Closure through Open Disclosure: Two Wrongs Don’t Make a Right.

Many years ago, I remember walking into the playroom to find two of my daughters screaming at one another – my younger daughter was in tears.

Using a firm, but much lower tone than theirs, I requested both of them to stop screaming. They did. At just seven and six years of age at the time, these little arguments were a regular occurrence. I bent down to their level and asked both girls what had happened.

I was abruptly met with more ear piercing screeches of:

“She did…” “No, she did..!” “NO, I DIDN’T…!”

Again, lowering my voice even further to almost a whisper, yet remaining stern, I asked them to speak one at a time. I had learned that raising my voice often had the opposite effect.

My youngest jumped in first telling me that her older sister wouldn’t play a game with her and in retort had grabbed her hairbrush off her when she was using it, and it had pulled her hair in the process. Almost immediately, my eldest daughter defensively intervened, telling me that it wasn’t true and that she had simply seen it on the floor and picked it up, and that her younger sibling had hit her.

I sighed. I had a good idea who was at fault but I needed them to admit it. So I again asked each of them to reiterate their stories, but this time I watched their eye contact and body language closely. My youngest, again, held her ground with me (while also glaring at her sister!), but when it was my eldest’s turn, she glanced around the room and looked uncomfortable.

I couldn’t make judgement based on this evidence alone though. That wouldn’t be fair, nor would it be the right thing to do.

I sat them both down and told them how two wrongs don’t make a right and that telling a lie, on top of a wrongdoing, would mean they could be in trouble for two things instead of just one. As they were so young, I informed them that “Santa Clauses Robin” could tell me either way about what happened and I gave them a second chance to tell their story. My youngest daughter was adamant that she was telling the truth. My eldest however, paused and in this short window of opportunity, I quickly reminded her that two wrongs could mean double punishment, but if she felt there was anything she wasn’t telling me, I would give a momentary chance for redemption,.

She looked down and thought about it.

She then looked up at me, not looking at her sister, and admitted she had pulled the hairbrush from her sisters hair. And just before she got a chance to add any excuse as to why she did it (i.e. not wanting to play her sisters game) I promptly praised her for being honest. She now looked up at me wide eyed, but now her eyes were filled with remorse, not defense.

I asked her why did she lie.

She told me she was afraid she would get in trouble. I asked her would she not feel guilty after hurting her sister and would have to live with that fact? She not only would have hurt her once, by pulling her hair, but thrice, by also getting her in possible trouble with me for both hitting her and lying about it. I told her it may be hard for her sister to be her friend in the future if she couldn’t trust her.

She said she hadn’t thought about it like that.

I asked her why she had hurt her sister with the hairbrush in the first instance and she said she did it because she was tired. I asked her what she would do differently and she said she probably would have come in to me to tell me, instead of hurting her sister.

I then asked my youngest daughter was there anything her big sister could do to help her feel better. She said if she said sorry and if she would play the game with her that that would make it better. And that was the punishment I gave to my eldest daughter. A punishment which ended up with them both rolling around the floor laughing – the best outcome, in my books!

But there was a lesson learnt too.

My three daughters, all older now, know the  strict rule in our house – two wrongs never make a right. Lies do not go down well.

Open disclosure is not just for healthcare – it can be applied in all areas in life.

I decided to use this principle with my staff. From day one, I always told my team to tell me if they felt they had done something wrong, and not hide behind it. That we would deal with one problem, and not two. Also, living with a lie can eat away at a person, subconsciously.

The same goes for business contracts, partnerships and deals. If issues arise, people can often want to jump into taking a legal case. Often, resolution can come, just by having frank, open and honest conversations – with an aim to find solutions together.

Who wants to make something private, public and possibly damage the reputation of a business or the people working there?

I know sometimes this method doesn’t always work out, but it’s definitely worth trying in my opinion.

Building trust is key for organisations, and it is even more important for those working in healthcare.

We are all human. We can all make mistakes.

But what if that mistake harms another person, or worse, kills them?

I truly do believe that 99% of those working in healthcare aim to help patients, not harm them [of course there are a few cases where this has occurred (eg. Dr Harold Shipman Case, 1998)] but that is a tiny, tiny percentage.

I do not think people who chose their career to help others would ever intentionally make decisions to hurt their patients.

But what happens when they accidentally do? Do they tell the truth? Do they hide behind it?

Open disclosure in healthcare is defined as:

The open discussion of incidents that result in harm to a patient while receiving health care with the patient, their family, carers and other support persons. The essential elements of open disclosure are outlined in the national Australian Open Disclosure Framework.”

Australian Commission on Safety and Quality in Healthcare

But is open disclosure always practiced as it should be, even if it is in policy and departmental recommendations?

Unfortunately the answer is, no.

Legalities can be blamed as a major causation for same. I completely agree that all parties should be given the right to fair proceedings; but sometimes it is completely unnecessary. The fear of being sued is very real. But remember, much like “Santa’s Robin”  – investigations will often reveal the real truth anyway.

And sometimes patients and families are left with no other choice but to take this route, or need to be compensated for damages done.

Another factor which also comes into play with regard practicing open disclosure, especially in small communities and countries, is reputational damage for health professionals. The fear of everyone knowing you did something wrong, is the same as was the case for my daughter. The fears we may get in trouble; or that people will judge us are very real. But there is also the fear of a career we spent years building, being taken away from us.

And I get this. I really do. 

But what about a patients or family’s lives?

Especially those left permanently damaged, disabled or…sadly, dead.

Patients and families living with constant questions unanswered, self-doubt – and a guilt that they could have done more for their loved ones, never leaves their mind.

Closure, through open disclosure, could help alleviate much of this. 

As could the early interventions upon learning of a potentially harmful event caused by a health professional to a patient. If in the case a health professional disclosed an error early enough, treatment could be administered and/or protocols and safety measures could be put in place to ensure incidences do not recur again. I do not believe a health professional who has harmed someone and not disclosed it can simply wash their hands from it and delete it from their minds. I do tend to think that if preventable harm was known by the person who caused it they would feel elements of remorse too. But just like a harmed patient or family, relief from these emotions may never ease – if it is never dealt with.

I feel guilt would live with a health professional all their own lives. And while this may change how they personally do things in the future – if it is not disclosed openly, it doesn’t change anything at all at a systematic level.

Maybe on the day of the incident the health professional was just so tired (like my daughter) that it caused an error. Maybe there were other uncontrollable external factors? If these are not highlighted openly how can management teams know to change the length of shifts or how their health service needs to change to support staff?

It is hard to admit we did something wrong. It’s even harder if it involves a persons life.

But it is far, far harder for those living forever with the pain caused by same.

I myself have experienced this pain.

I have sat through my dads public inquest. I can say that the immense pain and confusion I lived with was somewhat alleviated when I met with some of the health professionals prior to this inquest. Apologies were given and tears were shed, by us as a family, and the health professionals who cared for him.

This conversation led to on the day of the inquest, when offered an adjournment by the coroner, we as a family, chose to close the case.

We felt lessons had been learned and we shook the hands and hugged the health professionals when we left the courtroom.

One health professional told us he would never forget our dads firm hand shake and anytime he met with someone who had a limp handshake, it reminded him of our dad. This was so personal to me and it was at that point that I saw the “human” behind the “professional”.

You see, not all patients and families are out to get “payback” or “payouts”.

We just want answers, apologies, if necessary – and if it is noted that compensation is required to help families cover health expenses or losses, this should be forthcoming too. It is the right thing to do.

Two wrongs never make a right – and when in doubt about what the right thing to do is, do what you would want done to yourself.

Telling a constant lie could mean a double punishment. Trust can be regained, but only if there is a willingness for the trust to be restored.

Articles related to open disclosure:

Irish Health: The high price of medical negligence

Irish Medical Times – And Open Door on Open Disclosure 

Mr Stephen Mc Mahon [IPA] advocates for Open Disclosure

HSE: Open Disclosure

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