Only Human
For some time, I've wanted to write something about Martin Bromiley.
I've never met or seen Martin Bromiley (well, I don't think I have - I've got no idea what he looks like); the only reason I know of his existence is a combination of good fortune, Phil Hammond, and a thirty-minute programme on BBC Radio 4. Still, if anyone should know about anyone, it's Martin Bromiley.
Martin Bromiley is an English father-of-two. In 2005 he drove his 37 year-old wife, Elaine, into hospital for a routine operation. He brought their children, too; the couple wanted to emphasise that hospitals are good places, where people go to get better. They dropped her off, and went home.
To shorten the account for a moment, the operation went wrong. The hospital told Martin Bromiley a few hours later that there had been a problem. Elaine was already on life-support; she remained on it for a further 13 days, after which the machine was turned off.
It transpired that Elaine's airways had collapsed shortly after she was anaesthetised. Initial attempts to ventilate her lungs with an oxygen mask didn't work, and an unexpected blockage meant they failed to insert a tube into her lungs. In what was a fairly spectacular level of stoicism, Martin Bromiley accepted that his wife's death was a tragic freak occurrence, that it was "just one of those things". And things would probably have ended there.
However, during a conversation with the ICU specialist, he said that he hoped some lessons would be learned from the investigation. The ICU specialist told him that there wouldn't be one, unless a complaint was made.
But here's the thing. Martin Bromiley was a pilot, and was involved in "Human Factor" training. This is standard procedure for an airline; 75% of all incidents in air travel are due to human error, as a result of which they allow for it in their training. They manage human error, they put procedures in place to minimise its effects. A systematic series of investigations follows every single incident, as part of the ongoing procedures to prevent errors from occurring; when something goes wrong, airlines find out why. Bromiley assumed this would be standard procedure for a hospital, and was shocked to discover that it wasn't. So, he did what he was trained to do. He asked questions. An investigation did - eventually - take place.
It transpired that three consultants had been present, all of whom attempted to intubate, all of whom failed for unknown reasons. Of the four nurses present, two could see there was a problem. One booked a bed in intensive care, but was instructed to cancel it because she was overreacting. The other brought the equipment for a tracheotomy, but was ignored. The culture within British hospitals was - is - one of not questioning superiors. It was obvious to people within the operating room what was going wrong, and what should be done to stop it, they didn't feel able to intervene.
To put it another way; when his wife died, Martin Bromiley was shocked to find that no-one asked questions. And as it turned out, she died because she was in an environment where asking questions was not the done thing.
He could have sued, or written a letter to Gordon Brown, or sold his story to a tabloid newspaper; you wouldn't have blamed him for doing so. However, having realised that the system was corrupted, Martin Bromiley began trying to change it. He met, and cajoled, as many healthcare professionals as he could. He tried to unite the many people within the profession that thought the same way as him, but weren't aware of each other's existence. He became involved in a ridiculous number of organisations (here's one. And another. And another. There's more). He made videos, gave powerpoint presentations.
This is someone who could have been vindictive, or bitter. Instead, he tried to correct a system, and he might even win. He began by going wherever he could, asking questions. In the radio show I heard (To Err is Human, a great piece of work by Dr Phil Hammond, sadly no longer available online) the humbling thing about him was the lack of bitterness, or vindictiveness. He knew there was no benefit in apportioning blame. He just wanted to put things right.
If ever we needed a reminder of the value of questioning others - even more importantly, of questioning ourselves - then you can't do much better. Martin Bromiley's wife is just one person who died because people didn't ask questions. So at least, in the middle of all this, there's someone doing something important. It's a softly-spoken, modest man who just wants to tell his kids that their mother's death has changed things. That's the thing about heroes; they're usually the quietest people in the room.
I've never met or seen Martin Bromiley (well, I don't think I have - I've got no idea what he looks like); the only reason I know of his existence is a combination of good fortune, Phil Hammond, and a thirty-minute programme on BBC Radio 4. Still, if anyone should know about anyone, it's Martin Bromiley.
Martin Bromiley is an English father-of-two. In 2005 he drove his 37 year-old wife, Elaine, into hospital for a routine operation. He brought their children, too; the couple wanted to emphasise that hospitals are good places, where people go to get better. They dropped her off, and went home.
To shorten the account for a moment, the operation went wrong. The hospital told Martin Bromiley a few hours later that there had been a problem. Elaine was already on life-support; she remained on it for a further 13 days, after which the machine was turned off.
It transpired that Elaine's airways had collapsed shortly after she was anaesthetised. Initial attempts to ventilate her lungs with an oxygen mask didn't work, and an unexpected blockage meant they failed to insert a tube into her lungs. In what was a fairly spectacular level of stoicism, Martin Bromiley accepted that his wife's death was a tragic freak occurrence, that it was "just one of those things". And things would probably have ended there.
However, during a conversation with the ICU specialist, he said that he hoped some lessons would be learned from the investigation. The ICU specialist told him that there wouldn't be one, unless a complaint was made.
But here's the thing. Martin Bromiley was a pilot, and was involved in "Human Factor" training. This is standard procedure for an airline; 75% of all incidents in air travel are due to human error, as a result of which they allow for it in their training. They manage human error, they put procedures in place to minimise its effects. A systematic series of investigations follows every single incident, as part of the ongoing procedures to prevent errors from occurring; when something goes wrong, airlines find out why. Bromiley assumed this would be standard procedure for a hospital, and was shocked to discover that it wasn't. So, he did what he was trained to do. He asked questions. An investigation did - eventually - take place.
It transpired that three consultants had been present, all of whom attempted to intubate, all of whom failed for unknown reasons. Of the four nurses present, two could see there was a problem. One booked a bed in intensive care, but was instructed to cancel it because she was overreacting. The other brought the equipment for a tracheotomy, but was ignored. The culture within British hospitals was - is - one of not questioning superiors. It was obvious to people within the operating room what was going wrong, and what should be done to stop it, they didn't feel able to intervene.
To put it another way; when his wife died, Martin Bromiley was shocked to find that no-one asked questions. And as it turned out, she died because she was in an environment where asking questions was not the done thing.
He could have sued, or written a letter to Gordon Brown, or sold his story to a tabloid newspaper; you wouldn't have blamed him for doing so. However, having realised that the system was corrupted, Martin Bromiley began trying to change it. He met, and cajoled, as many healthcare professionals as he could. He tried to unite the many people within the profession that thought the same way as him, but weren't aware of each other's existence. He became involved in a ridiculous number of organisations (here's one. And another. And another. There's more). He made videos, gave powerpoint presentations.
This is someone who could have been vindictive, or bitter. Instead, he tried to correct a system, and he might even win. He began by going wherever he could, asking questions. In the radio show I heard (To Err is Human, a great piece of work by Dr Phil Hammond, sadly no longer available online) the humbling thing about him was the lack of bitterness, or vindictiveness. He knew there was no benefit in apportioning blame. He just wanted to put things right.
If ever we needed a reminder of the value of questioning others - even more importantly, of questioning ourselves - then you can't do much better. Martin Bromiley's wife is just one person who died because people didn't ask questions. So at least, in the middle of all this, there's someone doing something important. It's a softly-spoken, modest man who just wants to tell his kids that their mother's death has changed things. That's the thing about heroes; they're usually the quietest people in the room.
posted by Nyder O'Leary at
22:11
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