Systemic failure

A doctor has successfully appealed a decision to strike her name off the medical register after being held responsible for the tragic death of six-year-old Jack Adcock, who died from heart failure after going into septic shock in 2011.

Doctors in Unite (DiU) welcomed the ruling handed down on Monday (August 13) that reinstates Dr Hadiza Bawa-Garba – a trainee doctor at the time who had been working a 12-hour shift without a break – to the medical register.

Trial

In a controversial 2015 trial, Dr Bawa-Garba and a nurse were found guilty of manslaughter by gross negligence for their role in contributing to Jack’s death. Dr Bawa-Garba admitted to a number of mistakes including failing to clearly communicate with the consultant and underestimating the severity of Jack’s condition – the boy had initially been admitted for vomiting and diarrhoea.

But critics argued that systemic problems, such as serious staffing shortages and IT failures, had from the outset set up the medical team treating Jack to fail – and that these issues and other contributory factors weren’t examined in court.

When Jack was admitted to hospital Dr Bawa-Garba, a trainee doctor, had been the most senior doctor  at the Children’s Assessment Unit (CAU) at that time, and because of rota gaps, a consultant that should have been there was covering a different department. Two of the three nurses on duty that day were agency nurses, and so weren’t allowed to perform certain procedures. And critical blood test results were delayed because of hospital-wide IT system failures.

“Doctors became particularly concerned when they heard about all of the systems failings at the hospital and felt these weren’t heard fully in court,” Dr Cusack, Dr Bawa-Garba’s supervisor, who attended parts of the trial, told the BBC.

In the end, Dr Bawa-Garba received a two-year suspended prison sentence and was then suspended from practicing for one year by the Medical Practitioners Tribunal Service (MPTS). The General Medical Council (GMC) then appealed the decision, arguing in favour of erasing or ‘striking off’ Dr Bawa-Garba’s name entirely, which the GMC successfully did in January 2018.

But Dr Bawa-Garba appealed and won back her right to practice medicine on Monday (August 13).

“The lessons that I’ve learnt will live with me forever,” said Dr Bawa-Garba in response to the successful appeal this week. “I welcome the verdict because for me that’s an opportunity to do something that I’ve dedicated my life to doing, which is medicine. But I wanted to pay tribute and remember Jack Adcock, a wonderful little boy who started this story.

“My hope is that lessons learnt from this case will translate into better working conditions for junior doctors, better recognition of sepsis, and factors in place that will improve patient safety.”

‘Lessons must be learned’

Medical groups welcomed the court’s latest decision as they emphasised the importance of understanding the role that systemic failures can have in not only Jack’s case but in other patients’ cases as well.

“Lessons must be learned from this case which raises wider issues about the multiple factors that affect patient safety in an NHS under extreme pressure rather than narrowly focussing only on individuals,” said British Medical Association chair Chaand Nagpaul.

Doctors in Unite deputy chair Dr Jackie Applebee-Turner agreed.

“Behind the tragic death of Jack Adcock is an issue that goes to the heart of medical practice in the NHS today,” she said. “Dr Bawa-Garba was working in a hospital that had doctors missing from the rota, an IT system that had failed, nursing rotas covered by bank staff, senior cover that wasn’t readily available and a workload that was unsafe for a doctor to cover by herself.

“This decision must now lead to the GMC examining its decision to seek Dr Bawa-Garba’s erasure and the government must acknowledge their role in this by underfunding and understaffing the NHS for many years and make immediate changes to remedy this.”