The Second Victim

A few years ago, I was invited to mediate in a case where two female Consultants from an Acute Trust had fallen out. Both Consultants had been drafted in to help at a local hospice. There was a dispute about the handover process from one Consultant Sarah, to the other, Eva. Somehow, Eva who had just started her shift hadn’t registered that 67-year old Mr. Smith was allergic to morphine despite his notes indicating this. The Consultant proceeded to give Mr Smith a dose of morphine. Mr Smith got up to go to the bathroom 15 minutes later. He lost his balance, tripped and fell. He ended up with two black eyes and his teeth punctured his top lip. This image of him became lodged in his families’ memory. He died five days later. 

An investigation process commenced in order to establish what had happened. Eva was suspended whilst the investigation took place. Two years later, I found myself in a room with both Sarah and Eva. Sarah had reported the incident and had wanted to make sure Eva was suitably punished for the mistake she had made. Eva was devastated. During the mediation she made two comments in particular which struck me. The first was that she had lost five stone in weight as a result of the stress and anxiety she had endured. Secondly, Eva had wanted to engage in dialogue with Mr. Smith’s family to apologise for the mistake she had made. HR blocked Eva from making any contact with the family as the investigation was ongoing. This was very painful for Eva who felt as if she could not get any sense of closure. Her two year period off work had become a bad dream that someday she hoped to wake up from.  

Unwittingly, Eva had become The Second Victim. We saw something similar happen to Director of Children’s Services for Haringey, Sharon Shoesmith back in 2007.  You might recall her very public dismissal by the government minister Ed Balls. Sharon Shoesmith got to the stage where she could not leave her home for fear of her own safety. In this case, Sharon Shoesmith’s daughter was even threatened with murder, and had to go into hiding. None of this of course, would bring back Peter Connelly (Baby P).  

When feelings of guilt are compounded by unjustified accusations or by one being left out in the cold to suffer alone, they can be pushed over the edge. This phenomenon is now so prevalent that it has led to the introduction of a new term: The Second Victim. Numerous studies show that professionals suffer feelings of distress, anguish, fear, guilt and depression 1. Other studies reveal the prevalence of suicidal thoughts. One of the findings in the research ‘Mediation and Organisation Diagnosis in the NHS’ reveals that HR could sometimes be more supportive in allowing adult to adult conversations take place where mistakes or mishaps have occurred. This is irrespective of whether the patient or a member of staff has been impacted. The danger is that episodes such as this can contribute towards the psychology of blame. If our organisational systems force us to treat our senior colleagues as children rather than adults, a reluctance to own up for mistakes will develop. This means that issues will go underground and the opportunity for organisational learning becomes lost. Instant blame can lead to the circular firing squad where everyone is blaming everyone else. Increasing punishment does not reduce mistakes, it reduces openness. Teams in high blame environments will refuse to speak up as they will fear the consequences of such honesty.  

Research on this topic has been conducted at the Virginia Mason Health System. The research concludes that when professionals believed that errors and near-misses would be treated as learning opportunities crucial information began to flow. Insurance claims also fell by 74%.

Making a Second Victim of a colleague is unhelpful, dangerous and highly damaging. Holding people accountable and unfairly blaming them are two very different things. Eva faced the consequences of making a mistake and becoming The Second Victim to Mr. Smith. In good humour, she commented that she would have preferred another method of diet in which to shed five stone in weight. We can learn a great deal by applying the concept Second Victim to the field of conflict resolution. Once again, we have a solid strand on which to present the business case for incorporating well-thought though conflict resolution strategies and tools for healthcare and indeed other organisational settings.



  1. J.F Christensen, W. Levinson and P.M Dunn, ‘The heart of darkness: the impact of perceived mistakes on physicians’, Journal of General Internal Medicine, 1992, 7, 424-31.