To feel sorry for this doctor?(696 Posts)
MNHQ have commented on this thread.
I am not in any way downplaying the death of that beautiful little boy and it is clearly acknowledged there were some failures by the doctor in question however AIBU to feel as though this intervention by the GMC into the independent decision making by the MPTS is concerning? It appears to me that the MPTS took into account many things, not just the outcome (which I completely acknowledge is heartbreaking), the fact that this doctor was working the job of several other medical staff in an unfamiliar environment with significant IT issues with no senior input. It feels like this doctor has been made a bit of a scapegoat for huge systemic failures.
A different link to a blog by other medical practitioners http://54000doctors.org/blogs/an-account-by-concerned-uk-paediatric-consultants-of-the-tragic-events-surrounding-the-gmc-action-against-dr-bawa-garba.html
I should disclose whilst I’m not a medic I do work in healthcare and as such do think this has concerning implications for medical professions.
I have read the report and frankly am shocked. This Dr (And the agency nurse) were completely held accountable for government failings. The shift in question was the stuff of nightmares. I am in no way downplaying the tragedy of this little boy but the government is wholly responsible for his death in a failing crumbling system that is fast becoming not fit for purpose. There are no winners here.
I totally agree with you. Of course it was an absolutely tragic case and I really feel for the family of that little boy, but scapegoating this poor doctor helps no one. It was her first day back from maternity leave, in a new hospital with no induction, no handover, and covering the jobs of several absent colleagues. She should never have been put in that situation. These system failures happen every single day, we are just fortunate that tragedies like this are uncommon. There but for the grace of God go I. #iamhadiza
Sadly another nail in the coffin for healthcare as we know it. You’d have to be mad to consider medicine as a career these days. Every doctor I know is looking for an exit route.
YANBU No one can dispute the tragic loss of the little boy but that poor doctor and nurse have been completely scapegoated. It makes chilling reading particularly for those of us who work in healthcare.
I feel really sorry for the doctor. I read a report which said the boy took regular medication and was given some of this after he’d been stabilised and it’s that which caused his BP to fall as it wasn’t a good combination with him already being poorly. But the doctor hadn’t prescribed it and didn’t know he’d been given it. Wasn’t clear if a nurse gave it or his parents just had it with them and gave it as they normally would.
But the short staffed ness, The IT issues, the lack of induction is just a total shit storm and if anyone was to be charged with manslaughter I think the chief exec should have been charged with corporate manslaughter.
Sadly I think this is going to be more common. I know a doctor who was involved in a case where a patient died and the coroner stopped the inquest and asked the family if they wanted the police to look at prosecuting the doctor for manslaughter because if so he would halt the inquest.
Nhs go on about human factors, Swiss cheese models, full disclosure, reflection.....but when push comes to shove they will throw the nearest individual under the bus. Major blame culture these days.
I think it's frightening the way any HCP can end up the scapegoat for a failing system. My DH (Consultant) is becoming increasingly anxious and stressed as conditions get ever more dangerous in the hospital, he described his ward last week as "carnage" and "a tragedy waiting to happen".
If you try to raise it with senior management you are either ignored or labelled a troublemaker.
Not just doctors.
Can’t imagine why people become nurses these days. Crippling student debt then paltry pay scale.
And it sounds like the nurse was scapegoated because she tried yo stick up for the doctor.
I completely agree. There are no winners here.
I also think (as a nurse) you'd be crazy to go into medicine now. And agree that many of the doctors I know are desperate to get out/escape. For anyone considering a medical career this might be the nail in the coffin of their ambitions. And who would blame them?
This is a letter that her supervisors wrote
For those who want more details, here's a letter from 3 paediatric consultants in relation to this case:
On 18th February 2011 Jack Adcock was admitted to Leicester Royal Infirmary with a history of severe gastro enteritis. He had previously had an AVSD repair, doing well, on enalapril. He had a temperature of 37.7 degrees centigrade, dehydration and shock. A Blood gas showed a Ph, 7.0, base deficit, -14, lactate 11 mmols. He was prescribed a fluid bolus and maintenance fluids. Blood tests including CRP were undertaken and a chest x –ray ordered. There was a delay of two and a half hours in review of chest x-ray during which time Jack showed some recovery, playing with the radiographer, drinking juice from his beaker, improvement in blood gas, to ph 7.24. Jack was moved off the Children’s Assessment Unit (CAU) to the wards, where an unprescribed dose of enalapril was administered. Approximately one hour later he suffered a collapse from which he was very sadly unable to be resuscitated.
The registrar that day was Dr Hadiza Bawa-Garba, a high flying doctor, with an unblemished record who had done considerable work for charitable causes just returned from 13 months maternity leave. Her last general paediatric post, ST4 commenced four years earlier in a DGH, outside Leicester. She had received no Trust induction. When she came to work that day she found that the registrar covering CAU was on training, away from the wards. Dr Bawa-Garba was requested to cover CAU as well as her own ward duties. Working under her were a foundation doctor and SHO. Both had only rotated to paediatrics that month. The consultant covering CAU was teaching outside the city
Provision of care was dogged by the break down in IT facilities for the whole hospital, meaning that the team were constantly phoning to try to get results. Even when back on line, the flag system for abnormal results was down. The nursing staff were hard pressed, with staffing and equipment shortages logged. Jack was looked after by an agency nurse with a certificate in adult nursing.
It is not clear what debrief for the staff involved was undertaken after the tragic events of that day, but Dr Bawa-Garba met with her consultant in the hospital canteen, where she felt under pressure to fill in areas of a trainee encounter form. She continued to work without problem and indeed with plaudits. A serious untoward incident inquiry was undertaken following the patient’s death, which was completed on 24th August 2012. A 14-person investigation team concluded that a single root cause for the death was unable to be identified. Numerous parts of the clinical process were identified as needing change. The report highlighted 23 recommendations and 79 actions that were undertaken by Leicester Royal Infirmary as a result of the organisational learning.
At the beginning of 2012 Dr Bawa-Garba was arrested and questioned two weeks after her next baby was born. She was detained by police for 7 hours away from her baby who was fully breast fed, refusing bottles and at risk of hypoglycaemia. Dr Bawa-Garba was in no state to face sustained police questioning and sign documents.
On 17th December 2014 Dr Bawa-Garba was charged with manslaughter on the grounds of gross negligence and found guilty on 4th November 2015, after 25 hours deliberation, on a majority verdict of 10 to 2. On 8th December 2016 she was denied leave to appeal. On 13th June 2017 she was suspended for a year by the Medical Practitioners Tribunal service. The GMC applied to over turn the MPTS suspension and instead to erase Dr Bawa-Garba from the medical register. Health Education England (HEE) withdrew Dr Bawa-Garba’s training number.
On 7th December 2017, considering the arguments surrounding the GMC case for erasure, the judge asked to know what was different about 18th February 2011, the day of the tragic events surrounding Jack’s death Jack’s admission. This may pre-suppose that all works smoothly on other days although we do not know the level of incidents, recorded or unrecorded error, near miss, death or disability from care on other days.
What we do know is as follows:
On this day: The team were relatively new due to the February change over and Dr Bawa-Garba had not received Trust induction.
On this day: The registrar covering CAU did not attend. Dr Bawa-Garba was doing their job.
On this day: The consultant covering CAU was in Warwick. Dr Bawa Garba was doing their job.
On this day: Due to hospital IT failure the Senior House Officer was delegated to phone for results from noon until 4pm. For this period Dr Bawa-Garba was doing their job.
Therefore on this day Dr Bawa-Garba did the work or three doctors including her own duties all day and in the afternoon the work of four doctors.
On this day: Neither Dr Bawa-Garba (due to crash bleep) nor the consultant (due to rosta) were able to attend morning handover, familiarise themselves with departmental patient load and plan the day’s work.
On this day: Dr Bawa-Garba, a trainee paediatrician, who had not undergone Trust induction, was looking after six wards, spanning 4 floors, undertaking paediatric input to surgical wards 10 and 11, giving advice to midwives and taking GP calls.
On this day: Even when the computer system was back on line, the results alerting system did not flag up abnormal results.
On this day: A patient who had shown a degree of clinical and metabolic recovery due to Dr Bawa-Garba’s entirely appropriate treatment of oxygen, fluids and antibiotics was given a dangerous blood pressure lowering medication (enalapril) which may have precipitated an arrest.
So what did Dr Bawa-Garba personally miss? Her initial treatment was felt to be good. She was not informed of Jack’s further diarrhoeal fluid losses by the nursing team. In terms of laboratory results she missed raised creatinine which arguably may have not affected the ongoing treatment in and of itself. She was unaware of the time of the chest x-ray, that she had correctly ordered, upload to the system, but as she had been personally undertaking procedures such as lumbar puncture and covering six ward areas, this must be understandable. No–one is all seeing. She correctly prescribed antibiotics as soon as she reviewed the x-ray.
Dr Bawa-Garba has inexplicably been held responsible for
-The fact that more senior staff did not apparently realise the implications of a blood gas result. Seniors supervise juniors, not vice versa.
-The fact that the nursing staff were not adequately supervised and supported to do their job. This is the role of nursing management.
-The fact unprescribed medication (enalapril) was given, not checked with the medical team. Dr Bawa-Garba could not take measures to counteract the effect of this medication, before patient deterioration into an arrest situation, as she was not informed enalapril had given.
-The fact that she did not personally apologise. Dr Bawa-Garba would have needed to obey all Trust and Medical Protection Society directives and the advice of her legal team with respect to communication with the patient’s tragically bereaved family.
Dr Bawa-Garba did mistakenly stop resuscitative efforts, confusing Jack with another patient, although this was not seen as contributory to the final tragic outcome. There had been confusing movement of patients of which Dr Bawa-Garba was not informed, so that when she was crash bleeped 13 hours after attending one arrest situation, having had no time for food, drink or a break, she raced to the area and wrongly assumed that she was going to the same patient. There were a minimum of 7 professionals in the cubicle, including Jack’s named professionals and equally senior, less exhausted paediatric and intensive care doctors leading or assisting the resuscitation. No–one queried Dr Bawa-Garba or double checked the name but rather they stopped resuscitative efforts on her word.
After these events, Nurse Amaro, an agency nursed trained in adult medicine, who had worked for 17 years with feedback attesting to a high level of performance, who was helping out CAU in a crisis, was struck off for 5 years. In her statement to the nursing and midwifery council she said nursing was her life and she had always wanted to be a nurse, because she wanted to help people. Some staff from the Trust who were working on the day have left voluntarily, with some moving abroad. Public statements from the Trust medical director say that improvements have been put in place to prevent similar tragedies. Dr Bawa-Garba awaits the decision of the Court of Appeal.
Dr Lyvia Dabydeen, Consultant Paediatric Neurologist
Dr Hilary Klonin, Consultant Paediatric Intensivist
Dr Sethu Wariyar, Consultant in Paediatric Neurodisability
3. Bawa-Garba v R, Court of Appeal - Criminal Division, December 08, 2016,  EWCA Crim 1841 https://court-appeal.vlex.co.uk/vid/201505475b1-654950101
4. Back to blame: the Bawa-Garba case and the patient safety agenda BMJ 2017; 359 (Published 29 November 2017) doi: https://doi.org/10.1136/bmj.j5534
Nurses and Drs are always scapegoated when things go wrong managers never take responsibility for their own failings the NHS is rotten to the core imo.
Wow. This is shocking reading. Who did she pass off to get this treatment? Absolutely disgusted she was not allowed to feed her baby!
What can we do?
I feel absolutely awful for the family of the little boy but I agree with you, she was scapegoated along with the nurses who tried to back her up and the whole thing is quite chilling.
As part of their training junior doctors are required to write reflective notes on "when things went wrong" - these have always been fully anonymised and kept private within an electronic system, for the appraisal people and the doctor's supervisor to see but no-one else.
This doctor's reflective note about this case (which although anonymised was of course identifiable as they knew what had happened and were looking for it) was entered into evidence.
I worry that this will make doctors less likely to record reflections on such cases in the future and will actually have a really bad effect on patient care, as it will make people reluctant to even try and learn from mistakes - both systemic and personal.
I say this as a doctor in a totally different field and a different country, so I don't know the ins and outs, but it would make me think twice about saying yes to taking on additional tasks where there are clear system problems- like this doctor was.
I read a really good quote online about this - something like
"We compare healthcare unfavourably to the airline industry all the time, in terms of looking at safety protocols and procedures. But if the engine wasn't working and half the crew were missing, a plane would never be allowed to take off. In healthcare, we don't have that luxury"
You can complain to the GMC about her treatment
That's actually terrifying to read. That is a shocking level of mismanagement however you look at it. How on earth could one Doctor be responsible for all of that madness on their 1st day back? And even more shocking that there is no trail of who administered the fatal drug.
Message withdrawn at poster's request.
I’m a nurse. I’m shocked and dismayed by the treatment of these two people. I’m glad I don’t work in the nhs.
It was Febuary as well and as the consultant pointed out junior Drs rotate in August and February so the juniors would be very new to the department too, I was a nurse in mental health but i can quite see how it could have happened shes had no break they are short staffed the phones going constantly its a nightmare .
I would find it highly unlikely that any nurse would give a drug to an inpatient which wasn’t prescribed. It’s not a drug I’ve heard of before so I’m not even sure if it’s routinely kept in stock on most wards.
I really do worry about the situation in the NHS. I would really be happy to pay more tax to fund it properly but the government can't seem to do anything but sit on their hands.
At the moment we are just paying privately for everything we can, to take pressure off the NHS systems. There is no private A&E though, and that concerns me a lot.
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