‘Blaming and shaming’ healthcare staff sets dangerous precedent, say doctors

Press Release – New Zealand Medical Association
“‘Blaming and shaming’ the healthcare professionals involved in the care of Zachary Gravatt sets a dangerous precedent and will not help improve the care or safety of other patients in the health system,” says Dr Paul Ockelford, Chair of the New Zealand Medical Association.

Zachary Gravatt died of meningococcal disease in Auckland City Hospital in July 2009, having been admitted to the hospital about seven hours previously. A coronial hearing found the doctors and nurses involved in his care had not been negligent, but that they were part of a hospital system under extreme stress during a swine flu epidemic.

Name suppression granted by the coroner was lifted by Justice Christian Whata in a High Court ruling two weeks ago that sets a precedent on the protection often afforded doctors by the coroner.

“The greatest challenge to moving toward a safer health system, according to the Institute of Medicine, is changing the culture from one of blaming individuals for errors, to one in which errors are treated as opportunities to improve the system and prevent harm,” says Dr Ockelford. “This principle is at the heart of the need for open reporting, without fear of blame and retribution, and recognises the importance of this for overall patient safety and quality improvement.”

The original ruling of Coroner Brandt Shortland was clear that the system – rather than the individuals within it – was at fault. He also observed that “to publish the names and details leading to the identification of those involved…would be a form of punishment and would set an extremely dangerous precedent for future media coverage”, with the “potential to seriously undermine the confidence in the health system”.

“The NZMA agrees with this view, particularly given the widespread evidence and research that shows a ‘blame and shame’ approach actively works against achieving necessary quality of care improvements.” says Dr Ockelford.

“The coroner found no blame should be attached to those staff who did their best to care for Zachary. The NZMA believes, therefore, that the ‘shame’ of publicly naming these individuals is completely unwarranted and – ultimately – destructive of the coroner’s statutory purposes.”


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  1. Zachary's Dad, 16. March 2013, 12:14

    Justice Whata ruled that freedom of speech and open justice ‘trumped” the doctors’ general concerns about being named. Freedom of speech and open justice are part of the cornerstone of our society and so we applaud NZMA’s right to express their views openly. However, it is unfortunate that they should chose to discredit the judiciary knowing full well that they cannot respond.

    Learning from medical errors is critical. Coroner Shortland made several important recommendations following Zachary’s tragic death which were aimed at avoiding future deaths. We ask the NZMA and others involved what their response has been 18 months down the track to the Coroner’s recommendation for the development of a national early warning scoring system and a national protocol for pre-hospital antibiotics?

  2. Urologist, 22. March 2013, 23:23

    As a doctor I know that meningococcal disease is tremendously difficult to diagnose and this would have been even more difficult when the hospital was overwhelmed with swine flu cases. It is also very easy to analyse these events in retrospect and come up with obvious solutions in the cold light of day as opposed to in the fog of war.

    I’m not entirely sure that naming these individuals, who did their best under enormous constraints, will change how such unfortunate situations are managed in the future. Changing processes will save lives, not naming these blameless healthcare staff.

  3. Rachael, 23. March 2013, 9:54

    To Zachary’s Dad. I’m sorry for the loss of your son. One doctor involved in your son’s case still has name suppression. Why is this?

  4. Kim, 3. April 2013, 19:17

    Of course the NZMA would want to protect its members and does not want doctors with duty of care to take any responsibility.
    Didn’t the last big public “name and shame” create the HDC patients’ code of rights which tried to address the imbalance for patients.

    @urologist following the correct medical process is important, as is having faith in the public hospital system; a health system that should aim to see a better than a “fog of war” -don’t you agree.

    I have read a lot of HDC serious patient complaints with their findings, (and have first hand experience of an event myself). The common theme is that no one takes responsibility and no improvement for others occurs. This should change so that the health system can improve, not just get even better at make excuses. You must first acknowledge the problems/errors in order to change the health system.

    Learning from medical errors is critical, in this there cannot be denial of error.

    Zachary’s dad is wise, and we are sending our love and deepest sympathy.

  5. Zachary's Dad, 15. April 2013, 10:56

    So sorry for my late reply to Rachael’s question. The doctor who has permanent name suppression presented affidavit evidence to the Coroner of a potentially life threatening illness that stress could make worse. On this basis we chose not to oppose name suppression.