Why do nurses sometimes ask the wrong questions?

The recent high-profile case of Kane Gorny highlighted a number of systemic and individual failures that led to his death by dehydration in a hospital bed. This article asks how it happened and presents some psychological, "human" aspects that may have contributed to the tragic outcome. In looking for ways to prevent this happening again, the author suggests that nurses should first understand and accept their own psychological prejudices that may cause them to make the wrong choices or fail to ask the right questions. Reflective practice can help with this issue and perhaps offers the only route to change our own practice and ultimately the healthcare system as a whole.