The Moral Obligation to Learn from Mistakes
Today (Wednesday 22 May 2019) sees the launch at the Royal College of Anaesthetists 2019 Conference of The Cappuccini Test which heralds the introduction of an audit tool to improve patient safety in anaesthesia based on the lessons learned from Frankie Cappuccini’s death (see news piece here).
The Cappuccini Test will act as a checking system for the proper supervision of trainee and non-autonomous SAS anaesthetists. If they are identified from their rota as working alone they will be asked by the person carrying out the test who is supervising them and if they know how to get hold of that person. The supervisor will then be called to double check they know the individual they are supposed to be supervising and what that individual is working on.
The Cappuccini Test is being incorporated into the standards set by the Royal College of Anaesthetists and into their hospital accreditation process, and will be included as a quality improvement tool in their “QI Recipe Book’.
Tom Cappuccini, Frankie’s husband, comments as follows:
“It is such a relief to know that there has been genuine learning from Frankie’s death. I know that it is what she would have wanted and I am very grateful to David Bogod for his perseverance pursuing the project. Patient safety has got to be paramount and learning from awful events such as Frankie’s case must be the only way forward.”
David Bogod, Elected Consultant member, Royal College of Anaesthetists, comments:
“The NHS is dependent upon medical staff below the level of consultant for much of day-to-day patient care. Prompt identification of and access to a supervising consultant is vital for patient safety, and failure of this process was a key factor in Frankie’s death. I am grateful to my colleagues at the Royal College and in Nottingham for their help in developing this simple audit tool to test for effective supervision, and particularly to the Cappuccini family for their support. Inadequate consultant supervision is an issue that affects all areas of hospital care, and I hope to see the Cappuccini Test taken up by other medical specialities.”
Kate Rohde, Tom Cappuccini’s lawyer and partner in the medical negligence team at Kingsley Napley, observes that by developing this test David Bogod has started to close the loop between awful events with catastrophic consequences and genuine learning and system change. She comments that:
“after many years of practice in the area of medical law I hope that this test can mark a shift to reflect a new culture emerging within the NHS.”
For press enquiries / further information, please contact Deepika Misra on 020 3535 1641 or firstname.lastname@example.org
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