CEO Update - Let’s pilot a better system and learn from our mistakes
Let’s pilot a better system and learn from our mistakes
Many of us commenced the week confronted by the CCTV footage of Miriam Merten in such a distressed and distressing state in one of our mental health facilities.
The outpouring of anger and disgust was swift and sincere, but we are yet to see whether the horrific footage will be a catalyst for real and lasting reform, or whether it will quietly join the archive of historic abuses that stretch back to the Burdekin report and beyond.
I understand two inquiries have been established to recommend changes, but for those of us whose shelves are filled with such reports, it is hard to understand why yet more inquiries are needed to achieve change.
I happen to be an amateur pilot, and one of the things that is drummed into pilots from the beginning of their training is encouragement to be a “student of failure”.
Each week the Air Transport Safety Bureau send me notifications of incident reports. These reports take two forms – the first is an initial report on what is known about any recent events, the second is full reports on investigations that have been completed.
So if a light plane crashed anywhere in Australia this week, I am sent an initial report – me, a recently qualified, low hours pilot, flying for fun in Canberra. These reports include many details – weather, pilot readiness and planning, Air Traffic Conditions, mechanical information and service reports, any anomalies and irregularities – all of which will be examined more fully by a complete investigation.
Almost always, serious incidents are the consequence of the tragic alignment of a range of variables: a mechanical error arising from a recent service; not picked up because the pilot was too rushed to complete a pre-flight inspection; passenger eagerness to get to the destination meant flying into adverse weather conditions; all culminating not in an “accident”, but in what pilot’s call a “collision with terrain”.
Miriam Merten’s death is a tragedy, but not an accident. It resulted from staff neglect, but it also resulted from system failure, it resulted from political failure. We would not tolerate understaffing, by inadequately qualified and under-trained staff, under reporting, and lack of preventative programs in other parts of the health system - why do we tolerate it in mental health units?
How on Earth can we be in a circumstance where somebody is locked up more than a 100 times and it’s not ringing alarm bells? To have somebody locked up 100 times and to have nobody asking the right sort of questions about why this is happening, and what the alternatives could be, reflects the failures of our systems.
If the Air Transport Safety Bureau suspect a pilot was distracted by a message on an iPhone in an incident last week, the entire community of pilots across Australia know about it within a week.
And this reporting is not about witch hunts, it is about constantly improving the safety of flying, by improving the systems that support it. Everyone in the system is encouraged to report and reflect on failures so that the system can be improved, if possible, every time something goes wrong.
More people visit our mental health facilities than fly in light planes each week, and no one is there for fun. Where is this culture of quality, accountability and improvement in our mental health system? Who looks over the whole system to analyse and comment on how failures can be avoided?
Until we develop a similar focus on quality, and ultimately safety of consumers and carers, and put in place the processes, accountabilities and most importantly the culture we need to achieve continuous improvement, we will continue to see tragedies like this.
Let’s not let Miriam Merten’s death be in vain.