Disaster at Bristol: Explanations and implications of a tragedy

Abstract

Recent tragic events at the Bristol Royal Infirmary represent a disaster for a number of different actors. First, and greatest, is the disaster for the bereaved families. Secondly, the unusually high mortality and morbidity rates exposed at the hospital unit suggest both clinical and managerial failures on behalf of practitioners and administrators. Thirdly, that the ‘scandal’ took almost a decade to uncover, and relied largely on the efforts of one individual, questions the institutions of medical self-regulation, and provides a graphic illustration of the culture of patronage embedded in British medicine.

This article attempts to unpack some of the issues raised by the ‘Bristol case’. After tracing some background, and examining the system of medical accountability and the nature of medical culture, I will ask how can we explain and attribute responsibility for such events? Adopting ideas from the study of disasters and errors permits a greater understanding. In particular, it is claimed that focusing the lens exclusively on the acts of the individuals in question hinders appreciation of the broader reality. For true learning and prevention, a larger picture must be taken, encompassing organizational and cultural aspects often ‘hidden’ in the quest to name and blame.

Key Words:

• accountability
• disasters
• errors
• medical culture
• medical profession
• self-regulation