A final act

This post is about the difference between responsibility and accountability. If you are a doctor it is likely that at some point you will be asked to attend the coroner’s court. It is a nerve-wracking and intimidating experience. The relatives of the deceased patient may be just a couple of metres away from you. Sometimes there are reporters from local newspapers. You may take the stand as the patient’s consultant or GP, even if you were not present when certain actions and omissions occurred. You will explain your own thought processes, the ways of the system, and you will defend, to an extent, what went on. You may even have to explain the actions of others. The inquest is an exercise in information gathering, its aim is to allow a confident judgment as to the cause of death. It is not primarily about blame, but the penetrating questions and forensic approach may make it feel that way. The coroner may be hard on you, and their conclusions may be harsh.

You will be asked to go because you were responsible for the patient. That sense of responsibility is something you have to learn to live with as a senior doctor. But a visit to the coroner’s reinforces how heavy the burden of responsibility can be. How can you carry on with life outside the hospital if responsibility continues even after you leave the building? How can you ever relax?

One way to deal with it is to understand that responsibility does not equal accountability. What’s the difference? The two words are largely synonymous, but the difference probably revolves around the place of blame and the likelihood of being asked to pay a penalty. A doctor can function if they accept that they are responsible, in charge, directing the therapeutic strategy… but not if they are fearful that the blame for success or failure (assuming that treatment is undertaken in good faith and with appropriate expertise) will arrive at their door. And not if all actions taken in their name, as the consultant whose name is ‘over the end of the bed’ are attributed to them.

There is a balance, certainly. One cannot take on a senior position in any organisation or service and be entirely immune to blame, but fear of blame cannot infect every interaction. Yet, for all the personal indemnity that working in the NHS offers, you will still feel vulnerable as the doctor in the spotlight.

The four paragraphs above seem to lead nowhere; the sentences circle back to the state of mind of the poor, overburdened doctor… because they are written from the point of view of the doctor. Perhaps this is the error. Thinking in this way, there appears no escape from the blinding storm of pressure. It is not possible to compartmentalise the burden of responsibility unless another approach is adopted.

The lesson I learned from my day at the coroner’s court is that the need for a named, responsible person as a focus if inquiry is incontrovertible, because relatives of the dead have a right to answers and the record must show how or why people died. If not you – as consultant (or GP) in charge – who else will provide those answers? That is the responsibility, to stand up and explain events that would otherwise remain opaque. However, you cannot expect to be blamed for everything that happened in a complex system that is the hospital. Blame, if apportioned, will be directed at the organisation for which you work. So, bruised and sensitised by the experience, I came out of it is realising that it wasn’t about me. It was about the patient and those who have been left behind. I was a source of information, and had to be professional enough to give a clear narrative without becoming personally defensive. It was the least I could do.

Doctors will have to attend inquests at least once during their careers unless they are extraordinarily lucky or working in a specialty that does not take in patients who are at risk of dying. Surgeons, general physicians, GPs, they will probably find themselves standing up and taking responsibility at some point. Handling the hard questions is a role that must be played in the final, posthumous act of their patients’ lives.

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