Learning a lesson from the Butcher of Bundaberg

The culture of safety that this engenders generates far more information about adverse events to be analysed and encourages professionals constantly to improve and optimise their own systems and performance.

The Utah system is predicated on the idea that well over 90 per cent of adverse events arise from systems that can be improved rather than from individual idiosyncrasies and inadequacies - let’s face it we all have those!

So this system reduces errors far more effectively than a punitive approach based on identifying individual wrongdoing. Indeed, it turns out to be much better at detecting rogues. Not only do generally lower accident rates and better information systems mean that rogues stand out like a politician at Gallipoli on Anzac Day. But there’s also a virulent culture of identifying problems and fixing them.

And, just as the Japanese discovered building cars, better quality needn’t cost money. Getting it “right first time” saves squillions in rework and all the disruption that goes with it. It also facilitates constant improvement further down the production line.

If we’d had such a system in Bundaberg we’d have prevented most or all of the outrages of the Dr Patels. But we’d also prevent over ten times more problems arising from mundane errors by well-intentioned and well-credentialled professionals working in systems that could be improved out of sight.

Building such a system would be the most fitting monument to the victims - alive and dead - of the Butcher of Bundaberg.