The Story of Beth Bowen

We had all the pre-op stuff done and chatted to all the doctors, before arriving at the hospital on 27 July. She went down for her operation at 1pm – we didn’t hear from the doctors for several hours. At 4pm we spoke to a nurse, asking her why it was taking longer than it should. The nurse said it was fine as these operations take a long time.

Just after 6pm, the surgeons, the anaesthetist and the nurses came into our tiny waiting room – without any warning they said something awful had happened. The doctors seemed unable to comprehend what had happened. I asked one doctor: “Is she dead?” He said “yes”, adding that she’d lost a lot of blood during the operation as a blood vessel had been cut and she hadn’t survived. He said they’d been trying to save her for an hour and half prior to coming to see us, but she hadn’t survived – she’d lost too much blood.

The immediate aftermath

In the weeks after Beth’s death we received no answers from the hospital – it was very difficult to get them to talk to us. Slowly we gathered bits of information. We found out that at the last minute a new piece of equipment was used called a morcellator – like an apple corer – that removes chunks of flesh through laparoscopic portholes.

Searching for answers

It was only when we enlisted help from a friend with a medical background that we started asking questions that really needed asking.

Why did the hospital throw away all the equipment they used that night? Why didn’t they keep the blood that Beth lost? Why didn’t they try and retrieve the items when we’d asked them, even though they were still at the hospital? Everything that could have given us clear answers was disposed of immediately. It didn’t allow us to get the answers we so needed.

It surfaced that the surgeon who carried out Beth’s operation had only ever done three laparoscopic surgeries before – William had been her first. In her head she deemed it ok to try to operate that piece of equipment on my daughter.

Confusion

That was something we as parents could never understand – why would a doctor allow themselves to operate a new piece of equipment that they weren’t comfortable with, while their senior was in the room? I don’t think any of the surgeons understood that there was a technique to what they were doing, one that had to be learned.

The inquest

We did not receive an apology before or after the inquest. The hospital admitted they had failed in their duty of care and they were sorry that they had failed to prevent Beth’s death. They didn’t fail to prevent Beth’s death – they caused it.

The three-day inquest took place 18 months after Beth died. Unfortunately, the only way we could afford a solicitor was to take legal action against the hospital, which is something we never really wanted to do. For us it was never about money; it was about answers.

The only way I can describe the inquest from a parent’s point of view is that it’s like being tortured and you can’t escape. We had to listen to different stories about Beth’s last hours, while trying to fi t it all together in our heads – it was horrible. Information that came out in the inquest was contrary to what the hospital had been telling us in the months previously.

Photographs were revealed of the theatre and information was shared on Beth’s medication, which she’d been given but we were unaware of. A trainee surgeon was the one specifically holding the morcellator – they had never used it before and she was not allowed to perform surgery on her own.

During the inquest the hospital admitted that they had not received consent from us to carry out the operation on Beth.

I left the inquest room while they showed pictures of Beth’s autopsy, but my husband Richard felt he had failed Beth by allowing the hospital to do the operation, so he remained in the room – the pictures destroyed him. No-one should have to see their child cut up on an autopsy table.

The striking thing during the inquest was the arrogance and complete disregard by the medical professionals in the room for our feelings, and for the part that they played in Beth’s death.

In the months after the inquest, Richard suffered a massive heart attack and died – he was only 31 years old.

On a national level

Beth’s death was reported widely in the media and the UK government became interested in what happened. The Health Select Committee1 started looking at many incidents where hospitals hadn’t been open and honest with parents and relatives after operations or treatment that had gone wrong.

The Committee published a report about the death of Beth. It generated a lot of dialogue and interest in the subject that wasn’t there before – it was a catalyst for change. That said, I do think there is still a long way to go.

The Committee came up with some good ideas for ways to drive things forward, but it’s not always about rules and making people do things; it’s about a change in culture. Bringing in a law to enforce open candour and openness is not necessarily the right way forward.

Reflections

Attitudes need to change. Some medical professionals are too arrogant to believe they can be any better and that they can make mistakes. With this attitude you blind yourself to mistakes, and you won’t see one heading straight for you.

Junior doctors should feel empowered to stand up to cultures that threaten patient safety. They should be able to speak out and be supported by their seniors. They may not be correct all the time, but that should be ok – they shouldn’t be berated for being wrong; they should be rewarded for asking questions and having the courage to say “can we stop; can we check this is right?” Seniors should not view this as frustrating but as affording an opportunity to rethink what they are doing.

Learning to live again

I can’t do anything to bring my daughter back. My daughter has gone – I can’t do anything for her now; I can’t help her. But I can encourage doctors to be safer, to work as a team and to speak out. I want people to understand that once you’ve made a mistake or done something wrong, or been in a situation out of your control where something has gone dreadfully wrong, then you should be open and honest about what’s happened. Allow yourself to be found at fault because that is the only way that people can improve.

No-one can truly understand the pain of losing a child unless you’ve been there, but if you can think – even for a second – that you’re putting someone’s life at risk, stop and consider the pain that I feel every single day. Then I know you’ll do the right thing.

Opinion

"We’re moving from paternalism with patients – let the doctor tell you what’s right for you – to an openness and a patient partnering, where the patient not only has a right to know, but we want them to know." 

Lucian L Leape MD
Adjunct Professor, Health Policy, Harvard School of Public Health

"Don’t think we can become safer secretly. There’s some very inescapable connection between openness and honesty and disclosure and involvement, confession, apology... all acts of openness in building a safe culture. I think this idea of transparency and openness is an essential part of our future."

Dr Donald Berwick
MD, MPP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement

"Information about errors and adverse events, harmful outcomes in healthcare, has very seldom been studied openly; it’s been treated as a nuisance, something we don’t want to know about, an occasion for shame, guilt, and other sorts of problems. In the last few years in healthcare we’ve come to realise that it can also be – if treated properly – a resource, and an essential way of achieving a safe culture."

Professor Charles Vincent
Professor of Psychology, Emeritus Professor of Clinical Safety at Imperial College London, Imperial College, London

"When something goes wrong, you need to lose sleep over it. Why did it happen? Do I understand what happened here? Have I made sure that I know the reasons this happened? What can I do to prevent it? Have I said sorry to the patient? Have I involved the patient in this situation? Have I talked to staff? I think that’s a really important obligation of doctors."

Professor Mayur Lakhani
GP and Chairman of the National Council for Palliative Care, UK

"Medical teams are human. Medical teams are driven to succeed and have the needs of the patient at heart. They need to be pre-occupied with the possibility that they will make errors. The team leaders, usually consultants, must understand that they will make mistakes and try to break rules in order to achieve results. The safety net is their team who must trap or mitigate the consequences of such errors or violations. Research shows that if the leader briefs the team in an open, interactive and inclusive manner then team members will speak up in an assertive manner when the situation demands."

Guy Hirst
Former British Airways training captain and human factors expert

References

1. Note to non-UK readers: the Health Select Committee is part of the UK parliament, and oversees the operations of the UK Department of Health.

Here is a link to the Health Select Committee report: www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/151/151we22.h