When a medical error causes serious harm, patients, families, and healthcare professionals want to understand what happened. But does the way such incidents are currently investigated primarily lead to better healthcare, or does it also provide acknowledgement and healing for those most directly affected? This question was at the heart of the Adrienne Cullen Symposium 2026.
Since 2018, the Adrienne Cullen Lecture at UMC Utrecht has focused on openness following serious harm caused by a medical error. What began as a personal and confronting call for greater transparency has grown into an annual reflection on how hospitals deal with errors, accountability and recovery.
For the first time since the COVID-19 pandemic, this year’s event once again took the form of a live symposium, bringing together physicians, researchers, policymakers, patient representatives and regulators. The auditorium was filled with participants and lively interaction.
The symposium opened with an honest conversation between moderator Miriam Wardenaar and paediatrician Louis Bont, Acting Chair of the Executive Board of UMC Utrecht. He spoke about a medical procedure he once performed as a paediatrician that ended well, but could just as easily have gone terribly wrong. Even today, the thought of what the consequences might have been and how he would have had to explain this to the parents still affects him deeply.
“Making mistakes is unavoidable. It is part of our work. So too is the openness to discuss such experiences when they occur, however difficult that may be,” said Louis Bont.
His words captured the essence of the annual Adrienne Cullen Symposium.
Every year, UMC Utrecht provides care to a vast number of patients. On average, patients rate the care they receive at UMC Utrecht at 8.7 out of 10 (Patient Experience Monitor 2025). An impressive score. Yet Marcel Albers, Deputy Director of Quality of Care and Patient Safety at UMC Utrecht, demonstrated through figures how much lies behind that number (Annual Report 2025):
• Approximately 500 complaints from patients and relatives each year.
• Thousands of reports concerning healthcare incidents submitted by patients or healthcare professionals.
• Between 50 and 60 internal reports of serious incidents annually; approximately 15 of these are formally classified as healthcare calamities by the Dutch Health and Youth Care Inspectorate (IGJ). Examples include failing to identify dangerously high blood glucose levels resulting in a patient’s death, an incorrectly performed treatment requiring further surgery, or the case of Adrienne Cullen herself, who died after a missed diagnosis.
The fact that our care is highly valued does not automatically mean that it is always safe or good enough.
When a healthcare calamity occurs, healthcare organisations are legally required to investigate what happened. At UMC Utrecht, this is done using the Systematic Incident Reconstruction and Evaluation (SIRE) methodology. The purpose of this formal accountability process is clear: to learn from mistakes and prevent recurrence.
Patients and families, however, often have different questions. They seek acknowledgement, clarity and meaning. They want to understand what happened and what impact it will have on their lives. A SIRE report does not always meet these needs. Some patients and relatives experience such reports as distant and impersonal, and they can sometimes raise more questions than they answer.
According to Marcel Albers, this illustrates the tension between two perspectives and demonstrates how patients, healthcare professionals, investigators, administrators and regulators can experience the same process in very different ways.
“Is incident investigation primarily intended for accountability and organisational improvement? Or should it also contribute to healing and meaning-making for patients and families?”
This tension is also reflected in the experience of Herma Spek and her husband Hans. Hans became seriously ill, was admitted to hospital with urosepsis and ultimately passed away. Herma had feared from the very beginning that her husband had also suffered a heart attack, but this only became apparent later. The treatment focused primarily on the urosepsis. By then, it was too late.
The SIRE investigation following Hans’s death left Herma and her children with many unanswered questions. How could this have happened? What went wrong?
Under the guidance of moderator Miriam Wardenaar, Gina Bottger (patient representative), Indira Bade (nurse advisor and SIRE investigator) and Maurice Vlemminx (Inspector at the Dutch Health and Youth Care Inspectorate, IGJ) discussed the tension between formal accountability and the need for recognition and meaning among patients and families.
The panel shared a common view. All were moved by Herma Spek’s story and recognised the pain of feeling powerless.
Drawing on her own experience, Gina Bottger explained: “The feeling that you are left outside the system while it is your life as a patient that is at stake is deeply distressing. You do not know the procedures, so you have little choice but to surrender yourself to them.”
Maurice Vlemminx emphasised the importance of involving patients and bereaved relatives in investigations and listening to their stories. “Meaningful involvement helps people feel part of the process. It begins with genuinely listening to their experiences and needs.”
At the same time, the panel stressed the necessity of formal accountability and the core objective of SIRE investigations: learning from mistakes to prevent future harm. The purpose is to implement improvements that benefit current and future patients.
Indira Bade (SIRE investigator): “Differences in expectations can emerge early in an incident investigation. That is why Patient Support explains the purpose of the process from the outset, and why we, as SIRE investigators, revisit this during our conversations with patients and family members. We genuinely try to listen and incorporate their perspectives into the investigation. Being transparent and doing what we say we will do is essential.”
The audience also participated actively through live polling and open discussion. The emotions expressed during the session highlighted once again how important it is not only to learn from mistakes, but also to give patients and families a voice and involve them throughout the entire process.
“Good aftercare is about human connection, attention, listening, attitude and behaviour—from one person to another.” – Bereaved family member in the audience
A bereaved family member added: “This is about the importance of good aftercare. It begins immediately after something has gone wrong, long before a report is filed and a SIRE investigation begins. But support should not only be provided at the start. It must continue, because these processes can sometimes last many years.”
The conclusion of the symposium was clear. There remains a disconnect between the objectives of SIRE investigations and the needs of bereaved families. Formal learning and accountability should connect more closely with the experiences of those directly affected.
A possible solution emerged from the audience: “Could patients and families become part of the SIRE investigation process itself? And how can we do this in a meaningful way?”
This is not an easy challenge, but it may be the only way forward if the perspectives of patients and relatives are to become an integral part of the system.
Only then can learning from healthcare calamities gain a new and sustainable dimension for everyone: helping people find meaning in what has gone wrong while ensuring that something positive emerges from it—that the same event does not happen again in the future.
With this symposium, UMC Utrecht continues the path initiated by Adrienne Cullen: critically examining how we deal with errors in healthcare and continuing to strive for improvement.
Not only to improve systems, but also to create space for the stories of patients and their loved ones.
Because openness is about more than sharing facts. It is also about listening, acknowledging experiences and searching together for meaning when care does not go as intended.
Since 2018, the Adrienne Cullen Lecture at UMC Utrecht has focused on openness following serious harm caused by a medical error. What began as a powerful revelation about what took place between a patient and a hospital has evolved into an annual reflection on how we learn from what goes wrong in healthcare—one that we are keen to share more broadly.
In 2026, the event was held live as a critical symposium with an audience, organised by physicians, policymakers, researchers and patients.
