Black Triangle

Currently there are calls to obtain a head on a stick for the death of Jean Charles de Menezes at the hands of armed Police. One head of interest is that of Sir Ian Blair, who some wish to see resign – he does not wish to do so. Others, such as the de Menezes family, want Police personel lower down the chain dealt with by criminal law. Even Oliver Kamm, a strong supporter of action against terrorism, wants Blair to go; although his argument is based more on Blair’s demeanor after the shooting, rather than the operational failings themselves.

David Aaronovitch recently argued that those responsible for de Menezes death were not the Police, but the terrorists who had planned suicide attacks in London. While this is a position I find understandable, I’m more interested in whether the outcome that people want will reduce the chances of future deaths in similar circumstances. To do so I think a comparison with the NHS is illuminating.

While the London Met has tragically shot one man dead on the London Underground, the NHS has been calculated to kill 30,000 patients a year due to medical error. That’s about 80 people a day, killed by NHS staff making mistakes with prescriptions, scalpels and other complex procedures. While the desire to continue to blame individuals still exists, especially with regard to manslaughter charges and medical staff, the NHS has attempted to move away from a blame culture towards an open learning culture to give a higher reliability of service. Rather than criticising individuals, it has been argued that the focus should be on systems. One of the early advocates of this approach expressed this view succinctly as:

Humans make mistakes because the systems, tasks, and processes they work in are poorly designed.
Lucian Leape.

Lucian Leape also highlights another reason why focusing on individuals is counter-productive:

Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. Thus, a punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes.

In the UK government policy on medical error has been changed by the reports An Organisation with a Memory, and Building a Safer NHS. This has led to the development of the National Patient Safety Agency, which has already made in-roads into changing systems in the NHS to provide greater patent safety.

Open reporting cultures create more opportunity to learn from errors. James Reason noted in the BMJ, and in his excellent book, several years ago that:

the most important distinguishing feature of high reliability organisations is their collective preoccupation with the possibility of failure. They expect to make errors and train their workforce to recognise and recover them. They continually rehearse familiar scenarios of failure and strive hard to imagine novel ones. Instead of isolating failures, they generalise them. Instead of making local repairs, they look for system reforms.

I see no logical reason for why this approach should not apply to the London Met, as well as it does to medicine, the nuclear industry, air traffic control, or pilots. On the basis of the argument being put forward for Blair’s resignation, the heads of all UK NHS trusts should immediately resign, and large number of health care professionals should be prosecuted, because of the deaths caused each year. While blaming individuals may give a short-term facade of improved safety, the real focus should be on the systems of work.

In the case of the de Menezes shooting, the IPCC report gives a way forward. Just like medicine, modern policing is a highly technological system that requires highly trained personnel. There needs to be a detailed run through of procedures, training, equipment, intelligence gathering and other operational issues, in order to discover potential failure points and neutralise them. There should also be some public acceptance of the rapidly changing situation the Police were dealing with, in the wake of bombings that had been foiled the previous day, and bombings that had killed 52 people two weeks previously. There should also be an acceptance that similar errors may also occur in future – if the police are going to act against terrorist cells effectively.

Sacking Blair will do little for public safety, however much it might feel emotionally right in the short-term or suit your political stance.