Learning from mistakes

Until recently, I had thought of rickets as a disease that had been eradicated, like polio and smallpox. But the prevalence of rickets is increasing again, which is worrying, as the disease has been well understood for many years. Rickets is still relatively rare, and when Baby Jayden was taken to hospital, rickets was not diagnosed, leading to abuse allegations. Had antenatal services been effective, or the hospital diagnosis been accurate, the outcome for Baby Jayden might have been different. All this has led me to think more generally about how things sometimes go wrong.

There have always been cases of error or negligence, or where services haven’t been properly joined up. Tragedies have occurred because of warning signs that have been missed through poor training, excessive caseloads or faulty systems. Much of the present system was designed to minimise such problems. The 2004 Children Act was aimed to ensure that everyone knew who was accountable, and that the different services worked well together. Some cases still fall through the net, and we need to learn from these tragic cases. Serious case reviews are an important part of that learning, as is the work of the Children’s Improvement Board.

But it’s not just systems we need to get right – “good practice” must itself be effective and based on evidence, not gut feeling or anecdote. The health sector is generally good at learning from the evidence, largely because of a long-term approach to medical trials and research, as well as learning from poor outcomes. So the chief medical officers have issued a general reminder to health professionals about the need for pregnant women and breast-feeding mothers to take vitamin D supplements. And I hope that paediatric radiologists are now being updated on the symptoms of rickets.

Baby Jayden’s death was a tragedy, but it will be a worse tragedy if we do not learn from it. Frontline professionals must be alert to the possibility of rickets. As always, prevention is better than cure. Good antenatal care and advice are essential, alongside the provision of nutritional supplements, especially for those families in poverty and those with a poor understanding of health issues.