On the front page of London's Evening Standard of 14 February the face of 3 year old Najiyah Hussain, beside the headline “She was killed by a hospital,” looks the epitome of wronged innocence. The paper's principal focus is the human tragedy of Najiyah and of her family. There has been little time, and little space, for analysis. But we are told: “Police are investigating the incident and a doctor has been suspended.”
The facts seem obvious. Najiyah, “given laughing gas instead of oxygen,” was the victim of a mistake that you would not expect could happen in a modern health service. A victim, just like Wayne Jowett, who died on 2 February, a month after vincristine was injected into his spine instead of a vein at Queen's Medical Centre, Nottingham. And just like the 74 year old man who died at the Royal Sussex County Hospital, Brighton, after the wrong drug was administered during surgery on 7 February.
Yet mistakes of the kind that led to such deaths are not as rare as the public believes. It is just that, by focusing—as newspapers and other popular media almost invariably do—on the human tragedy of the victims and notions of individual culpability, the extent of errors and the system failures responsible are overlooked. The Daily Mail's first report on the death of Najiyah Hussain was: “Doctor may face gas death charge.” Lower down the story mentions that safety procedures are meant to ensure that nitrous oxide cannot be confused with oxygen, but the finger has already been pointed.
In all this there is an assumption that doctors generally don't make mistakes, and those who do have failed to live up to some imagined medical paragon. But is there a point in the reporting of errors at which the volume of cases will lead away from a focus on individuals to an acceptance that mistakes are inevitable in any system operated by humans and that there is a need for a system based rather than a blame based approach? In this respect, Alison Harper's following account of how she covered two incidents in Brighton offers some hope.