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

it is awful when staff get blamed for the system failures.

jeremy hunt has just been on the radio, only caught the last sentence...

Hic I hold my hands up there, and say that I'd transplanted my adult knowledge to Paeds and overlooked that most hospitals don't have a PICU. Mine doesn't. But we have regional networks and phones.

Are you genuinely saying that a pH of 7.08 in anyone would be debatable for you, with a lactate of 11.00, if they are normally reasonably fit and well? Especially bearing in mind that this is someone who is presenting with cold peripheries, unresponsive, blue lips, breathlessness, diarrhoea, vomiting, a temperature of 37.7c. Do you really think that shouldn't make any qualified health professional have alarm bells screaming in their head that this is likely Sepsis?

Having said that, why weren't they using a Sepsis screening tool on admission? That's the first systemic failing right there. If they had, it would have pushed the poor doctor down the Sepsis path straight away, overworked or not, back from maternity leave or not, induction or not. Unless of course, there was one and she hadn't been shown it.

Draylon I think it's slightly different to have pressures on running a service (and I've been in that area before [angiography]) and ensuring the ongoing safety and care of sick patients.

When I said "if you're short-staffed, prioritise", I wasn't saying it's OK. It angers me. I am horrified when I hear the conditions some ward nurses work under. What I was saying though, is that when you're short staffed, even in Critical Care, or rather, when your patients are all really sick, and you may as well just spin in a circle in the middle of the ward, because you don't know who to go to next, as they are all the priority, then you have to be able to work out what is life-saving, what is essential, what is important, and what is nice to do.

As nurses, we are taught that every patient needs a wash, according to their preference, every day, in the morning if they would like it. It's really hard for a nurse to step outside of that model and 'fail' their patient. They need to know that patients don't die if they don't get a wash in the morning.

But they do die if they don't get their antibiotics and other essential medications, and they do cry if they don't get their pain relief.

Etc.

But she was found guilty by a jury and sentenced to a 2/year jail sentence.The jury would have had access to all the information about the circumstances.
She thought a young boy had a DNR in place when he didn't.That is one collosal mistake .It is something she should have been 100% on whatever the circumstances

Lougle
From what I’ve read he was treated for sepsis, fluid bolus, IVAB etc with an improvement in his bloods.

I get your point about priorities and nursing staffing, however this was an admissions unit. Unfortunately when nursing in admissions units you do not have the luxury of refusing patients due to staffing. Or refusing the sickest until the others have moved. You just have to ‘do your best’ which is the quote from that poor nurses NMC hearing. You escalate, but there are simply not the nurses to come.
You cannot refuse the cardiac arrest/stroke into resus because you’re too busy you have to do it, there is no option. Same as admitting sick children to a CAU, what else happens? Sick child can’t come to hospital? No staff, sorry?

5plus, the sentence was suspended and it is thought that the defence weren’t able to put forward a number of factors including the serious system failures.

The MPTS panel will also have had all the info and as an independent body believed she did not warrant erasure from the register.

She was accountable - certainly. I agree with lougle’s comments and 5plus1 (and I will just repeat here there are 1200 unnecessary deaths of people with learning disabilities in the NHS each year - it is very rare for anyone to be held accountable - that is outrageous).

It sounds as if her consultant should also maybe have been accountable - and managers and probably Jeremy bloody Hunt but that’s a different issue. She still made very big mistakes. I certainly wouldn’t want her anywhere near my son with severe learning disabilities.

We should be reporting all mistakes whether of consenquence or not and using them to develop safety net practices, offer retraining and generally making hospitals a safer place

Yep but while the NHS continues to bully and destroy the careers of whistleblowers (& I have seen that happen to someone very close to me & others i’m not so close to) that’s just not going to happen.

I suppose one potential consequence of doctors seeing this colleague held fully accountable with slopey shoulders from those around her is that they may become more confident about refusing to work in unsafe conditions. Tricky when you have patients in front of you.

Why would her defence not have put forward the system failures? That makes no sense!

YANBU

I think she has been totally scapegoated in this situation.

Read the letter written by two paediatric consultants at her hospital, describing the scenario she found herself in that day.

While I don't dispute that the outcome was completely horrendous for the poor little boy and his family, I really do not thinking that striking this doctor off was the right thing.

I think, more to the point, how the hell did the jury convict her of manslaughter in the first place?

It is illustrative to me of another scenario where managerial and administrative failings are not examined and sanctioned but the poor person on the coal face has to take all the punishment.

It seems clear that mistakes were made by the doctor but the systemic failings contributed far more to this situation. When I worked with consultants in a non-clinical environment, there didn’t seem to be much external control over their diaries; they seemed to manage them, themselves. That’s the impression I got anyway. So would it have been possible for someone to say to them, ‘you’ll have to cancel that training as we are too shortstaffed’? It seems completely unbalanced to blame the junior doctor for ‘not being assertive enough in stating their concerns’ rather than the consultant with overall responsibility. As the senior person, they should take responsibility for seeing something as urgent when the overloaded and less experienced doctor needs support.

There is interesting point made by I think Malcolm Gladwell about cultural issues affecting outcomes in a far eastern airline. The number of air crashes was much larger than expected. It turned out it was because of culture of not challenging decisions made by more senior people. I wonder if medicine is a bit like that, in that junior doctors are trained to be able to cope and not able to admit if they’re out of their depth.

Devilishpyjamas the excess deaths of patients with LDs is indeed something which should be tackled, but not by hanging one doctor out to dry- by education of staff. Lougle you can’t as a doctor or nurse in an acute setting decide you have too many patients- you can escalate, beg for help etc but you mostly have to get on with it unfortunately.

This shouldn’t have gotten as far as a manslaughter charge against 2 people- perhaps the institution but not individuals.
This isn’t a doctor with a history of recurrent bad decision making. Her record before and after was excellent. The DNAR mistake was emotive but almost certainly was not contributory.

Investigating mistakes should happen in a transparent way, but should be in a way which ENCOURAGES reporting and reflection.

Just seen that the letter has been posted up thread- good, people need to read it to get even a small glimpse into the total shit storm she was facing that day (and also on her very first day back from maternity leave).

Also not forgetting the nurse who was struck off too- I believe she was an adult trained nurse, not clear why she had been put on the children's ward.

I suppose this reflects the utter dire circumstances that the wards/hospital were in that particular day.

Paranormal - to date there has been case after case where nothing has been learned. No outrage from the public, just more deaths. Constant failures both from individual medics and the system.

And the mistake about DNR was surely due to his DS (& that’s an appalling error) - or are there many young kids with a DNR in place.

I do think others should have been held accountable as well but she made some terrible errors.

This is very interesting. The local media has been covering this story from the start and has been totally biased - The narrative is one bad doctor has killed a child with no consideration of the actual circumstances. Last night's TV news showed the parents drinking champagne and a headline in the local rag was something about the parents drinking champagne at their son's grave - because they had finally got justice for their son.
In truth both the child and his family, and the doctor and nurse, have been sacrificed by an NHS system that is failing because of government funding. I wish local media was covering that angle rather than the simplistic one they're covering now.

I used to work for that hospital, and my brother is still regularly treated there. Neither the situation, nor the choice to find and blame scapegoats, surprises me. Poor little boy, poor family, and poor doctor and nurse. What a mess.

I considered training as a nurse when I left school - feels like a bullet dodged these days.

She has been thrown under the bus. What consultant wouldn't want to see a child with a blood gas like that?

I find this so sad.

I know the family are grieving as they lost their little boy when they shouldnt have but they are laying the blame at the doctors feet rather than looking at the whole picture. If it was me i would be asking what can be done to stop this happening again not celebrating because a doctor doing 4 peoples jobs was let down by the government and the failing nhs. And then made into a scapegoat to cover it all up.

With respect you have no idea what you would do if your child died as a result of poor care (whether individual, collective or both).

Well you can’t blame the family for wanting justice, nor for celebrating when they think justice has been done. But the system should look at these cases objectively.

Devilish nobody knows why the error was made re DNAR. Perhaps there was another child with a similar name or on the same ward with a DNAR. On her first day back from leave, completely overwhelmed perhaps she simply confused them in her head. Again the CPR should have continued until the notes consulted, not simply taken her word for it. Team failing, not just individual.

If you think the child having DS has nothing to do with her mistake re the DNR then I think you are naive or maybe don’t realise how shockingly poor healthcare is for people with learning disabilies.

I’d read that having been called to an arrest earlier she simply mixed the two up in her head, given the amount of patients she had probably seen that day it’s understandable. Not acceptable. But I can understand how it happened.

"As nurses, we are taught that every patient needs a wash, according to their preference, every day, in the morning if they would like it. It's really hard for a nurse to step outside of that model and 'fail' their patient. They need to know that patients don't die if they don't get a wash in the morning."

I'm fascinated by this, as in my experience (limited admittedly) of my own and relatives time in hospital, is that washes were a twice weekly affair at best. My sick mother went seven weeks without her hair washed before she died. And she was awake and lucid and speaking for all but the last few days. She felt utterly degraded and demeaned as a lady who'd always washed her hair every day. She was told they 'don't offer that service'.

It must show how far things have come that as a relative of patients who continue to have lengthy multiple hospital admissions, I didn't even realise a daily wash was supposed to be part of normal nursing care.

I suspect it's small comfort for this doctor, but I do hope she's reading the outpouring of support towards her. I doubt she would want to continue practising medicine if this is how the system treats her, but I can't imagine how awful it must be to have to live with this.

never acceptable and terrifying that a doctor could mix two patients up, did they both have DS?

Sorry, I was unclear - I don't blame the parents for doing whatever they have to do to even begin to manage their grief; but I do think the local media has been irresponsible in its one side coverage, without any analysis or probing of what is going on in local hospitals.

Hmm.

If this case has fired an interest in preventing avoidable deaths within the NHS and learning from mistakes Richard Handley’s inquest is being live tweeted from 10.30am Part of trying to reduce the number of avoidable deaths and ensuring people learn from mistakes. Can follow at @HandleyInquest