0

In my book Black Box Thinking, I write about the tragic case of Elaine Bromiley, who went to a local hospital for a routine operation and tragically died. The significant aspect of the case is that the nurses in the operating theatre had an idea about how to save her life but didn’t communicate it to the senior surgeons because they felt they were not supposed to “speak up”.

After all, they were the junior people in the room. The surgeons were in charge. The nurses felt that it might be inappropriate, perhaps even professionally unacceptable, to make suggestions in such august company. What if the surgeons were offended by their “interference”? What if they had already decided against the proposed solution for reasons they (the nurses) hadn’t considered?

If this sounds like an idiosyncratic case, consider that it is now regarded as a seminal moment in healthcare; the moment that insiders realised that “steep hierarchies” in teams can undermine (and sometimes destroy) communication. In aviation, a number of crashes in the 1970s occurred due to the same cultural problem, not least United Airlines 173 where the engineer didn’t communicate dwindling fuel reserves to the all powerful captain.