To feel sorry for this doctor?

[HarryStylesismycrack]

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.

www.independent.co.uk/news/uk/crime/jack-adcock-latest-downs-syndrome-death-doctor-hadiza-babwa-garba-struck-off-general-medical-council-a8177721.html

A different link to a blog by other medical practitioners 54000doctors.org/blogs/an-account-by-concerned-uk-paediatric-consultants-of-the-tragic-events-surrounding-the-gmc-action-against-dr-bawa-garba.html

If you look at Martin Bromilley. He and his family suffered a devestatinh blow when his wife died from an Anaesthetic complication during routine surgery.

He has been magnanimous to a degree I'm not sure I could have managed and channeled his expertise in error and human factors into a huge force for good within the profession.

He has earned enormous respect and done a great deal of positive work.

He takes pleasure in the fact that all the clinicians involved in his wife's care returned to work.

If I am ever a second victim of medical error I hope I can handle it like him. But non of us know how we will react iwhen someone we love dies.

Not read all of this but this poor doctor and the nurse have been completely scapegoated. Why would anyone do medicine now? How many other jobs can you wake up in a morning to go to work and do your best and then end up in prison?
I’m astounded that there’s a forum on here for medicine. My children will do medicine over my dead body. It’s too risky now.

opinionatedfreak you are right, of course, but he was an airline pilot, who was well versed in Human Factors training and process. He came from a place of understanding, and used that to apply himself to the situation he saw. What he couldn't understand is why it hadn't been used there, and why it hadn't saved his wife's life.

I think that's very different to a family who probably had their whole lives turned upside down by the birth of their son, and had it redefined as a mission to get him the care and support he needed to thrive. A common illness shouldn't have ended it, and that's probably why they have reacted the way they did. Perhaps wrongly, we'll never be in a position to judge, they have fought for their perception of justice for their son.

This may not be relevant, but as a paediatrician I am struck that Jack had a pH of 7.0 on admission and was so sick, it suggests that perhaps medical advice should have been sought earlier (especially given his medical history). I think these parents are stuck in the "anger" phase of their grief and possibly their guilt around both the enalapril dose and the delayed presentation are contributing to that.

I would absolutely let her treat my children....that is the greatest message of support I can give to Dr Bawa-Garba x

This poor doctor has been hung out to dry by her Trust and her seniors.

Read the legal summary and you'll see its not as clear as many posters seem to think:

www.bailii.org/ew/cases/EWCA/Crim/2016/1841.html

Here's a chunk of it (apologies for the huge C&P):

The case advanced on behalf of Dr Bawa-Garba was that she was not at any stage guilty of gross negligence. Reliance was placed on the following details.
i) Dr Bawa-Garba had taken a full history of the patient and carried out the necessary tests on his admission;

ii) At 11.30-11.45 am, Jack was showing signs of improvement as a result of having been given fluids (although it was agreed that this improvement had not been documented). There were also clinical signs of improvement from the second blood gas results which were available at 12.12 pm; Jack had been sitting up and laughing during the x-ray and reacted to having his finger pricked.

iii) Dr Bawa-Garba was correct to be cautious about introducing too much fluid into Jack because of his heart condition.

iv) A failure in the hospital's electronic computer system that day meant that although she had ordered blood tests at about 10.45am, she did not receive the blood test results from the hospital laboratory in the normal way and she was without the assistance of a senior house officer as a consequence. The results were delayed despite her best endeavours to obtain them. She finally received them at about 4.15pm.

v) Dr Bawa-Garba had flagged up the increased CRP infection markers in Jack's blood to the consultant, Dr O'Riordan, together with the patient's history and treatment at the handover meeting at 4.30pm. The consultant had overall responsibility for Jack

vi) A shortage of permanent nurses meant that agency nurses (who included Nurse Amaro) were being used more extensively.

vii) Nurse Amaro had failed properly to observe the patient and to communicate Jack's deterioration to her, particularly as Dr Bawa-Garba was heavily involved in treating other children between 12 and 3pm (including a baby that needed a lumbar puncture). The nurse also turned off the oxygen saturation monitoring equipment without telling Dr Bawa-Garba and, at 3 pm, when Jack was looking better, the nurse did not tell her about Jack's high temperature 40 minutes earlier or the extensive changing of the nappies.

viii) Dr Bawa-Garba had prescribed antibiotics for Jack at 3pm as soon as she saw the x-ray (which she agreed she should have seen earlier), but the Nurses failed to inform her that the x-rays were ready previously and then failed to administer the antibiotics until much after she had prescribed them (an hour later).

ix) At 7 pm, the decision to transfer Jack to Ward 28 was not hers and she bore no responsibility for the administration of enalapril:

x) The mistaken belief that Jack was a "DNR" was made towards the end of her 12/13 hour double shift and was very quickly corrected. It was agreed that her actions in attending with the resuscitation team and communicating this made no difference, although that incident would have been highly traumatic for Jack's family.

So the mother had given the enalapril, the (adult not paediatric) nurse had insufficiently monitored the child, hadn't told the doctor the XR was back and delayed administering the IVAB prescribed. The doctor hadn't instructed the transfer to the ward and wasn't aware he had moved. Her senior, who should have been more involved and supervising and supporting, did bugger all.

She appears to be utterly scapegoated in this tragic situation. The legal stuff is complicated IMO, I'm a nurse not a lawyer, but she appears to have been convicted on a legal argument rather than a clear criminal one.

Yep i agree with that lougle I have a child with similar disabillities it changes Your life fighting for everything for them ,to lose a child particularly after everything his parents must have gone through well they will be devastated .

When you google the doctor's name, this thread is on the first page. I think it's likely that she will at some point see it if it remains there (I suspect the same goes for Jack's parents). Dr Bawa Garba, if you do read this, know you have the support of many, many people. I'd happily have you treat any of my relatives.

By the same token lemon Jack's parents acted in what they thought were his best interests and I imagine they want to blame someone personally I think they are misguided In blaming Dr Bawa Garba and should look at how the trust let their son down but I can be objective they are living their hell.

Completely agree, no matter the truth of the medication if it was Jacks parents I’m certain they were trying to do their very best for their boy in what I’m sure was clear to anyone on the day was a disorganised and chaotic environment. And it’s easy to see how this happened, your son is poorly, you’re an expert in his condition, you know he needs this medication to be well normally, it would be easy to assume that this would remain the same in a different situation. And well, you don’t want to ask and bother someone because you can see they are all busy and doing their best and your child appears to be improving and tbh even if you did want to ask there is hardly any staff around. A totally understandable decision to think, well this is one thing I can do for my child that will help.

The consultant had overall responsibility for Jack

The more I read the more shocked I am at the verdict.

And you do become an expert in your child's disability my child has a rare chromosome disorder although he has autism and learning disabilities he is generally very healthy apart from chronic constipation when we mention his chromosome deletion most Drs have never heard of it I have become an expert in constipation!

I am a doctor who is thankful to be at the end, rather than the beginning, of her career. Without a doubt this doctor has been scapegoated (and the nurse). She was doing the work of 4 doctors, she had no support from her seniors, a drug was given by the little boy's mother that he shouldn't have had, by the time this poor child arrested he had been moved into the bed of a previous child who had had a DNAR in place who this doctor had attended only hours before.....the failings go on and on. Years ago (nearly 30) I found myself, as a very junior doc, doing the work of 3 doctors. It was not safe, I was out of my depth and I complained (or I guess the term would be whistle-blew now). The result? I was disciplined. Sadly this kind of thing has been around for decades. I stopped working clinically 5 years ago and virtually every doctor I know is desperate to get out of medicine. There is no justice for anyone with this outcome, not for Jack, not for his parents and not for this doctor.

Yes that’s all understandable. What is less understandable- or certainly less excusable - is the parents’ subsequent behaviour.

They are grieving parents but this does not give them a free pass to vilify and scapegoat, especially as their actions could be seen as contributing to their son’s death.

They had a choice about how to honour their son’s life; it’s certainly not a choice that is productive of anything that will actually help anybody.

And if Dr Bawa-Garba reads this, I’m so so sorry that you were so badly supported in your work. Thank you.

Has she? Could you link please Uterus?

www.crowdjustice.com/case/help-dr-bawa-garba/

I feel so sorry for the doctor. She’s been unfairly scapegoated.

This case has big brother stamped all over it.

Will those individuals who are really culpable have the courage to stand up and be counted or let their cowardice haunt their consciences for the rest of their days.

In the meantime how can we comfort and help this poor doctor? She deserves every ounce of public support to reverse this unholy judgement upon her.

You have got to love paragraph 51 from the judgement:

"Dr. Bawa-Garba, before and after the tragic events, was a competent, above average doctor. The day brought its unexpected workload, and strains and stresses caused by IT failings, consultant absences and her return from maternity leave. But there was no suggestion that her training in diagnosis of sepsis, or in testing potential diagnoses had been deficient, or that she was unaware of her obligations to assess for herself shortcomings or rustiness in her skills, and to seek assistance. There was no suggestion, unwelcome and stressful though the failings around her were, and with the workload she had that this was something she had not been trained to cope with or was something wholly out of the ordinary for a Year 6 trainee, not far off consultancy, to have to cope with, without making such serious errors".

Basically "the system is sh*t but that's life and you're a senior trainee so deal with it". Thank God this wasn't me this time, although it very easily could have been.

Please can we not switch to blaming the parents. I'm sure they were at all times doing what they thought was the best for Jack, and have had to live every day with every possible regret, and agonising over every what if. They lost the centre of their universe that day.

I firmly believe that this was predominantly a systems and trust level failure. I am not claiming that Dr Bawa-Garba's care was perfect, but she was place in a position where something was very likely to go wrong. And tragically for that poor wee lad, it did. But she did not choose to be covering for several doctors. She did not choose to have her consultant disappear offsite. She did not choose for the IT system to be down, robbing her of both prompt access to results, and the help of the doctor who got stuck chasing them. She did not choose to only have the help of new juniors. She did not choose to have no handover. She did not choose to be completely dumped into impossible working conditions.

The organisation placed her in that position. And, I do not seek to dump the blame on another individual, but I have to ask where the consultant was in all this? It is our job to protect the patients, and the trainees. It is our job to muck in when things go to pot. It is our job to help prioritise. It is our job to spot where something might be missed. It is our job, in handover, to suddenly go "hang on, what did you say that result was??!!! Where is this patient I must go see them now!"

It is our job to accept the clinical buck stops with us. If a patient I have seen clinically deteriorates, it is my responsibility. If a patient I haven't seen deteriorates, it is my responsibility because I did not realise I needed to see them. And if a patient no one told me about deteriorates it is still my responsibility, because it is my job to make sure my team knows when to call me.

But the blame was with the system. I cannot understand whey this ended up as individual manslaughter charges, when corporate would have seemed so much more appropriate. And so much better for changing things to safeguard the next patient, to save the next life. Jack was a tragic victim that day. But the future safety of hospitals has now become another victim. And I fear what that may mean for more children in the future.

Great post nocool.

"It is our job to accept the clinical buck stops with us. If a patient I have seen clinically deteriorates, it is my responsibility. If a patient I haven't seen deteriorates, it is my responsibility because I did not realise I needed to see them. And if a patient no one told me about deteriorates it is still my responsibility, because it is my job to make sure my team knows when to call me."

Isn't that all of our responsibilities, too, though? Maybe it's because I work in ITU, so I'm very tuned in to the deteriorating patient, but I don't work clinically now (a very recent change), but if I walk past a patient and they look very unwell, and their nurse is at the computer, or on the telephone, etc., I look to see if there is an acute problem that needs to be fixed (ie a dangerous monitor reading), I check that this isn't a new change for them on their chart, and I either say hello to them, or catch eyes with the nurse to say "alright?" I don't just walk on and think 'not my patient'.