NHS trust responds to tragic accident

head of workplace development at a hospital where a nine-year-old boy died
after errors during an operation said communication with staff was a vital part
of trying to prevent a repeat of the tragedy.

Clowes died a day after surgery at Broomfield Hospital, Chelmsford, in July
2001, when an oxygen tube became blocked causing irreversible brain damage.

a five-day inquest into the incident last week, a jury ruled the death was
accidental, but noted ‘system neglect’.

inquest heard that anaesthetic tubes designed to be used only once were
regularly re-used, and staff were often unaware of safety guidelines laid down
by the Medical Devices Agency.

Groves, director of workplace development, Mid Essex Hospital Services NHS
Trust, which runs the hospital, said the whole organisation had been "very
chastened" by the tragedy.

trust used its monthly newsletter and cascade briefings to keep staff informed
about changes being made to working practices, operation procedures and the way
equipment was used in the aftermath of the tragedy.

said effective communication was also important to maintain morale in the weeks
and months following the accident.

organisation has made sure it had appropriate counselling for staff that wanted

think it’s about being honest with the organisation about where we have made
mistakes, where the NHS has made mistakes, and where we need to improve, said
Groves.  "The way you support staff
is by being honest with people and making the necessary changes," he said.

said the culture should not focus on where individuals failed, but rather where
the organisation failed and the steps needed to address the problem.

Quentin Reade

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