While the presentations today were enlightening and provided me with a good framework and better tools to think about and discuss patient safety, Dave was absolutely correct in saying that it is the stories that stick out to you most. I was deeply disturbed as most would and should be by Lewis Blackman’s story. The missed alarming symptoms, the lack of respect for the family, the miscommunication, the strained staff came together in a horrific (all too common) perfect storm.
What struck me the most, however, was Helen (Lewis’s mother) speaking of the guilt she felt. It honestly made me angry to think that after this nightmare she went through, the completely preventable death of her son at the hands of healers, this mother felt responsible for her son’s too soon departure from this world. She thought it was her fault. I find this atrocious that not only did the medical staff leave her alone without any apology or closure, they left her footing the blame in her own mind. Can you imagine that burden?
In Helen’s case, a doctor finally told her to not blame herself, that it was his and the hospital’s fault. The way she described a form of relief at this gesture shows it may have helped her begin to move forward. I can’t help but wonder how many families, mothers, fathers, spouses, have been left thinking they were somehow to blame. They could have said more, they were there in the room, weren’t they? Or maybe they didn’t take care of them well enough? Without any transparency, these loved ones have been left not only with the unnecessary loss of a loved one, but with the immense burden of guilt. I fear that the costs on their mental health have been high.
I hear physicians say all the time that being a pediatrician would be great if it weren’t for the parents; they are overbearing and overreact. This dangerous thinking may have led to ignoring Helen and thousands of parents who knew better and should not be left to wallow in the depths of despair and particularly guilt when we make an error.