FACEM Dr Alex Buttfield works in Campbelltown, Sydney. About ten years ago, on a night shift at a different hospital, a patient arrived to his then department and to his care. Her unexpected death a day later provided him with personal and professional challenges that have shaped his career.

The death – an ‘unexpected bad outcome’ – was the subject of a root cause analysis (RCA) and a coronial inquiry. The former is a hospital or health district-level investigation to discover if there were any systems issues that led to a bad outcome. It is designed to make recommendations so that similar errors can be avoided in the future. The latter is a formal inquiry into a patient’s death – determining both the cause of death and any systems issues that might have been at play.

The RCA for Alex happened in the immediate aftermath of the event.

‘I spoke to a FACEM from another hospital about the case, several aspects of it. Luckily I had a support person on hand – my DEMT at the time, who was a mentor to me then and continues to be one.’

The report from the RCA included statements from everyone involved in the case.

‘The comments are included without contest, so if you disagree with something you do not have the opportunity to say so.’

He says this feels quite intimidating, but finds now it has played a role in his participation on RCA panels.  

‘Since then I’ve had the opportunity to be part of an RCA panel as a consultant and I think that early experience certainly affected my approach.

‘I would like to think it has made me more supportive and protective of junior doctors. I have fought what I perceive to be unjust adverse findings against medical and nursing staff.’

Despite an intimidating experience, Alex today recommends being part of a RCA panel.

‘It allows forthright clinicians who work at the coalface of clinical care to have an input into case review.’

Three years following the patient’s death, Alex faced seven lawyers in a courtroom as part of the Coronial Inquiry. In the courtroom were the patient’s family and enlarged photos of his patient.

He says his support network got him through.

‘I had moved hospitals by the time of the inquiry but was very fortunate to have two mentors there and they were fantastically supportive. They ensured that at any one time that I was in that courtroom one of them would be too.

‘It was very reassuring to have someone in the room who was in my corner unequivocally. I could look to them when I was upset and I knew they had my back.’

Alex recommends doctors (even junior ones) are proactive to protect and look after themselves.

His top three tips are:

  • Make sure that consult your medical indemnity insurer to ensure it protects your reputation and other interests, not just costs, as it can be devastating personally and professionally.
  • Make sure you have a mentor, a good one is worth their weight in gold. I always found my mentors informally, rather than as part of a mandated program.
  • If you are involved in an unexpected bad outcome, make a detailed note of events in a diary that is contemporaneous. It helps formulate your thoughts after the fact and may help in forming your statement to the coroner or RCA.


  • Wellbeing