Dr Bawa-Garba – the Impact on Patient Safety

17 August 2018

On Monday the Court of Appeal reinstated Dr Hadiza Bawa-Garba to the medical register after she was struck off earlier this year following her criminal conviction for gross negligence manslaughter in 2015.

It is a case which has garnered considerable interest and raised significant concerns amongst the medical profession, particularly junior doctors, who feel that Dr Bawa-Garba was unfairly made a scapegoat for systemic failings within the NHS.

The case concerned Dr Bawa-Garba’s treatment of Jack Adcock, a 7 year old boy who, in 2011, presented at her hospital with vomiting and diarrhoea. Dr Bawa-Garba’s working diagnosis was that he had gastroenteritis. By her own admission, she failed to appreciate how sick Jack was and she did not consider that he might have sepsis, a condition which an estimated 37,000 people die from every year in England.  Sadly, Jack’s condition deteriorated and he died later that same day. However, there were a number of circumstances which led to Jack’s death which went beyond Dr Bawa-Garba’s clinical decision making. Dr Bawa-Garba was a junior doctor who had not long returned from maternity leave to an understaffed department, with no direct Consultant supervision, and an IT systems failure which led to a delay in accessing Jack’s test results. She was, in the words of her former supervisor and a consultant neonatologist at Leicester Royal Infirmary Dr Jonathan Cusack, working “in a perfect storm” on the night in question.

The circumstances of Jack’s death led to Dr Bawa-Garba’s conviction of manslaughter and her ultimate striking off from the medical register. However, the Court of Appeal found that the General Medical Council (GMC) was wrong to permanently remove Dr Bawa-Garba from the register, a decision which has been met with relief from many members of the medical profession who were worried that they could find themselves in similar circumstances to Dr Bawa-Garba in an underfunded and overstretched NHS, and consternation from others who felt the medical profession was “closing ranks” to protect one of their own.

In 2013, Professor Don Berwick was asked by the government to advise on how to improve patient safety in the NHS following the Mid Staffs scandal. His report recommended moving away from blaming an individual to looking to learn from errors. One of the main issues with the Dr Bawa-Garba case which concerned the medical profession so deeply was the fact that Jack’s death was blamed on two people (Dr Bawa-Garba and an agency nurse).  This was despite the many systemic faults which may have contributed to the tragic outcome. The concern was that this “blame culture” was not in line with the proposed move towards a patient safety and a learning focussed approach and did little to encourage clinicians to openly and honestly reflect on their mistakes for fear of reprisal or civil or criminal prosecution.

Ultimately, this was a tragic case involving the death of a little boy which could have been avoided. But blaming a clinician for mistakes that she openly accepted making is not the way to promote a culture of learning from errors and therefore improve patient safety, particularly when dealing with conditions such as sepsis, which can be very difficult to diagnose. Following her re-instatement to the medical register, Dr Bawa-Garba said that she hopes this case will improve working conditions for junior doctors, lead to better recognition of sepsis and improve patient safety.  Whether this will happen remains to be seen but I think that learning from this case, and others like it, can only be achieved by understanding and addressing the system within which Dr Bawa-Garba was working on that day in 2011.

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