When silence threatens safety: lessons from the first Canberra Hospital neurosurgical inquiry

J Law Med. 2004 Aug;12(1):112-8.

Abstract

Despite widespread institutional and professional support, the recommendations of the Bristol Royal Infirmary Inquiry may be insufficient to reduce patient risk from impaired senior medical practitioners. Using the First Inquiry into Neurosurgical Services at the Canberra Hospital as a case study, this article argues that the Bristol-type recommendations--which emphasise reformulation of clinical governance structures, including early reporting of "sentinel events" and compulsory clinical audits--will be ineffective without a reformed institutional ethos that encourages open transparency and respect for those committed to such processes. Such reformulation may need to commence in medical education and involve new strategies including the use of portable digital technology to facilitate self-assessment of performance and immediate reporting of adverse incidents.

MeSH terms

  • Australia
  • Cardiac Surgical Procedures / adverse effects
  • Cardiac Surgical Procedures / mortality
  • Cardiac Surgical Procedures / standards
  • Child
  • Decision Making
  • Hospital Administration / standards*
  • Humans
  • Legislation, Hospital*
  • Physicians / standards*
  • Quality Assurance, Health Care / organization & administration
  • Risk Factors
  • Safety / legislation & jurisprudence*
  • Safety / standards
  • Whistleblowing*