title: When silence threatens safety: lessons from the first Canberra Hospital neurosurgical inquiry.
abstract: Despite widespread institutional and professional support, the recommendations of the Bristol Royal Infirmary Inquiry may be insufficient to reduce patient risk from impaired senior medical practitioners. Using the First Inquiry into Neurosurgical Services at the Canberra Hospital as a case study, this article argues that the Bristol-type recommendations--which emphasise reformulation of clinical governance structures, including early reporting of "sentinel events" and compulsory clinical audits--will be ineffective without a reformed institutional ethos that encourages open transparency and respect for those committed to such processes. Such reformulation may need to commence in medical education and involve new strategies including the use of portable digital technology to facilitate self-assessment of performance and immediate reporting of adverse incidents.
authors.affiliation: Law Faculty, the Australian National University, Fellows Rd, Acton, ACT 0200, Australia. Thomas.Faunce@anu.edu.au
authors.forename: Thomas
authors.initials: T
authors.lastname: Faunce
authors.forename: Kerry
authors.initials: K
authors.lastname: Mure
authors.forename: Catherine
authors.initials: C
authors.lastname: Cox
authors.forename: Brigid
authors.initials: B
authors.lastname: Maher
mesh_terms: D001315:Australia; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality / Q000592:standards; D002648:Child; D003657:Decision Making; D006739:Hospital Administration / Q000592:standards*; D006801:Humans; D007882:Legislation, Hospital; D010820:Physicians / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000458:organization & administration; D012307:Risk Factors; D012449:Safety / Q000331:legislation & jurisprudence* / Q000592:standards; D035642:Whistleblowing