Written evidence submitted by Professor Hugo van Woerden (MWL0001)

Summary

This is a simple and brief submission in relation to the principle of Maxwellisation, which argues that there are lessons from the realm of Improvement Science that have been applied to healthcare and aviation that may be relevant to the approach taken to public inquiries and have implications for the most effective use of Maxwellisation.

1. The timescales for response need to the findings of public inquires need be proportionate, or this tool can be used to unduly delay the release of findings.  However, I would argue that there is very little evidence that delay in release ultimately does harm.  Even in the context of the Chilcot Inquiry, the most that can be argued is that delay has slightly reduced embarrassment.  That has to be balanced against the fact that the passage of time often provides greater perspective.
2. My main argument in relation to Maxwellisation is, as Proverbs 18:17 puts it, “He who pleads his cause first seems right; until another comes and questions him” (WEB).  There are always two sides to every story and it is an essential principle of justice to allow both sides to be heard.  It is also essential that there is a presumption of innocence.  There seems to be an increasing sub-conscious desire in society to equate public accountability with a need to find someone to blame whenever something goes wrong.  A public inquiry which does not find someone to blame, and in fact does not draw some blood, seems increasingly to be perceived as having in some sense failed.  This culture is highly problematic and needs to be challenged at the start of every public inquiry by a clear statement that the role of the inquiry is to learn the lessons, not to find someone to blame.
3. In contrast, evidence was presented at a recently global patient safety summit that the culture in healthcare is moving from a “blame culture to a learning culture”[1].  There is increasing recognition in the health sector, as there has been for many years in the aviation sector, that finding a scapegoat to blame reduces systems level learning and increases the likelihood that a mistake will be made again.  Public inquiries should have as their main goal societal learning that reduces the risk of recurrence of any errors that have been made.  This is best done by separating out the actions taken by individuals from value judgements in relation to those individuals; critiquing what happened rather than criticising the person.
4. The following is an extract from the article referenced above1:
5. A learning culture not a blame culture
6. In his book Black Box Thinking, Matthew Syed, whom we will hear from later, talks about how that same blame culture used to exist in the airline industry.
7. He tells the tragic story of United Airlines flight 173, where 10 people died in a crash that happened in December 1978. The pilot, Captain Malburn McBroom, was trying to rectify a potentially dangerous problem with the landing gear but failed to notice that the plane was dangerously low on fuel. When he was forced to crash land the plane, he did so with extraordinary skill saving the lives of over 150 passengers. But because of his mistake – not noticing the low fuel levels, he got tied up in a 7-year long court case, came close to suicide, lost his pilot’s licence, and ultimately died a broken man.
8. But that tragedy had a surprisingly positive ending.
9. Because it became the moment the airline industry realised that if it was going to reduce airline fatalities, it needed to change its culture. They realised that ‘human factors’, rather than technical or equipment failure had been at the heart of the problem. Anyone could have failed to notice low fuel levels when they were trying to fix the landing gear. Why didn’t other crew members spot the problem and speak out? The issue was not that particular person, but what could have happened to any person in the same situation.
10. As a result the airlines transformed their training programmes. They mandated reforms that required pilots to attend group sessions with engineers and attendants to discuss communication, teamwork and workload management. Captains were required to encourage feedback, and crew members were required to speak up boldly.
11. And the result? There were dramatic - and immediate - reductions in the number of airline fatalities. The number of deaths overall halved over 30 years - at the same time as air travel increased nine fold. 10 people died in the United 173 crash, but experts are unanimous that the learning that resulted has saved thousands more.
12. I would suggest that this inquiry should focus on ways in which public inquiries can maximise learning and reduce blame.  This will minimise the risk that those who feel ‘got at’ use Maxwellisation as a delaying tactic.  It is essential that witnesses to public inquiries are  encouraged to contribute to systems level learning from the mistakes that they may have been involved in and are protected from a lynch mob mentality, often egged on by the press,  who want a simplistic and exciting story that will boost the sale of news.  The appropriate use of anonymity might be a tool that could be further explored in this regard.
13. This evidence is provided in a personal and not in a professional capacity.

9 July 2016