Reviews

Critical event audit

I noticed the previous evening that she wasn't her usual lively self, but it was still a shock to discover her curled up, stiff and cold, the next morning. The children immediately attempted post hoc resuscitation by generously refilling her food tray. But to an experienced eye, there was no denying the clinical reality. Smokey Bin Hamster was no more.

Their next reaction was to stage a cover up. Don't tell the cleaner, they insisted. Their ill formed plan was to leave the dead creature curled up in her cage, shifting her position daily, and to walk past occasionally within the cleaner's earshot saying, "Gosh, Smokey's asleep again."

This plan was soon seen to be untenable, and our communal guilt surfaced. We started to trade indictments. Who had tried to see if she would eat cold chips two days before she died? Who had tied a conker to the roof of the cage? Who had first abandoned the rota for cleaning her out? Who had walked her along the piano keys? Whose friends had all had a go at Pokey Smokey?

One of the kids decided that she had died of depression. He had been the only one who had ever understood her feelings. The rest of us, he claimed, had taken her for granted. Rubbish, I said, the culprit was Bart Simpson. It said in the guidelines ("Caring for your hamster") that you shouldn't keep them near the television, especially loud and violent programmes. If you kids hadn't kept playing that bloody video she would still be alive.

In the silence following the row, I regretted my outburst and reflected on the blame culture that we had allowed to develop. The hamster could not be brought back, but the event should be seen as a learning experience, and processes put in place to prevent a similar disaster in the future. I found it hard to admit, even to myself, that I'd never read the guidelines properly, nor had I arranged appropriate training for the principal carer. Lines of accountability were unclear, and, worst of all, the crucial task of changing the water was either everybody's or nobody's job.

One week on, we are still slightly numb from the event, but we have all learnt a lot and we now have an evidence based care pathway in place with essential roles assigned to named individuals who are appropriately trained and supervised. And six days on, young Ginger is still the picture of health.

Trisha Greenhalgh, professor of primary health care. 

University College London