# Independent Review on the Care Given to Mrs Elaine Bromiley

*Harmer · Safety & Error, Power & Equity · Independent clinical review (The xx Clinic) · 2005 · Open access*

An independent medical review of the death of Elaine Bromiley during a routine sinus operation in March 2005, commissioned by the clinic and made public by her husband Martin Bromiley so that others might learn. Three experienced clinicians failed to perform a straightforward life-saving tracheotomy while nurses who recognised the emergency were unable to make themselves heard. The case is now a landmark in patient safety education: it demonstrates normalisation under pressure, task fixation, and — critically — the silencing of lower-status voices (nursing staff) by the social dynamics of a clinical team under stress. Martin Bromiley's decision to make the report public, and subsequently to establish the Clinical Human Factors Group, transformed a personal tragedy into one of the most influential patient safety teaching cases in existence.

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