Having just returned from a week’s winter sun, I was reflecting on one of my holiday reading selections, Malcolm Gladwell’s Outliers. It struck me how his case studies on paddy fields and plane crashes resonated with my experiences in the NHS.

After flying eight hours each way to my sunny destination, I didn’t really relish the idea of reading about fatal plane crashes. However, this compelling chapter brought together the concepts of technology, safety, quality, human error, cultural differences and, most crucially, the language and style used in different airlines’ cockpits.

“I have heard lots of code in the NHS and I have spoken in code myself”

The use of clear, unambiguous language is so important in airline safety - and in theatres, wards and boardrooms across the NHS.

A stark example

In 1990, a Colombian airliner ran out of fuel and crashed, killing over half the passengers. When an expert pilot reviewed the black box recorder, he was amazed at the silences in the cockpit, the length of time between communication and the ambiguity of the language used by the co-pilot. The co-pilot spoke in code that he assumed the captain and air traffic control would understand, but didn’t feel able to tell either unambiguously: “We will crash unless we land in the next two minutes.”

At no time did the co-pilot explicitly and firmly say to the traffic controller that they were seriously running out of fuel. He also hid the detail of the conversation he had with the controller from the captain. What led him to withhold information and subserviently talk to the controller?

Why didn’t the captain intervene? He had heard what he wanted to hear. He was tired. He trusted his co-pilot.

The co-pilot’s final conversation with the air traffic controller went something like this:

Control: “I’m gonna bring you about 15 miles north east and then turn you back on to the approach. Is that OK with you and your fuel?”

Co-pilot: “I guess so. Thank you very much.”

Seconds later, this incredibly ambiguous use of language and the need to retain the pecking order in the cockpit led to 73 deaths.

Cut to an operating theatre in a district general hospital. Communication is all. Yes, there are roles, a pecking order and there will be a lead surgeon, but if that communication breaks down between the key players, the death of a patient could happen. There is a code that is spoken but a good surgical team will always ensure clear, unambiguous statements.

Let’s move to a weekly executive team meeting - a hotbed of pecking orders, politics, targets, information and camaraderie. I have heard lots of “code” spoken, seen lots of different behaviours - both explicit and not so explicit - and have spoken in “code” myself. In our working lives in the NHS, we should be mindful of this at all times.

We all want the organisation and its stakeholders to work effectively, happily and safely. Clear, unambiguous language can cut through the politics and bring new energy and clarity into difficult and complex situations.