Friday, August 28, 2009

Kidnapped Girl Found In California After 18 Years


The shocking story of an 11 year old girl, snatched off the street at Lake Tahoe and found 18 years later after being held as a sex slave captive, is all over the news. Kidnapped at age 11, little Jaycee Dugard was found in Antioch, California, living in a squalid tent in her abductors back yard, with two children he fathered. The kidnapper, Phillip Garrido is a known sex offender and was on parole for a sex offense in the 90's. At least one suspicious neighbor had called police over two years ago, yet a home visit by sheriffs found nothing amiss. The car he used to kidnap the girl was still in the junky back yard, broken down and covered with a tarp, along with the sheds and tents that housed the kidnapped woman and her children. Somehow this parolee got away with this in a regular suburban neighborhood.

There are so many questions in this case and some answers may emerge over time. The tabloids will run wild with speculation and this story will eventually fade from the pubic eye.

I am proud to say that in medicine we have a process we use to investigate serious events and learn from them. Medical mistakes are not caused by one event or one person. They occur because we deal with complex systems and when a number of random things occur together a serious error can happen. If there is an error, we do a "Root Cause Analysis" (RCA).

A Root Cause Analysis is a rigorous problem solving method, undertaken so changes can be made so the problem never happens again. Here is an example of how it would work in the hospital world:

Let's say a patient receive the wrong drug and died from it. As soon as the error was discovered a team would be formed with a top administrator and every person involved in the problem. This might be the nurse, the pharmacist, the charge nurse supervisor, the quality and safety expert and the physician. This team would go through every step in medication administration from the actual manufacture and labeling of the drug to the ordering and administration. They might uncover a problem in how the drug was stored or how the label looked identical to another label. They might find drug names that are nearly the same, just begging for an error to be made. They might find a problem with the nurse being interrupted as she was preparing the drug. Or a patient's name band that was on the wrong wrist. The hundreds of variables in just administering one simple medication would be broken down and investigated for process improvement and change.

Does law enforcement do a Root Cause Analysis of the many steps that go wrong in a case like the Dugard kidnapping? What about the parole process? What about investigations (to the house after a neighbor report) that were cursory?

Did the police do a RCA after the mistakes that were made in the Polly Klass kidnapping? Or the Elizabeth Smart kidnapping in Salt Lake City? Could there have been some process improvement that would have allowed rescue in this known sex offender before 18 years had passed?

These situations beg for a RCA and changes in how law enforcement can better protect us. Perhaps they could learn from how we do it in the hospital.

13 comments:

Debra said...

Well said Toni!

thomas jones said...

This is crazy, to believe that the search stopped and she was alive accepting the fact that people gave up on her...damn.

Kellie said...

That is good to know there is an RCA
I'm glad they have it in medical cases.

Anonymous said...

This case is so sad and very weird too. I like the way you talked about RCA in medicine and how it should be used by the police to improve their processes too.

Jonathan said...

The NTSB (National Transportation Safety Board) acts as our Federal center of excellence on RCA for transportation accidents. Inasmuch as the NTSB is a Federal agency, the expertise it possesses is applied uniformly across the nation. In a similar vein, hospitals or police departments, which are local entities, ought to share their RCA protocols so that we disseminate best practices nationally and organizations learn from each others' experiences.

Cockroach Catcher said...

Such a sad story. It is worth reading the Fred West story http://en.wikipedia.org/wiki/Fred_West . Sometimes we need to think: conspiracy.

The Cockroach Catcher

cacimbo said...

With omni present surveillance cameras, gps, ezpass, cellphone etc. - law enforcements investigative methods and responses are changing. The biggest challenge is balancing all this big brother stuff with John Q Citzen's right to privacy. In this case, not enough information is given about the 911 call 3 yrs ago. For example if I annoymously call 911 & report your a pervert and have kids in your house, the police can not legally do anything except knock on your door and question you- providing your agreeable. If you slam the door in their face, without something more -like knowing his name and that he was a registered sex offender, their hands are tied. What info should be available to police and when is an on going battle being duked out in the courts. I suspect that with a missing child the public is more accepting of police "bending the rules", however, I think you will find less and less police willing to do so, since they too are under more and more surveillance. Lets not forget the media in all this. What was recently done to the poor women who called 911 to report a burglary in Cambridge is sure to discourage many a future witness from being willing to get involved. I agree that law enforcement needs more improvement, especially with inter-department cooperation and info exchange. But the public has to accept that sometimes safeguarding your privacy means the bad guy/gal gets away.

Toni Brayer MD said...

cacimbo: Rather than get theoretical and talk about privacy rights, let's talk about this case. He was a registered sex offender on parole. There is a website (see the links on my blog) where anyone can see what offenders (with photos and crime) are living in their neighborhood. Certainly the police knew.

A 911 call reporting anything suspicious should warrant an investigation... more than just knocking on the door and asking if everything is OK.

The car he used to abduct her was in the backyard (hidden with the shacks and housing).

So I repeat my position that law enforcement should have processes where they learn from their mistakes. This is a great case study for looking at the process from the beginning and seeing what could have been done differently to avoid such a tragedy.

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After 18 years? God, that poor creature must be so traumatized that she will not be able to overcome such a rough experience. It's so sad to know any one can ruin your life for such selfish reasons!

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