On 29 March 2005, Elaine Bromiley was admitted to a private clinic for routine sinus surgery. During the operation, a nurse fetched a surgical airway kit and told the consultants that she had brought it in. Elaine Bromiley died on 11 April 2005.
According to an account of the case, the nursing staff “didn’t know how to broach the subject with the doctors.” Her husband, Martin Bromiley, is an airline pilot. In 2007, he formed the Clinical Human Factors Group.