Sometimes a concept
serendipitously appears that helps shape my thoughts and today I came
across Dr Frank Hoffman's Black Swans and Pink Flamingos article
which does exactly that. Hoffman uses the concepts in relation to
defence planning but they have wider utility. Since the inquest
verdict into the death of Connor Sparrowhawk on Friday, I've been
reflecting on its meaning.
The Black Swan concept
has been popularised by the writings of Nassim Nicholas Taleb who
used it in relation to financial events. As Hoffman describes “[a]
black swan is an event or situation which is unpredictable and for
which the consequences could not be measured”. You cannot plan for
black swans but only cope with their aftermath.
A Black Swan event is
exactly what two of my closest friends experienced when their
youngest child contracted and died of neuroblastoma. The thing about
neuroblastoma is that it is a childhood cancer which has no known
genetic or environmental markers. It is a random cruelty that visit
children under the age of ten.
It still pains me to
remember their hurt, grief, dignity and bravery when their child
died. The funeral is still fresh in the memory. That no-one
witnessing that cruelty would be anything but heart-broken by it. It
was a profound event for me and has been one of my motivations for my
involvement with #JusticeforLB and #LBBill. The unconscionable
behaviour that Southern Health NHSFT display towards Connor's family
has been untempered by any empathy or sense of responsibility.
That sense of outrage
remains after the considered, comprehensive and damning jury verdict.
A verdict which fits Hoffman's Pink Flamingo concept. To quote
Hoffman:
Thinking historically about the future means dealing openly with those things we want to avoid or are in denial about. These are what I call our pink flamingoes. A pink flamingo is a predictable event that is ignored due to cognitive biases of a senior leader or a group of leaders trapped by powerful institutional forces. These are the cases which are “known knowns,” often brightly lit, but remaining studiously ignored by policymakers.
Having read the
timeline for @LBInquest (as tweeted over the fortnight by the
phenomenal George Julian) and then the written verdict of the jury, I
find Hoffman's concept resonates powerfully. The jury found that
Connor's epilepsy was a known known, brightly lit by his family, and
was studiously ignored.
Here 'policymakers'
refers to both the clinical practice team at STATT and the corporate
structures within Southern Health. Many of the criticisms of the jury
should have been picked up by due diligence in Southern Health's
takeover of Ridgeway which previously operated STATT. I thoroughly
recommend Chris Hatton's blog Diligence My Arse for those wanting a
more detailed analysis.
The take home point for
the corporates in Southern Health NHSFT is that the jury has pointed
accountability at you. Mouthing platitudes to the media and sacking a
low level grunt doesn't absolve you of your responsibilities. However
there is some useful advice in Frank Hoffman's article which you
might reflect upon especially this: “[a] crash in the real world is
not subject to “no fault” rules; there truly are consequences to
complacency and to faulty strategy”.
In this case, the
devastation inflicted on a family.
The jury agreed that
multiple 'very serious failings' occurred under the watch of Southern
Health NHSFT leading to a preventable death. Fault occur at all
levels. It wasn't an unpredictable event.
To be honest, I'm still
struggling with that. I can't imagine how Sara, Rich and their family
can reconcile those facts. Life can be randomly cruel, it really
doesn't need so-called caring organisations to inflict further
cruelties. Yet Southern Health actions, especially post July 4th
2013, have done exactly that.
As the media reports
have given Katrina Percy the last word, I shall direct my final
comments to her: kindly shut up, take some responsibility and resign.
