Aditi Desai

When repeated harm occurs in healthcare, public debate often centres on identifying an individual responsible. Although accountability is essential, patient safety may be better served by asking another question first: Were there earlier signals that something was going wrong? This blog reflects the perspective of Aditi Desai, a surgeon with nearly three decades of clinical experience and an interest in patient safety systems, surgical quality monitoring and organisational learning. Recent high‑profile cases, such as the case of surgeon Yasser Jabbar at Great Ormond Street Hospital,[1] have prompted difficult reflection across the profession about how systems detect repeated patient harm. These situations understandably lead to questions about individual responsibility, but they also highlight the importance of recognising warning signals earlier. After nearly three decades in surgical practice, I have seen how outcomes can fluctuate. A surgeon may perform many procedures safely, then experience several complications in close succession. Some of this represents natural variation. But sometimes patterns emerge that should prompt earlier concern. Modern healthcare systems collect large amounts of clinical data, yet we rarely use it systematically to detect deteriorating performance early.[2] Risk‑adjusted monitoring of outcomes over time, combined with supportive mentoring and fair accountability, could help organisations intervene sooner, protecting both patients and clinicians. Improving patient safety requires moving beyond a simple choice between blaming individuals or fixing systems. Safer care depends on recognising both the human realities of clinical practice and the need for strong organisational oversight. Recognising the early warning signs of unsafe surgical practice Having practised surgery for more than 28 years, I have learned that clinical outcomes are rarely perfectly predictable. A surgeon may perform a hundred operations without complication. Then, within a short period, several adverse outcomes may occur—like unexpected bleeding, infection or an unintended injury during surgery. When this happens, patients suffer first and most. For clinicians, complications also carry a heavy emotional weight. Many doctors recognise the sleepless nights and intense self‑reflection that follow when a patient is harmed. In recent years, public discussions around cases of repeated patient harm have raised difficult questions about how healthcare systems detect unsafe practice. The case of Yasser Jabbar at Great Ormond Street Hospital, widely reported in the UK, has prompted reflection not only about accountability but also about whether earlier signals of unsafe care might have been detectable. The instinctive response is often to ask: “Who is the rogue clinician?” But from a patient safety perspective, an equally important question may be: “Where was the signal that care was becoming unsafe?” Distinguishing variation from unsafe care All clinical practice carries risk. Even highly skilled surgeons experience complications. Medicine is complex, and outcomes vary according to patient condition, procedural difficulty and chance. The real challenge is distinguishing between: Expected complication rates and natural variation, and Patterns that may indicate deteriorating performance or unsafe practice. This distinction is rarely straightforward. It requires careful interpretation of clinical outcomes and trends over time. The human side of surgical practice Medicine often expects clinicians to perform at a consistently high level throughout long careers. Yet surgeons, like everyone else, experience illness, fatigue, personal stress and periods of reduced resilience. Most clinicians continue working through these pressures because the culture of medicine places great value on strength, reliability and professionalism. Recognising this human reality does not diminish professional responsibility. Instead, it highlights the importance of systems that can identify when a clinician may be struggling and offer support or review before patient harm accumulates. The missing safety infrastructure Healthcare organisations collect vast amounts of data about procedures and outcomes. Yet in many systems, we still lack robust mechanisms that can: Risk‑adjust outcomes for patient complexity. Monitor outcome trends over time. Identify negative outliers early. Trigger timely peer review or mentoring. Such systems are not primarily about punishment. Their purpose is to protect patients while supporting clinicians to maintain safe practice. Moving beyond 'individual versus system' Patient safety discussions often frame harm as either the fault of an individual clinician or the result of system failure. In reality, safety depends on both. Strong systems should be able to detect emerging risks early, while still ensuring fair accountability when unsafe practice becomes clear. This approach aligns with the principles of a just culture, where organisations seek to understand and respond to risks rather than relying solely on retrospective blame.[3] A role for data, mentorship and oversight In other high‑performance fields, such as aviation and elite sport, continuous monitoring and coaching are routine. Medicine has traditionally been slower to adopt this approach. Yet supportive oversight and mentoring could help clinicians identify and address problems earlier in their careers or during periods of difficulty. Clinicians may benefit from ongoing coaching and feedback, not only during training but throughout their professional lives.[4] Surgeon and writer Atul Gawande, the WHO checklist pioneer, highlighted this idea in his TED Talk “Want to get great at something? Get a coach”, where he describes how even experienced surgeons can improve performance and safety through structured coaching and peer observation.[5] Looking forward Cases where repeated harm occurs inevitably raise questions about accountability. Where clear incompetence or unsafe practice exists, fair accountability is essential. But patient safety improves most when healthcare systems are able to recognise warning signs early, before serious harm accumulates. By combining risk‑adjusted data, supportive oversight and a culture of learning, healthcare organisations can better protect patients while supporting clinicians to maintain safe practice. Ultimately, safer care depends not only on responding to failure, but on building systems capable of recognising risk sooner. References Triggle N. Great Ormond Street doctor who botched surgery harmed nearly 100 children. BBC News, 29 January 2026. Royal College of Surgeons of England. Surgical outcomes data and transparency. Outcomes FAQ. NHS England. Being fair tool: supporting staff following a patient safety incident. 9 May 2025. Pradarelli JC, Yule S, Panda N, et al. Optimising the implementation of surgical coaching through feedback from practicing surgeons. JAMA Surgery, 2021; 56;(1): 42-49. doi:10.1001/jamasurg.2020.4581. Gawande A. Want to get great at something? Get a coach. TED Talk, April 2017.