Sense of duty: Martin Bromiley founded the Clinical Human Factors Group to bring change to the NHS. Photo: Muir Vidler
Show Hide image

How mistakes can save lives: one man’s mission to revolutionise the NHS

After the death of his wife following a minor operation, airline pilot Martin Bromiley set out to change the way medicine is practised in the UK  – by using his knowledge of plane crashes. 

1.

Martin Bromiley is a modest man with an immodest ambition: to change the way medicine is practised in the UK.

I first met him in a Birmingham hotel, at a meeting of the Clinical Human Factors Group, or CHFG. Hospital chief executives, senior surgeons, experienced nurses and influential medical researchers met, debated and mingled. Keynote speakers included the former chief medical officer for England Sir Liam Donaldson. In the corridors and meeting rooms, rising above the NHS jargon and acronyms and low-level grumbling about government reforms, there floated a tangible sense of purpose and optimism. This was a meeting of believers.

A slow transformation in the way health care works is finally gaining traction. So far, it has gone largely unnoticed by the media or the public because it hasn’t been the result of government edict or executive order. But as Suren Arul, a consultant paediatric surgeon at Birmingham Children’s Hospital put it to me: “We are undergoing a quiet revolution and Martin Bromiley will, one day, be recognised as the man who showed us the way.”

Although I knew whom to look for, Bromiley was hard to spot at first. He wasn’t on stage, and he didn’t address the full conference. He was, I discovered, sitting at a table at the edge of the hall, in the suburbs of the meeting. You would hardly have guessed that the CHFG was a group he’d founded, or that everyone at the meeting that day was there because of him. Bromiley doesn’t fit with our preconceived ideas of a natural leader. He speaks with a soft voice. He doesn’t command your attention, though you find yourself giving it.

Neither is he a doctor, or a health professional of any kind. Bromiley is an airline pilot. He is also a family man, with a terrible story to tell.

 

2.

Early on the morning of 29 March 2005, Martin Bromiley kissed his wife goodbye. Along with their two children, Victoria, then six, and Adam, five, he waved as she was wheeled into the operating theatre and she waved back.

Over Christmas, Elaine had suffered a swelling of her face, connected to sinus problems that had troubled her for years. She was advised by a consultant that the only way to deal with the problem once and for all was to undergo a minor operation to straighten the inside of her nose. Bromiley knew of colleagues who had undergone the operation – the sinuses of pilots take a beating from sharp changes in air pressure – so he didn’t feel overly concerned, that morning, as he drove Victoria and Adam back to the family home in a peaceful Buckinghamshire village.

At about 11 that same morning he received a call from the ear, nose and throat consultant. “Elaine isn’t waking up properly from the anaesthetic,” said the doctor. “Can you come back in?” At the hospital, Bromiley was met by the consultant, who explained that there had been a problem keeping Elaine’s airway open after she had been anaesthetised and her oxygen levels had fallen to dangerously low levels. A decision had been taken to move her to the intensive-care unit.

Grasping for medical knowledge from half-remembered episodes of Casualty, Bromiley asked if the doctors had attempted a tracheotomy – a cut to the throat to allow air in. They explained that the safer option had been to let her wake up naturally. He made his way to the intensive-care unit. When he got there, the first person to approach him was the consultant anaesthetist, who, without saying anything, gave him a hug. Bromiley found himself trying to console him. “I said, ‘I know these things happen.’

He took a seat and waited for news. After ten minutes, two doctors emerged and took seats opposite him. In sombre tones, they told Bromiley that Elaine had been without oxygen for a long period of time and, as a consequence, had suffered severe brain damage. He could hardly process what they were saying. “I just thought, ‘Fuck. What? How?’ I was stunned. My whole world changed.”

An hour later, Bromiley was allowed to see his wife. “She didn’t look any different,” he told me. But she was different. After finally settling her oxygen levels, the doctors had put her into a coma to prevent her brain from swelling to the point where it crushed itself against the top of her spine.

It soon became apparent that it was a coma from which she would never recover. Days later, after a series of discussions with the doctors, he consented to having her life support switched off. The doctors were surprised at the strength of her heart, which continued to beat for another week until, on 11 April 2005, Elaine Bromiley died.

 

3.

How could this have happened? When he surfaced from the shock, that was the question to which Bromiley wanted an answer. At first, he accepted the word of the ENT consultant, who told him that the doctors had made all the right decisions but had simply come up against an emergency for which nobody could have planned: the exceptional difficulty of getting a tube down Elaine’s throat.

Still, he assumed that the next step would be an investigation – standard practice in the airline industry after every accident. “You get an independent team in. You investigate. You learn.” When he asked the head of the intensive-care unit about this, the doctor shook his head. “That’s not how we do things in the health service. Not unless somebody complains or sues.”

This doctor was privately sympathetic to Bromiley’s question, however. Shortly after Elaine’s death, he got in touch with Bromiley to say that he had asked a friend of his, Professor Michael Harmer, an eminent anaesthetist, if he would be prepared to lead an investigation. Harmer had said yes. After Bromiley gained the hospital’s consent, Harmer set to work, interviewing everyone involved, from the consultants to the nursing team.

In July that year, he submitted his report. As Bromiley read it, his mind went back to one of the last nights he had spent in the hospital during his wife’s coma, and to something the duty nurse had said to him: “It’s terrible. I can’t believe that happened.” With hindsight, that was a hint.

Harmer’s minute-by-minute narrative of the operation revealed a different story from the one Bromiley had heard when he spoke with the ENT surgeon. The truth was that Elaine had died at the hands of highly accomplished, technically proficient doctors with 60 years of experience between them, in a fine, well-equipped modern hospital, because of a simple error.

4.

Doctors make mistakes. A woman undergoing surgery for an ectopic pregnancy had the wrong tube removed, rendering her infertile. Another had her Fallopian tube removed instead of her appendix. A cardiac operation was performed on the wrong patient. Some 69 patients left surgery with needles, swabs or, in one case, a glove left inside them. These are just some of the
incidents that occurred in English hospitals in the six months between April and September 2013.

Naturally, we respect and admire doctors. We believe that health care is scientific. We think of hospitals as places of safety. For all these reasons, it comes as something of a shock to realise that errors still play such a significant role in whether we leave a hospital better or worse, alive or dead.

The National Audit Office estimates that there may be 34,000 deaths annually as a result of patient safety incidents. When he was medical director, Liam Donaldson warned that the chances of dying as a result of a clinical error in hospital are 33,000 times higher than dying in an air crash. This isn’t a problem peculiar to our health-care system. In the United States, errors are estimated to be the third most common cause of deaths in health care, after cancer and heart disease. Globally, there is a one-in-ten chance that, owing to preventable mistakes or oversights, a patient will leave a hospital in a worse state than when she entered it.

There are other industries where mistakes carry grave consequences, but the mistakes of doctors carry a particular moral charge because their job is to make us better, and we place infinite trust in the expectation they
will do so. When you think about it, it’s extraordinary we’re prepared to give a virtual stranger permission to cut us open with a knife and rearrange our insides as we sleep.

Perhaps because of the almost superstitious faith we need to place in surgeons, we hate to think of them as fallible; to think that they perform worse when they are tired, or that some are much better at the job than others, or that hands can slip because of nerves, or that bad decisions get taken because of overconfidence, or stress, or poor communication. But all of these things happen, because doctors are human.

 

5.

Within two minutes of Elaine Bromiley’s operation beginning, the anaesthetic consultant realised that the patient’s airway had collapsed, hindering her supply of oxygen. After repeatedly trying and failing to ventilate the airway, he issued a call for help. An ENT surgeon answered it, as did another senior anaesthetist. The three consultants struggled to get a tube down Elaine’s throat, a procedure known as intubation, but encountered a mysterious blockage. So they tried again.

“Can’t ventilate, can’t intubate” is a recognised emergency in anaesthetic practice, for which there are published guidelines. The first instruction in one version of the guidelines is this: “Do not waste time trying to intubate when the priority is oxygenation.” Deprived of oxygen, our brains soon find it hard to function, our hearts to beat: ten minutes is about the longest we can suffer such a shortage before irreversible damage is done. The recommended solution is to carry out a form of tracheotomy, puncturing the windpipe to allow air in. Do not waste time trying to intubate.

Twenty minutes after Elaine’s airway collapsed, the doctors were still trying to get a tube down her throat. The monitors indicated that her brain was starved of oxygen and her heart had slowed to a dangerously low rate. Her face was blue. Her arms periodically shot up to her face, a sign that brain tissue is being irritated. Yet the doctors ploughed on. After 25 minutes, they had finally intubated their patient. But that was too late for Elaine.

If the severity of Elaine’s condition in those crucial minutes wasn’t registered by the doctors, it was noticed by others in the room. The nurses saw Elaine’s erratic breathing; the blueness of her face; the swings in her blood pressure; the lowness of her oxygen levels and the convulsions of her body. They later said that they had been surprised when the doctors didn’t attempt to gain access to the trachea, but felt unable to broach the subject. Not directly, anyway: one nurse located a tracheotomy set and presented it to the doctors, who didn’t even acknowledge her. Another nurse phoned the intensive-care unit and told them to prepare a bed immediately. When she informed the doctors of her action they looked at her, she said later, as if she was overreacting.

Reading this, you may be incredulous and angry that the doctors could have been so stupid, or so careless. But when the person closest to this event, Martin Bromiley, read Harmer’s report, he responded very differently. His main sensation wasn’t shock, or fury. It was recognition.

 

6.

Shortly after 5pm on the clear-skied evening of 28 December 1978, United Airlines Flight 173 began its descent to Portland International Airport. The plane had taken off from New York that morning and, after making a pre-scheduled stop in Denver, it was reaching its final destination with 189 souls on board.

As the landing gear was lowered there was a loud thump and the aircraft yawed slightly to the right. The flight crew noticed that one of the green landing gear indicator lights wasn’t lit. The captain radioed air-traffic control at Portland, telling them, “We’ve got a gear problem.”

Portland’s control agreed that the plane would orbit the airport while the captain, first officer and second officer worked out what to do. The passengers were told that there would be a delay. The cabin crew began to carry out checks. The flight attendants were instructed to check the visual indicators on the wings, which suggested that the landing gear was locked down.

Nearly half an hour after the captain told Portland about the landing gear problem, he contacted the United Airlines maintenance centre, informing the staff there that he intended to continue the holding pattern for another 15 or 20 minutes. He reported 7,000lbs of fuel aboard, down from 13,000 when he had first spoken to Portland.

United’s controller sounded a mild note of concern. “You estimate that you’ll make a landing about five minutes past the hour. Is that OK?” The captain’s response was ostentatiously relaxed: “Yeah, that’s a good ball park. I’m not gonna hurry the girls [the cabin crew].” United 173 had 30 minutes of fuel left.

The captain and his two officers continued to debate the question of whether the landing gear was down. The captain asked his crew how much fuel they would have left after another 15 minutes of flying. The flight engineer responded, “Not enough. Fifteen minutes is gonna – really run us low on fuel here.” At 18.07 one of the plane’s engines lost power. Six minutes later, the flight engineer reported that both engines were gone. The captain, as if waking up to the situation for the first time, said: “They’re all going. We can’t make Troutdale [a small airport on the approach route to Portland].” “We can’t make anything,” said the first officer. At 18.13, the first officer sent the plane’s final message to air-traffic control: “We’re going down. We’re not going to be able to make the airport.”

 

7.

This story of United 173 is known to every airline pilot, because it is studied by every trainee. To the great credit of the aviation industry, it became one of the most influential disasters in history. Galvanised by it and a handful of other crashes from the same era, the industry transformed its training and safety practices, instituting a set of principles and procedures known as CRM: crew resource management.

It worked. Although we usually notice only the high-profile exceptions, crashes are at the lowest level they have ever been, and flying is now one of the safest ways you can spend your time. As they are fond of saying in aviation, these days the most dangerous part of a flight is the journey to the airport.

CRM was born of a realisation that in the late 20th century the most frequent cause of crashes wasn’t technical failure, but human error. Its roots go back to the Second World War, when the US army assigned a psychologist called Alphonse Chapanis to investigate a curious phenomenon. B-17 bombers kept crashing on to the runway on landing, even though there were no apparent mechanical problem with the planes. Rather than blaming the pilots, Chapanis pointed to the instrument panel. The lever to control the landing gear and the lever that operated the flaps were next to each other. Pilots, weary after long flights, were confusing the two, retracting the wheels and causing the crash. Chapanis suggested attaching a wheel to the handle of the landing lever and a triangle to the flaps lever, making each easily distinguishable by touch alone. Problem solved.

Chapanis had recognised that human beings’ propensity to make mistakes when they are tired is much harder to fix than the design of levers. His deeper insight was that people have limits, and many of their mistakes are predictable effects of those limits. That is why the architects of CRM defined its aim as the reduction of human error, rather than pilot error. Rather than trying to hire or train perfect pilots, it is better to design systems that minimise or mitigate inevitable human mistakes.

In the 1990s, a cognitive psychologist called James Reason turned this principle into a theory of how accidents happen in large organisations. When a space shuttle crashes or an oil tanker leaks, our instinct is to look for a single, “root” cause. This often leads us to the operator: the person who triggered the disaster by pulling the wrong lever or entering the wrong line of code. But the operator is at the end of a long chain of decisions, some of them taken that day, some taken long in the past, all contributing to the accident; like achievements, accidents are a team effort. Reason proposed a “Swiss cheese” model: accidents happen when a concatenation of factors occurs in unpredictable ways, like the holes in a block of cheese lining up.

James Reason’s underlying message was that because human beings are fallible and will always make operational mistakes, it is the responsibility of managers to ensure that those mistakes are anticipated, planned for and learned from. Without seeking to do away altogether with the notion of culpability, he shifted the emphasis from the flaws of individuals to flaws in organisation, from the person to the environment, and from blame to learning.

The science of “human factors” now permeates the aviation industry. It includes a sophisticated understanding of the kinds of mistakes that even experts make under stress. So when Martin Bromiley read the Harmer report, an incomprehensible event suddenly made sense to him. “I thought, this is classic human factors stuff. Fixation error, time perception, hierarchy.”

 

8.

It’s a miracle that only ten people were killed after Flight 173 crashed into an area of woodland in suburban Portland; but the crash needn’t have happened at all. Had the captain attempted to land, the plane would have touched down safely: the subsequent investigation found that the landing gear had been down the whole time. But the captain and officers of Flight 173 became so engrossed in one puzzle that they became blind to the more urgent problem: fuel shortage. This is called “fixation error”. In a crisis, the brain’s perceptual field narrows and shortens. We become seized by a tremendous compulsion to fix on the problem we think we can solve, and quickly lose awareness of almost everything else. It’s an affliction to which even the most skilled and
experienced professionals are prone.

Imagine a stalled car, stuck on a level crossing as a distant train bears down on it. Panic rising, the driver starts and restarts the engine rather than getting out of the car and running. The three doctors bent over Elaine Bromiley’s throat were intent on finding a way to intubate, just as the three pilots in the cockpit of United 173 were determined to establish the status of the landing gear. In neither case did these seasoned professionals look up and register the oncoming train: in the case of Elaine, her oxygen levels, and in the case of United 173, its fuel levels.

When people are fixating, their perception of time becomes highly erratic; minutes stretch and elongate. One of the most striking aspects of the transcript of United 173’s last minutes is the way the captain seems to be under the impression that he has plenty of time, right up until the moment the engines cut out. It’s not that he didn’t have the correct information; it’s that his brain was running to a different clock. Similarly, it’s not that the doctors weren’t aware that Elaine Bromiley’s oxygen supply was a problem; it’s that their sense of how long she had been without it was distorted. When Harmer interviewed him, the anaesthetic consultant confessed that he had no idea how much time had passed.

Imagine, for a moment, being one of those doctors. You have a patient who has stopped breathing. The clock is ticking. The standard procedure isn’t working, but you have employed it dozens of times before and you know it works. Each of the senior colleagues around you is experiencing the same difficulty, which reassures you. You cling to the belief that, between the three of you, you will solve the problem, if it is soluble at all. You vaguely register nurses coming into the room and saying things but you don’t really hear what they say. Perhaps it occurs to you to step back from the patient and demand a rethink, but you don’t want your peers to see you as panicky or naive. So you focus on the one thing you can control: the procedure. You repeat it over and over, hoping for a different result. It is madness, but it is comprehensible madness.

Team trauma: British Midland Flight 92 came down near the M1 at Kegworth after a breakdown in communication among the crew

 

9.

In the months after Elaine’s death, as Bromiley tried to rebuild his family life, he couldn’t stop wondering about the difference between the way people in health care treated accidents and the way his industry dealt with them. So he would phone people in and around the National Health Service and ask them about it.

He discovered that many others – an anaesthetist in Scotland, a medical researcher in London – had been wondering the same thing. Eventually, he accumulated a long list of like-minded people, none of whom was talking to any of the others. So he booked a room in a hotel, called a meeting and invited them all, along with experts from other industries and academics, including James Reason. Everyone agreed that when it came to safety, health care was languishing in the Dark Ages. Hospitals more or less pretended that mistakes didn’t happen, failed to learn from them and, as a result, repeated them. If we don’t like to think that doctors make mistakes, doctors like to think about it even less.

One of the biggest problems identified was the unwritten but entrenched hierarchy of hospitals. Bromiley, who has worked with experts from various “safety-critical” industries, including the military, told me that the hospital is by far the most hierarchical workplace he has come across. At the top of the tree are consultant surgeons, the rock stars of the hospital corridors: highly driven, competitive, mostly male and not the kind who enjoy confessing to uncertainty. Then come anaesthetists, often quieter of disposition and warier of risk. Further down are nurses, valued for their hard work but not for their brains.

A key principle of human factors is that it is the unspoken rules of who can say what and when that often lead to crucial things going unsaid. The most painful part of the transcript of Flight 173’s final hour is the flight engineer’s interjections. You can sense his concern about the fuel situation, and his hesitancy about expressing it. Fifteen minutes is gonna – really run us low on fuel here. Perhaps he’s assuming the captain and his officers know the urgency of their predicament. Perhaps he’s worried about being seen to speak out of turn. Whatever it is, he doesn’t say what he feels: This is an emergency. We need to get this plane on the ground – NOW. Similarly, the nurses who could see the urgency of Elaine Bromiley’s condition didn’t feel able to tell the doctors that they were on the verge of committing a grave error. So they made tentative suggestions that were easy to ignore.

John Pickles, an ENT surgeon and former medical director of Luton and Dunstable Hospital NHS Foundation Trust, told me that usually when an operation is carried out on the wrong part of the body (a class of error known as “wrong-site surgery”), there is at least one person in the room who knows or suspects a mistake is being made. He recalled the case of a patient in South Wales who had the wrong kidney removed. A (female) medical student had pointed out the impending error but the two (male) surgeons ignored her and carried on. The patient, who was 70 years old, was left with one diseased kidney, and died six weeks later. In other cases nobody spoke up at all.

The pioneers of crew resource management knew that merely warning pilots about fixation error was not sufficient. It is too powerful an instinct to be repressed entirely even when you know about it. The answer lay with the crew. Because even the most experienced captains are prone to human error, the entire aircraft crew needed to act as a collective intelligence, vigilant for problems and responsible for solutions. “It’s the people at the edge of the room, standing back from the situation, who can often see it best,” Bromiley said to me.

He recalled the case of British Midland Flight 92, which had just taken off for its flight from London to Belfast on 8 January 1989 when the pilots discovered one of the engines was on fire. Following procedure, they shut it down. Over the PA, the captain explained that because of a problem with the right engine he was making an emergency landing. The cabin staff, who – like the passengers, but unlike the cockpit crew – could see smoke and flames coming from the left engine, didn’t pass this information on to the cockpit. After the pilots shut down the only functioning engine, British Midland 92 crashed into the embankment of the M1 motorway near Kegworth in Leicestershire. Forty-seven of the 126 people on board died; 74 sustained serious injuries.

The airline industry pinpointed a major block to communication among members of the cockpit crew: the captain. The rank of captain retained the aura of imperial command it inherited from the military and from the early days of flying, when pilots such as Chuck Yeager, immortalised in Tom Wolfe’s book The Right Stuff, were celebrated as audacious mavericks. The pioneers of CRM realised that, in the age of mass air travel, charismatic heroism was precisely the wrong stuff. The industry needed team players. The captain’s aura was a force field, stopping other crew members from speaking their mind at critical moments. It wasn’t just the instrument panel that had to change: it was the culture of the cockpit.

Long before they started doing more good than harm, surgeons were revered as men of genius. In the 18th and 19th centuries, surgical superstars performed operations in packed amphitheatres before hushed, admiring audiences. A great surgeon was a virtuoso performer with the hands of a god. His nurses and assistants were present merely to follow the great man’s commands, much as the planets in an orrery revolve around the sun. The advent of medical science gave this myth a grounding in reality: at least we can be confident that doctors today make people better, most of the time. But it reinforced a mystique that makes doctors, and especially surgeons (who, of course, still perform in operating theatres), hard to question, by either patients or staff.

Better safety involves bringing doctors off their pedestal or, rather, inviting them to step down from it. Modern medicine is more reliant than ever on teamwork. As operations become more complex, more people and procedures are involved. Operating rooms swarm with people; various specialists pronounce judgement or perform procedures, and then leave. Surgical teams are often comprised of individuals who know each other only vaguely, if at all. It is a simple but unavoidable truth that the more people are involved in something, and the less well they know each other, the more likely it is that someone will make an error.

The most significant human factors innovation in health care in recent years is surprisingly prosaic: the checklist. Borrowed from the airline industry, the checklist is a standardised list of procedures to follow for every operation, and for every eventuality. Checklists compensate for the inbuilt tendency of human beings under stress to forget or ignore what is important, including the most basic things (the first item on one aviation checklist is FLY THE AIRPLANE). They also empower the people at the edges of the room: before the operation and at key moments during it, the whole team goes through each point in turn, including emergencies, which gives a cue to more reserved members of the team to speak up.

Checklists are most effective in an atmos­phere of informality and openness: it has been shown that simply using the first name of the other team members improves communication, and that giving people a chance to say something at the beginning of a case makes them more likely to speak up during the operation itself.

Naturally, this spirit of openness entails a diminishment of the surgeon’s power – or a dispersal of that power around the team. Some doctors don’t mind this – indeed, they welcome it, because they realise that their team can save them from career-ruining mistakes. Others are more resistant, particularly those who treasure their independence; mavericks don’t do checklists. Even those who see themselves as evolved team players may overestimate their openness. J Bryan Sexton, a psychologist at Johns Hopkins University in the US, has conducted global surveys of operating-room staff. He found that while 64 per cent of surgeons rated their operations as having high levels of teamwork, only 28 per cent of nurses agreed.

The lessons of human factors go far beyond the status of surgeons. From his earliest conversations with insiders, Bromiley realised that the NHS needed to undergo a profound cultural change if it was to reach the level of the aviation industry in terms of safety. Hospitals gave little or no thought to how their teams functioned. Doctors underestimated the effects of tiredness on their own performance. Medical schools taught doctors that technical excellence trumped everything else and spent little or no time teaching communication or team management skills. Specialists saw their job as fixing parts of the body, rather than helping a person (at this year’s Clinical Human Factors Group conference, Peter Jaye, a consultant surgeon at Guy’s Hospital in London, remarked: “At medical school I was trained to think of a patient as a pair of kidneys”). There was little or no data on which hospitals and doctors were making mistakes, and therefore which required the most urgent improvement.

Safety risks were routinely misperceived. The “can’t ventilate/can’t intubate” emergency happens about one in every 20,000 times, which anaesthetists consider a remote possibility. Yet as Bromiley told me: “In aviation, when we find out there’s a one-in-a-million chance of an engine failing, we worry. To me, one in 20,000 means a regular occurrence.”

As James Reason showed, mistakes arise out of coincidence. Suren Arul, the consultant paediatrician in Birmingham, told me that “when mistakes happen, it’s almost never one person’s fault. It’s usually a whole series of things, some of them tiny.” Bromiley asks hospital boards to consider their procurement of marker pens, used to mark the part of the body about to be operated on (best practice is for the surgeon to make the mark and to sign it with his initials). “I tell them, ‘I understand your need to cut budgets. But do you realise that because you didn’t buy those marker pens you’ve just trebled your likelihood of having a wrong-site surgery case?’

There is now greater awareness of the complexity of safety than ever. The body that Bromiley founded, the Clinical Human Factors Group, has no official status within the NHS, but its influence has been felt right across that sprawling and multifarious institution. At the meeting I attended, everyone to whom I spoke seemed to believe that things are moving, albeit too slowly, in the right direction.

10.

It was a trauma situation: an 18-month-old baby boy had fallen down the steps at Euston Square station, smashing his head and injuring his leg. Through a one-way mirror, I watched as a young doctor entered the operating room and was greeted by the baby’s distressed mother. The woman sitting next to me turned to her team. “Why don’t you play the orthopaedic surgeon this time, Dave?” she said. “Clare, can you be the anaesthetic consultant?”

In recent years, simulations have started to become part of the training of doctors. Sarah Chieveley-Williams, the consultant anaesthetist who is director of clinical simulation at University College London Hospitals (UCLH), had invited me to watch junior paediatricians being put through their paces. The room before us was a near-perfect replica of an operating theatre, with an anaesthesia machine, various equipment, monitors and a stock of medication. The dummy baby had pupils that dilate, a heartbeat and a noisy cry.

Chieveley-Williams and her team were interested in the doctor’s ability to identify the right priorities: first, stabilise the baby’s condition by anaesthetising it; second, get a neurological consultant to look at its head injuries, in order to prevent or minimise brain damage. On our side of the glass, one of the team sat by a computer from where she could manipulate the baby’s vital signs. She slowed down its heart rate, ratcheting up the urgency of the situation.

Chieveley-Williams turned to another colleague: “Dave, see if you can get her fixated on the leg.” Dave left us and a moment later reappeared in the operating room wearing a white coat. After examining the patient, he proposed, with the air of someone used to being agreed with, that an X-ray be taken of the injured leg. Chieveley-Williams watched intently. In a quiet but firm voice, the young doctor said, “Right now, the priority is his head injury. The leg will have to wait.”

Chieveley-Williams turned to me with a grin. “That told him,” she said.

Over the next 20 minutes, a succession of people entered and left the room. Specialists were summoned, medications ordered and procedures arranged. At times the impression was one of near-chaos. A trauma incident, Chieveley-Williams explained to me, presents an acute management challenge, as well as a medical one. Because it often involves injuries to different parts of the body, many specialists come into the treatment room, each with his or her own agenda. “The doctor needs to establish leadership and keep everyone focused on the big picture – the patient’s health.”

In the case of Elaine Bromiley, there was too much hierarchy and too little. On the one hand, the nurses didn’t assert themselves. On the other hand, nobody was taking ultimate responsibility for the patient’s safety. As John Pickles remarks, “You had three very senior people in the room and no one in charge.”

Hierarchy, in the sense of clear leadership, is a good thing, as long as the leaders are confident enough to confess uncertainty. A common problem, Chieveley-Williams said, is young doctors being reluctant to say they don’t know what the answer is because they are so eager to project competence. A member of her team told me, “We tell them that when you’re stuck, ask everyone in the team for their view. One of them probably has the answer, but until you speak up they’ll assume you have it, too.”

These sorts of lessons weren’t being given ten years ago. Like UCLH, Great Ormond Street children’s hospital in London is at the forefront of the new thinking about patient safety, and is absorbing lessons from other industries. The transfer of patients from surgery to the intensive-care unit is a complex process that has to be accomplished at speed, and involves several people. Unsurprisingly, it is a well-known danger zone: things get dropped, tubes are left unattached, and patients suffer. In collaboration with the human factors researcher Ken Catchpole, the hospital studied the process of pit-stop changes in Formula 1, learning the importance of every individual on the team being allocated a precisely defined task. Mistakes fell.

 

11.

Martin Bromiley has rebuilt his life. Happily remarried, he is stepdad to his second wife’s two children, as well as still dad to Victoria and Adam. He is not haunted by the tragedy of Elaine’s death but driven by it. Between flying commitments, he talks to doctors, nurses, researchers and NHS boards, connecting the like-minded; telling his story to those, whether managers or medical students, who most need to hear it. It is a heavy workload. I wondered if he was ever tempted to leave it behind, now that the CHFG has its own momentum. He shook his head. “This is a duty.”

Improving the safety of patients in health care doesn’t necessarily require spending on expensive new technologies, or complex structural reorganisation. It requires forethought, empathy, humility and a willingness to learn from mistakes. Which, after all, is a duty to those who have suffered from them. Bromiley insisted that the Harmer report be made public as happens with air accident reports, and he chose for it an epigraph borrowed from aviation: “So that others may learn, and even more may live.” All of the medical staff involved in Elaine’s operation are back at work. That, says Bromiley, is exactly what he wanted, because they will be better clinicians for their experience, and advocates for the cause.

There are two approaches to reforming a large institution. You can impose change from outside by invoking the will, or the wrath, of the public – or you can persuade those inside to let you in and to listen to your message. Both can work. When Julie Bailey exposed the gross malpractices of staff at Stafford Hospital, she shook the health service from top to bottom. Bromiley greatly admires what Bailey has achieved, but he has taken a different path. Rather than using his story as a club – and nobody would have blamed him for doing that – he has deployed it as you would wish a surgeon to apply the knife to someone you love: with skill, subtlety and precision.

“From the moment something went wrong with Elaine, it was different, because they knew my profession,” he says. Responding to his calmness and extraordinary ability to empathise with their situation, the team rose to their best. As Elaine lay in a coma, they involved him in every decision they took, right up until the last one. It was proper teamwork, and a model for the long campaign that followed. “I’m an outsider who is also an insider,” he says.

Martin Bromiley has reminded clinicians that not everything is or should be clinical. His legacy, says Professor Jane Reid, a researcher in nursing at Queen Mary’s Hospital in south London, is “a new safety culture” in the NHS. He has no desire to take up any official position. “I’m not an expert on medical practice,” he told me. “I’m just a guy who flies planes.” 

Ian Leslie is the author of Curious: The Desire to Know and Why Your Future Depends on It (Quercus, £10.99)

Ian Leslie is a writer, author of CURIOUS: The Desire to Know and Why Your Future Depends On It, and writer/presenter of BBC R4's Before They Were Famous.

This article first appeared in the 28 May 2014 issue of the New Statesman, The elites vs the people

RAY TANGT/ANADOLU AGENCY/GETTY IMAGES
Show Hide image

Losing Momentum: how Jeremy Corbyn’s support group ran out of steam

Tom Watson says it is destroying Labour. Its supporters say it is a vital force for change. Our correspondent spent six months following the movement, and asks: what is the truth about Momentum?

1. The Bus

 The bus to the Momentum conference in Liverpool leaves at seven on a Sunday morning in late September from Euston Station, and the whole journey feels like a parody of a neoliberal play about the failings of socialism. We depart an hour late because activists have overslept and we cannot go without them. As we wait we discuss whether Jeremy Corbyn will be re-elected leader of the Labour Party this very day. One man says not; a young, jolly girl with blonde hair cries: “Don’t say that on Jezmas!” She is joking, at least about “Jezmas”.

A man walks up. “Trots?” he says, calmly. He is joking, too; and I wonder if he says it because the idea of Momentum is more exciting to outsiders than the reality, and he knows it; there is an awful pleasure in being misunderstood. Momentum was formed in late 2015 to build on Corbyn’s initial victory in the Labour leadership election, and it is perceived as a ragtag army of placard-waving Trots, newly engaged clicktivists and Corbyn fanatics.

We leave, and learn on the M1 that, in some terrible metaphor, the coach is broken and cannot drive at more than 20mph. So we wait for another coach at a service station slightly beyond Luton. “Sabotage,” says one man. He is joking, too. We get off; another man offers me his vegan bread and we discuss Karl Marx.

A new coach arrives and I listen to the others discuss Jeremy Corbyn’s problems. No one talks about his polling, because that is depressing and unnecessary for their purpose – which, here, is dreaming. They talk about Corbyn as addicts talk about a drug. Nothing can touch him, and nothing is ever his fault. “There are problems with the press office,” says one. “Perhaps he needs better PAs?” says another.

One man thinks there will be a non-specific revolution: “I hope it won’t be violent,” he frets. “There have been violent revolutions in the past.” “I stuck it out during Blair and it was worth it,” says another. “They’ve had their go.” “We don’t need them [the Blairites],” says a third. “If new members come in, it will sort itself out,” says a fourth.

I have heard this before. Momentum supporters have told me that Labour does not need floating voters, who are somehow tainted because they dare to float. This seems to me a kind of madness. I do not know how the Labour Party will win a general election in a parliamentary democracy without floating voters; and I don’t think these people do, either.

But this is a coach of believers. Say you are not sure that Corbyn can win a general election and they scowl at you. That you are in total agreement with them is assumed, because this is the solidarity bus; and if you are in total agreement with them they are the sweetest people in the world.

That is why I do not tell them that I am a journalist. I am afraid to, and this fear baffles me. I have gone everywhere as a journalist but with these, my fellow-travellers on the left, I am scared to say it; and that, too, frightens me. MSM, they might call me – mainstream media. What it really means is: collaborator.

The man beside me has been ill. He talks sweetly about the potential renewal of society under Corbyn’s Labour as a metaphor for his own recovery, and this moves him; he has not been involved in politics until now. I like this man very much, until I mention the Jewish Labour MP Luciana Berger and the anti-Semitism she has suffered from Corbyn supporters and others; and he says, simply, that she has been employed by the state of Israel. He says nothing else about her, as if there were nothing else to say.

We listen to the results of the leadership election on the radio; we should be in Liverpool at the Black-E community centre to celebrate, but the solidarity bus is late. Corbyn thanks his supporters. “You’re welcome, Jeremy,” says a woman in the front row, as if he were on the coach. She nods emphatically, and repeats it to the man who isn’t there: “You’re welcome, Jeremy.”

In Liverpool, some of the passengers sleep on the floor at a community centre. The venue has been hired for that purpose: this is Momentum’s commitment to opening up politics to the non-connected, the previously non-engaged, and the outsiders who will attend their conference in a deconsecrated church, even as the official Labour conference convenes a mile away. But never mind that: this is the one that matters, and it is called The World Transformed.

 

2. The Conference

Later that day, outside the Black-E, a man comes up to me. Are you happy, he asks, which is a normal question here. These are, at least partly, the politics of feelings: we must do feelings, because the Tories, apparently, don’t. I say I’m worried about marginal seats, specifically that Jeremy – he is always Jeremy, the use of his Christian name is a symbol of his goodness, his accessibility and his singularity – cannot win them.

“The polls aren’t his fault,” the man says, “it’s [Labour] people briefing the Tories that he is unelectable.” I do not think it’s that simple but it’s easy to feel like an idiot – or a monster – here, where there is such conviction. As if there is something that only you, the unconvinced, have missed: that Jeremy, given the right light, hat or PA, could lead a socialist revolution in a country where 13 million people watched Downton Abbey.

But the man does say something interesting which I hope is true. “This is not about Jeremy, not really,” he says. “It is about what he represents.” He means Momentum can survive without him.

There is a square hall with trade union banners and a shop that sells Poems for Jeremy Corbyn, as well as a Corbyn-themed colouring book. When I am finally outed as a journalist, and made to wear a vast red badge that says PRESS, I attempt to buy one. “That’s all journalists are interested in,” the proprietor says angrily. That is one of our moral stains, apparently: a disproportionate (and sinister) interest in colouring books.

I go to the Black Lives Matter event. A woman talks about the experience of black students in universities and the impact of austerity on the black community. Another woman tells us that her five-year-old son wishes he was white; we listen while she cries. I go to the feminism meeting and change my mind about the legalisation of prostitution after a woman’s testimony about reporting an assault, and then being assaulted again by a police officer because of her legal status. Then I hear a former miner tell a room how the police nearly killed him on a picket line, and then arrested him.

This, to me, a veteran of party conferences, is extraordinary, although it shouldn’t be, and the fact that I am surprised is shameful. Momentum is full of the kinds of ­people you never see at political events: that is, the people politics is for. Women, members of minority communities (but not Zionist Jews, naturally), the disabled: all are treated with exaggerated courtesy, as if the Black-E had established a mirror world of its choosing, where everything outside is inverted.

When Corbyn arrives he does not orate: he ruminates. “We are not going to cascade poverty from generation to generation,” he says. “We are here to transform society and the world.” I applaud his sentiment; I share it. I just wish I could believe he can deliver it outside, in the other world. So I veer ­between hope and fury; between the certainty that they will achieve nothing but an eternal Conservative government, and the ever-nagging truth that makes me stay: what else is there?

There is a rally on Monday night. Momentum members discuss the “purges” of socialist and communist-leaning members from Labour for comments they made on social media, and whether détente is possible. A nurse asks: “How do we know that ‘wipe the slate clean’ means the same for us as it does for them? How on Earth can we trust the likes of Hilary Benn who dresses himself up in the rhetoric of socialism to justify bombing Syria? The plotters who took the olive branch offered by Jeremy to stab him in the back with another chicken coup?” I am not sure where she is going with that gag, or if it is even a gag.

The next man to speak had been at the Labour party conference earlier in the day; he saw Len McCluskey, John McDonnell and Clive Lewis on the platform. “Don’t be pessimistic, folks,” he cries. “On the floor of conference today we owned the party. Progress [the centrist Labour pressure group] are the weirdos now. We own the party!”

A man from Hammersmith and Fulham Momentum is next. “The national committee of Momentum was not elected by conference,” he says. “It’s a committee meeting knocked up behind closed doors by leading people on the left, including our two heroes.” He means Jeremy Corbyn and John McDonnell. This is explicit heresy, and the chair interrupts him: “Stan, Stan . . .” “I’m winding up!” he says. “We need a central committee of Momentum elected by conference,” he says, and sits down.

The following day Corbyn speaks in the hall in front of golden balloons that spell out S-H-E-E-P. It may be another gag, but who can tell, from his face? This is his commitment to not doing politics the recognisable way. He is the man who walks by himself, towards balloons that say S-H-E-E-P. (They are advertising the band that will follow him. They are called, and dressed as, sheep.) The nobility of it, you could say. Or the idiocy. He mocks the mockers of Momentum: is it, he was asked by the mainstream media, full of extremists and entryists? “I’m not controlling any of it,” he says calmly, and in this calmness is all the Twitter-borne aggression that people complain of when they talk about Momentum, for he enables it with his self-satisfied smile. “It’s not my way to try and control the way people do things. I want people to come together.” He laughs, because no one can touch him, and nothing is ever his fault.

I meet many principled people in Liverpool whose testimony convinces me, and I didn’t need convincing, that austerity is a national disaster. I meet only one person who thinks that Momentum should take over the Labour Party. The maddest suggestion I hear is that all media should be state-controlled so that they won’t be rude about a future Corbyn government and any tribute colouring books.

 

3. The HQ

Momentum HQ is in the TSSA transport and travel union building by Euston Station in London. I meet Jon Lansman, Tony Benn’s former fixer and the founder of Momentum, in a basement room in October. Lansman, who read economics at Cambridge, lived on the fringes of Labour for 30 years before volunteering for Corbyn’s campaign for the leadership.

The terms are these: I can ask whatever I want, but afterwards James Schneider, the 29-year-old national organiser (who has since left to work for Corbyn’s press team), will decide what I can and cannot print. ­Momentum HQ wants control of the message; with all the talk of entryism and infighting reported in the mainstream media, the movement needs it.

There is a civil war between Jon Lansman and the Alliance for Workers’ Liberty (AWL) and other far-left factions, which, I am told, “wish to organise in an outdated manner out of step with the majority of Momentum members”. Some of the Momentum leadership believe that the AWL and its allies want to use Momentum to found a new party to the left of Labour. Jill Mountford, then a member of Momentum’s steering committee, has been expelled from Labour for being a member of the AWL. It screams across the blogs and on Facebook; more parody. We don’t talk about that – Schneider calls it “Kremlinology”. It is a problem, yes, but it is not insurmountable. We talk about the future, and the past.

So, Lansman. I look at him. The right considers him an evil Bennite wizard to be feared and mocked; the far left, a Stalinist, which seems unfair. It must be exhausting. I see a tired, middle-aged man attending perhaps his fifteenth meeting in a day. His hair is unruly. He wears a T-shirt.

The last Labour government, he says, did one thing and said another: “Wanting a liberal immigration policy while talking tough about refugees and migrants. Having a strong welfare policy and generous tax credits while talking about ‘strivers’ and ‘scroungers’ unfortunately shifted opinion the wrong way.”

It also alienated the party membership: “Their approach was based on ensuring that everyone was on-message with high levels of control.” It was an “authoritarian structure even in the PLP [Parliamentary Labour Party]. Even in the cabinet. It killed off the enthusiasm of the membership. They never published the figures in 2009 because it dropped below 100,000. We’ve now got 600,000.” (The membership has since dropped to roughly 528,000.)

And the strategy? “If you have hundreds of thousands of people having millions of conversations with people in communities and workplaces you can change opinion,” he says. “That’s the great advantage of ­having a mass movement. And if we can change the Labour Party’s attitude to its members and see them as a resource – not a threat or inconvenience.”

That, then, is the strategy: street by street and house by house. “We can’t win on the back of only the poorest and only the most disadvantaged,” he says. “We have to win the votes of skilled workers and plenty of middle-class people, too – but they are all suffering from some aspects of Tory misrule.”

I ask about polling because, at the time, a Times/YouGov poll has Labour on 27 per cent to the Tories’ 41 per cent. He doesn’t mind. “It was,” he says, “always going to be a very hard battle to win the next election. I think everyone across the party will privately admit that.” He doesn’t think that if Yvette Cooper or Andy Burnham were leader they would be polling any better.

Upstairs the office is full of activists. They are young, rational and convincing (although, after the Copeland by-election on 23 February, I will wonder if they are only really convincing themselves). They talk about their membership of 20,000, and 150 local groups, and 600,000 Labour Party members, and the breadth of age and background of the volunteers – from teenagers to people in their eighties. One of them – Ray Madron, 84 – paints his hatred of Tony Blair like a portrait in the air. He has a ­marvellously posh voice. Most of all, they talk about the wounds of austerity. Where, they want to know, is the anger? They are searching for it.

Emma Rees, a national organiser, speaks in the calm, precise tones of the schoolteacher she once was. “A lot of people are sick and tired of the status quo, of politics as usual, and I think trying to do things differently is hard because there isn’t a road map and it’s not clear exactly what you’re supposed to do,” she says. She adds: “It is a coalition of different sorts of people and holding all those people together can sometimes be a challenge.”

Is she alluding to entryism? One activist, who asks not to be named, says: “I don’t want to insult anyone, but if you rounded up all the members of the Socialist Workers Party [SWP] and the Socialist Party and any other ultra-left sect, you could probably fit them in one room. Momentum has 20,000 members.”

The SWP were outside at The World Transformed in Liverpool, I say, like an ambivalent picket line. “Well,” James Schneider says pointedly, “they were outside.”

Momentum, Emma Rees says, “is seeking to help the Labour Party become that transformative party that will get into government but doesn’t fall back on that tried and failed way of winning elections”.

They tell me this repeatedly, and it is true: no one knows what will work. “The people who criticised us don’t have any route to electability, either,” says Joe Todd, who organises events for Momentum. He is a tall, bespectacled man with a kindly, open face.

“They lost two elections before Jeremy Corbyn. It’s obvious we need to do something differently,” he says. “Politics feels distant for most people: it doesn’t seem to offer any hope for real change.

“The left has been timid and negative. More and more people are talking about how we can transform society, and how these transformations link to people’s everyday experience. Build a movement like that,” Todd says, and his eyes swell, “and all the old rules of politics – the centre ground, swing constituencies to a certain extent – are blown out of the water.”

Momentum sends me, with a young volunteer as chaperone, to a rally in Chester in October to watch activists try to muster support for local hospitals. They set up a stall in the centre of the shopping district, with its mad dissonance of coffee shops and medieval houses. From what I can see, people – yet far too few people – listen politely to the speeches about austerity and sign up for more information; but I can hear the hum of internal dissent when an activist, who asks not to be named, tells me he will work for the local Labour MP to be deselected. (The official Momentum line on deselection is, quite rightly, that it is a matter for local parties.)

We will not know what matters – is it effective? – until the general election, because no one knows what will work.

 

4. The Fallout

Now comes the result of the by-election in Copeland in the north-west of England, and the first time since 1982 that a ruling government has taken a seat from the opposition in a by-election. Momentum canvassed enthusiastically (they sent 85 carloads of activists to the constituency) but they failed, and pronounce themselves “devastated”. The whispers – this time of a “soft” coup against Corbyn – begin again.

Rees describes calls for Jeremy Corbyn to resign as “misguided. Labour’s decline long pre-dates Corbyn’s leadership.”

This produces a furious response from Luke Akehurst, a former London Labour ­councillor in Hackney, on labourlist.org. He insists that Labour’s decline has accelerated under Corbyn; that even though Rees says that “Labour has been haemorrhaging votes in election after election in Copeland since 1997”, the majority increased in 2005 and the number of votes rose in 2010, despite an adverse boundary change. “This,” he writes, “was a seat where the Labour vote was remarkably stable at between 16,750 and 19,699 in every general election between 2001 and 2015, then fell off a cliff to 11,601, a third of it going AWOL, last Thursday.”

And he adds that “‘85 carloads of Mom­entum activists’ going to Copeland is just increasing the party’s ability to record whose votes it has lost”.

But still they plan, and believe, even if no one knows what will work; surely there is some antidote to Mayism, if they search every street in the UK? Momentum’s national conference, which was repeatedly postponed, is now definitively scheduled for 25 March. Stan who complained about a democratic deficit within Momentum at The World Transformed got his way. So did Lansman. In January the steering committee voted to dissolve Momentum’s structures and introduce a constitution, after consulting the membership. A new national co-ordinating group has been elected, and met for the first time on 11 March – although, inevitably, a group called Momentum Grassroots held a rival meeting that very day.

I go to the Euston offices for a final briefing. There, two young women – Sophie and Georgie, and that will make those who think in parodies laugh – tell me that, in future, only members of the Labour Party will be allowed to join Momentum, and existing members must join Labour by 1 July. Those expelled from Labour “may be deemed to have resigned from Momentum after 1 July” – but they will have a right to a hearing.

More details of the plan are exposed when, a week later, a recording of Jon Lansman’s speech to a Momentum meeting in Richmond on 1 March is leaked to the Observer. Lansman told the Richmond branch that Momentum members must hold positions within the Labour Party to ensure that Corbyn’s successor – they are now talking about a successor – is to their liking. He also said that, should Len McCluskey be re-elected as general secretary of Unite, the union would formally affiliate to Momentum.

Tom Watson, the deputy leader of the party, was furious when he found out, calling it “a private agreement to fund a political faction that is apparently planning to take control of the Labour Party, as well as organise in the GMB and Unison”.

There was then, I am told, “a short but stormy discussion at the away day at Unison” on Monday 20 March, where the inner circle of John McDonnell, Diane Abbott and Emily Thornberry “laid into” Watson, but Shami Chakrabarti made the peace; I would have liked to see that. Watson then released a bland joint statement with Corbyn which mentioned “a robust and constructive discussion about the challenges and opportunities ahead”.

Jon Lansman, of course, is more interesting. “This is a non-story,” he tells me. “Momentum is encouraging members to get active in the party, to support socialist policies and rule changes that would make Labour a more grass-roots and democratic party, and to campaign for Labour victories. There is nothing scandalous and sinister about that.” On the Labour right, Progress, he notes, does exactly the same thing. “Half a million members could be the key to our success,” he says. “They can take our message to millions. But they want to shape policy, too. I wouldn’t call giving them a greater say ‘taking over the party’” – and this is surely unanswerable – “it’s theirs to start with.”

Correction: This article originally named Luke Akehurst as a Labour councillor. Akehurst stood down in 2014.

This article first appeared in the 23 March 2017 issue of the New Statesman, Trump's permanent revolution