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The news that a young girl died as a result of a misunderstanding over a cup of hot chocolate is a tragedy…
… of course it is.
A tragedy for the family, the company and the member of staff involved, the dentist, the pharmacy that tried to save her and the NHS that couldn't...
... and not least the young girl who’s life was so full of potential none of us shall ever see come to fruition.
Her death is attributable, so the family lawyer claimed, to the coffee-shop company’s allergy-training for front-of-house staff being, ‘a tick-box exercise’.
Well, who hasn’t sat in front of a computer and ticked the boxes for mandatory training. It’s the way of the world…
… it is cheap, it ‘ticks all the boxes’ for the company with the statutory responsibility to train (in this case) every member of their 19,000 staff, in constant churn, in 2,467 locations.
The hospitality industry has an employee turnover rate of 30%… double the national average. It’s hard to see how they could make training anything but on-line… ticking boxes. But…
… that is not all. There was a wider combination of circumstances.
A misunderstanding about what was ordered, between the front-of-house staff and the mother for which, neither was English their first language.
Reasons for which as far as I know go unexplained, neither the young girl with a known serious allergy, nor the mother had an Epi-pen with them…
‘…a medical device for injecting a measured dose of epinephrine by means of auto-injector technology… often used for the treatment of anaphylaxis.’
The coffee shop incident was followed by a planned visit to the dentist. Whilst waiting the girl took a sip of the chocolate and became ill.
CQC regulations require dentists to carry Epi-pens but in this case...
... for reasons that are not clear, one wasn't used.
The mother and the girl went, instead to a pharmacy.
There the girl collapsed. The pharmacist gave her a paediatric (lower) dose of an EpiPen injection in her leg.
The inquest heard an adult dose would have saved her life but there was a general shortage of EpiPens.
The inquest also heard that a customer in the chemist who tried to resuscitate the girl, also had allergies and had an EpiPen with them.
For reasons that are not clear, that adult pen was not used.
The pharmacist told staff to look around to see if there were any EpiPens but none could be found.
The reasons for a shortage of Epipens go unexplained.
Had an ambulance been called, in a timely manner, this unnecessary death might have been avoided.
The reasons one was not called earlier are not clear to me.
We're left to wonder what might have been. What part the dead hand of coincidence played.
Happenstance, destiny, laxity, confusion, panic... a cumulative effect.
Since July 2016 the law demands food and beverage outlets make clear the ingredients of their menu and train staff in awareness.
It’s hard to see what more the law can do?
- Impose English language tests for coffee-shop staff, as do the NHS?
- Make the barrister and the customer sign for what is served?
- Make it mandatory for people with certain allergies to always carry an Epipen when in public?
If this is a management puzzle it was well described, in 1990, by James T. Reason, from the University of Manchester.
He proposed a model of 'accident causation' called the Swiss Cheese Model;
‘…it likens human systems to multiple slices of Swiss cheese, which has randomly placed and sized holes in each slice, stacked side by side, in which the risk of a threat becoming a reality is mitigated by the differing layers behind each other…
… lapses and weaknesses in one defence do not allow a risk to materialise in another… preventing a single point of failure.’
Systems only permit failure when all the holes, momentarily align…
… as they did in the coffee-shop; a language error, no appropriate Epipen and various well intended interventions that were too little or too late.
There are…
… active failures where unsafe acts can be directly linked to the accident… language difficulties, no pen and…
… latent failures include contributory factors… supply chain issues with Epi-pens and poor decision making.
To keep us safe we create layers of protection, all of them have holes in. Generally, they don’t align and it’s ok. When they do, they can produce unique outliers of failure…
Leaving us the question; can we expect all risk to be mitigated out of systems?
Probably, if you take away the people…
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