15 March 2013

laming 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.”