The last few weeks have seen some incomprehensible tragedies, ones for which individuals seem destined to shoulder much of the blame.
But is it completely fair to blame pilots for mis-judging the runway, contractors for misunderstanding a braking system or train drivers for going too fast – when each of these failings could and perhaps should have been “caught” by fail-safe systems?
Since the Herald of Free Enterprise disaster in 1987 to The Corporate Manslaughter and Corporate Homicide Act 2007, there have been attempts to shift the responsibility from individuals to “controlling minds” – those who might be held responsible for poor safety. The emphasis is on putting systems in place so that the safety of others is not dependent on individual human beings. The beauty of systems is that they can be subject to continuous improvement. The Manchester Airport disaster of 1985 (when pilots failed to realise a plane’s wing was on fire) led to video cameras on the roof of the fuselage so pilots could seen what might be happening. The Flixborough disaster of 1974 was the driver for management of health and safety at work regulations and safe systems. There are thousands of other examples where disasters have led to system changes.
It is not surprising therefore that the desire to improve care will necessitate sound systems; ones which can be improved upon continuously and which reduce dependence on individual human beings.
But there is a further dimension to this need to recognise human failings. The death of nurse Jacintha Saldanha at the centre of a hoax call to the bedside of the Duchess of Cambridge empathises the need to protect employees who may be in trauma from their actions. It is impossible to grasp the desolate trauma of some of those caught by recent events.
These examples, towards the extremes of human tragedy, nonetheless have their parallels in the care sector. Sound systems are required for the protection of service users and they need continuous improvement. Where individuals fail we need to remember that systems have failed too. Systems can be changed, permanently.
Malcolm Martin – QCS Expert Contributor on Human Resources
