my bereaved clients has been asked to put forward the issues they would like to be addressed in a Serious Untoward Incident report. I can't recall this happening before. This is a small gesture but much appreciated.
Hospitals, like other organisations, need to develop a memory to prevent the same accidents occurring.At Three Mile Island, it was the fresh shift who diagnosed the faulty reactor. In the same way I think allowing patients , with their fresh perspective, to make comments, prior to the commissioning of an SUI, would identify issues perhaps not covered by the organisation under investigation.
James Bell is a Principal Lawyer in the Slater and Gordon's clinical negligence team. If you or a member of your family have a clinical negligence enquiry please call our expert clinical negligence solicitors on 0800 916 9049, fill in our short online claim form and one of our specialist clinical negligence team will be in touch.