Readers of this blog, in fact everyone, is concerned that their well-intentioned actions could be the subject of scrutiny in legal proceedings. Whether a person is being sued (civil), prosecuted (criminal) or appearing as a witness to explain their conduct, the process and potential outcomes are frightening. But the upside is that the legal processes can reveal shortcomings and lead to improved practices. Employees may well be aware of the shortcomings in their workplace but cannot get change- but legal proceedings, or fear of them, may cause the employer to take action where the employees could not.
This blog is going to report on two recent stories and the reaction to them on social media. Neither of these events have yet lead to legal consequences but they are likely to; but staff and first responders should not fear those proceedings.
The first event happened in Sydney, Australia. A man went to Royal North Shore hospital for an appointment. He went to the toilet where he collapsed. He was located some 21 hours later and subsequently died.
- ‘Stroke victim left unattended in toilet for 21 hours dies‘ http://www.9news.com.au/national/2015/08/12/18/29/elderly-patient-left-undiscovered-in-sydney-hospital-toilet-for-21-hours#24wdYA3m6SMG8QkK.99
- ‘Coroner to investigate patient who died after 20 hours in hospital toilets” http://www.smh.com.au/nsw/coroner-to-investigate-patient-who-died-after-20-hours-in-hospital-toilets-20150814-giznr5.html#ixzz3irL6XJay
- ‘Man dies after being found unconscious in toilet cubicle at Sydney’s Royal North Shore Hospital’ http://www.abc.net.au/news/2015-08-15/hospital-stroke-victim-found-toilet-cubicle-dies/6699682
- ‘Sydney’s Royal North Shore Hospital amends protocols after man spent 20 hours unconscious in toilet’ http://www.abc.net.au/news/2015-08-12/man-spent-20-hours-unconscious-in-sydney-hospital-toilet/6693260
What concerns me is the reaction on social media – comments like “Last time I checked ‘checking public toilets’ was not in a nurses role description, good job blaming nurses once again” and “Response from the hospital, nurses did not check the toilets!” None of those articles blame the staff – they do say:
Dr Montague said nurses did not check the toilets when they closed up each day. That job was normally reserved for cleaners, but the toilets were not checked that evening.
That does not say the nurses should have checked the toilets- that was the cleaners work not the nurses. Neither do any of the articles claim that the outcome would have been different had he been discovered earlier but one has to infer that it may well have been as he only died some time after he was discovered.
Let us assume there is legal consequences here, a coroner will investigate and there may be civil action. A coroner may make recommendations regarding staffing, staff training for cleaning staff, perhaps a redesign of the toilets so doors and walls don’t go all the way to the floor.
If there is civil action the plaintiffs would have to prove the outcome would have been better had there been different procedures and that it would have been ‘reasonable’ to have them. Again the social media has debates about what or would not have been a viable alterative but should it go to court, then those matters will be calmly considered.
My point is that the community seems so indoctrinated to fear of blame that it is perceived that blame is being attributed here when that is not the case. Further already people are rushing to defend the ‘nurses’ and perceive ‘buck shifting’ when again there is no evidence of that. This is a tragic case and it does seem incongruous that a person was not discovered for 21 hours and the building was not properly secured when it was closed up. Rather than fear the legal outcomes, people and in particular the nurses and security staff, should welcome the inevitable coronial investigation. That may well make recommendations regarding staffing, training and toilet design to try to avoid a repetition rather than immediately see reporting of such an event as a complaint.
On a similar note is another case this time from the United States – ‘NTSB Criticizes Emergency Response in Tracy Morgan Crash’ (http://www.firefighternation.com/article/news-2/ntsb-criticizes-emergency-response-tracy-morgan-crash). The story relates to an investigation into a fatal motor vehicle accident on June 17, 2014. The NTSB (National Transport Safety Board) noted that the truck driver involved had not slept for 28 hours and that the passengers of the limousine were not wearing seat belts. The Board was also ‘sharply critical of the emergency response to it and are urging the state [of New Jersey] to establish minimum standards’.
So then there are comments like ‘So they don,t put on seat belts and blame EMS and Firefighters for their injuries . Bullshit!’ and ‘… must have someone to blame, but, not themselves. Volunteer some time in their local fire or ambulance.’
Again I fail to see any blame in this story. The deceased failed to wear seat belts and that contributed to their fatal injuries when the car they were in was struck by a truck. But the NTSB isn’t confined to finding only one causal factor, and if they find that there were “missteps on scene due to poor communication, lack of oversight, and nonstandard patient care practices” and to then recommend “the state Department of Health establish minimum training and practice standards for all the organizations that respond to emergencies” that does not involve blaming the responders. If it does reveal systemic errors, why should they not be identified and reported to bring pressure on the state to at least consider what, if anything they should do?
… called the [proposed] legislation well-intentioned and indicated it could help create a more coherent emergency response structure but ultimately said it would cost the state and towns millions of dollars. He also called for a comprehensive review of how the changes might affect taxes and volunteerism among emergency responders.
The NTSB can make recommendations (as can a coroner or Royal Commission) but it is up to the political leaders to balance the various competing factors to determine what to do.
Often enough I’ve argued that litigation can appear to be a futile waste of time and money and we should all be cautious of blaming individuals for outcomes that are the product of systemic failures. Fear of developing a litigation culture is all well and good, but we don’t want to go too far the other way.
Reporting, and investigating adverse events is important but merely reporting an event does not equate to criticism or blame of those involved. Investigating an event may well reveal shortcomings in practice, procedure or culture that can be addressed. Identifying those shortcomings is again not necessarily to blame nor to deny that actual outcomes may not have been caused by those shortcomings, the people in both these cases may have died with the best practice in the world, but that doesn’t mean there was best practice.
My concern is that we have created such a blame sensitive culture that people see blame being allocated where that is not the case, at least not in any of the articles cited. And a legitimate concern about the nature of legal proceedings has become an immediate adverse reaction to any suggestion that an event will be investigated. A middle ground has to be found.