Learning from the Bristol inquiry

A toxic triangle of destructive leadership at Bristol Royal Infirmary: A study of organizational Munchausen syndrome by proxy

Although leadership literature increasingly recognizes that leadership is a complex, co-creational process among leaders, followers, and context, destructive leadership scholarship has only recently embraced this paradigm. This article contributes to the toxic triangle debate by linking destructive leadership theory and disaster research in a case study of Bristol Royal Infirmary, a UK hospital that experienced a crisis in its pediatric cardiology unit resulting in the death of dozens of babies undergoing surgery. Thus, the article expands the literature on organizational failure by offering an assessment of how seemingly good, well-intentioned professionals can nonetheless create destructive leadership dynamics and proposes a new, more nuanced theoretical framework called organizational Munchausen syndrome by proxy as a way to analyze what went wrong.

The Hospital Mortality Project: A Tool for Using Administrative Data for Continuous Clinical Quality Assurance

The increasing demand for greater clinical accountability requires development of convenient tools to measure healthcare safety and quality, which are able to provide information contemporaneously. The purpose of this paper is to describe the development of the Hospital Mortality Project, a quality assurance initiative designed to encourage and facilitate clinical accountability for hospital mortality by all clinical departments and clinicians. The project was carried out in two stages. Part 1: After registration of in-hospital patient deaths (1 May 2004 to 31 December 2007), the consultant in charge of patient care was notified and requested to assign the death to a predefined category. This categorisation leads to further investigation as appropriate. Part 2: Hospital administrative data from 1 April 1997 to 31 December 2007 were used to assess a defined index, the Hospital Mortality Index (HMI), which was the expressed in the form of an Attribute Control Chart ( p-CHART) and then used as a performance indicator for hospital departments and clinicians. Summary data are reported to the clinical departments and to the hospital executive via the Quality Improvement Committee on quarterly basis. The clinical review was complete for 2,990 of 3,132 (95%) inpatient deaths till 31 December 2007, while a further 142 (5%) deaths are still in the process of being reviewed as of 7 April 2008. The median age of all the cases was 78 years (IQR 67-86) of which 1,657 (53%) were male. The Poisson regression analysis showed that since 1997 departments with a minimum of 100 deaths in total showed no clinically significant change in HMI over time. The Hospital Mortality Project provides a simple and efficient tool to analyse data for clinical managers to facilitate accountability.