Independent Review on the Care Given to Mrs Elaine Bromiley

Harmer / Bromiley · 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.

Harmer, M. (2005) Independent Review on the Care Given to Mrs Elaine Bromiley on 29 March 2005. Prepared for The xx Clinic.

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