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

Devilish I’ve cared for many many patients with learning disabilities over the years. I worked in a unit with people with learning disabilities part time all through my time in medical school. I always advocate for my patients in this situation. I have never seen Downs Syndrome be used as a reason for a DNAR (and it would be appalling if it was). Either way it wasn’t contributory in this case. I don’t know why she made the error- it could have been because of the Downs or for a multitude of other reasons. The team should have continued CPR while the notes were checked either way.

I agree with what everyone else is saying, and as a medic, I’m so glad to read the comments on this thread, and to know that the public can see how badly this has been handled.

I know no one can tell a family how to grieve, but I find it so sad for Jack’s family that this is the route they have taken. There’s a case that is very famous in healthcare of an Australian woman who died because they couldn’t intubate her for a routine operation, so her brain was starved of oxygen. Her husband was a pilot, and couldn’t believe that there wasn’t systems in place to deal with this scenario- so instead of blaming one person, he campaigned and has brought massive global awareness to the issue and real changes to how it is managed. Goodness knows how many lives have been saved because of his actions. I don’t blame Jack’s parents for wanting what they see as justice, but I feel real justice would have been if the system was held accountable and changes were made. A really simple thing that happens in NZ that could be implemented here is that if you’re short a Reg, the consultant on call has to hold their bleep and do their job- keeps everyone safe and means there’s much more effort put in to finding cover!

While I have some sympathy for the doctor we need to step back and consider :

1. The cps thought there was enough evidence of negligence to prosecute
2. A public jury, made up of people just like the ones posting here, heard the case and found the doctor guilty
3. A high court judge heard the case for an appeal of the criminal conviction and refused that appeal
4. The gmc did not 'go against the mpts'.. The gmc appealed the mpts decision (as is its legal right to, a recent change in law decided in Parliament now allows this). This appeal is heard by a high court.
5. The high court judge heard the whole case again and decided the mpts were wrong.

So there is the cps, a public jury, an appeals judge and a high court judge who all heard All the details of the case and they all felt that Dr b-g was guilty of negligence of such a high proportion that a conviction was Warrented and erasure was the correct consequence of this conviction.

The gmc has only recently had the ability to appeal mpts decisions... Most of the appeals heard have resulted in the high courts overturning the mpts decisions, perhaps the mpts should scrutinised as there seems to be some kind of discord between them and the regulator.

From reading the letter from the 3 paediatric consultants, it does shed some light on the "terrible errors" that the doctor is said to have personally made.

The one about stopping the resusicitation- it appears that patients had been moved on the wards during the shift- bear in mind, this doctor was covering a minimum of 4 wards or something and she would not have been aware of every single transfer/change of bed by each patient. That sounds more like the responsibility of senior ward staff.

It seems she attended an arrest situation for one patient several hours previously in her shift- that patient had a DNAR (do not resuscitate) form completed for them.

It then sounds like the patient Jack was transferred into this bed/bay.

Being called back to the same bed/ward, it was not unreasonable for the doctor to assume that it was the patient who she had treated earlier.

It is inexcusable that the resuscitation was stopped on the wrong patient, but surely there would have been a ward manager/senior nursing staff present who would know (presumably) where each patient on their ward was located and any recent movements?

And in an emergency situation, surely there would have been other staff members responding?

I do not think that this doctor can be given the blame entirely for this.

Rinceoir surely you know how appalling the care so often is for people with learning disabilities then? I find it bizarre that no-one would question a DNR on a young child (although the trainee present did? If what I read is correct - and checked the notes).

The problem is that doesn’t happen fraggle. There has been case after case after case where system and individual failures leading to the death of someone with learning disabilities has been identified. No-one is held accountable and nothing changes. And more people die. I suppose this outcry may lead to some positive change. But if there was a similar outcry over other deaths then maybe this could have been avoided. Maybe people need to see getting as outraged by unnecessary deaths.

*start

Comments in the DM are truly depressing. The doctor has been made out to be some kind of monster and honestly I don’t think her race, her headscarf and general appearance have done her any favours. Easy to vilify and dehumanise someone who doesn’t look like you. I am concerned for her safety and what this treatment might push her to. It has happened before.

That’s not to take away from Jack’s parents immense suffering, I am a bereaved mother myself. But agree with fraggle that opportunities are being missed to improve totally shoddy systems

Opportunities aren’t being missed in this case though. They are missed repeatedly. The slopey shoulders and defensive response to each case means changes aren’t made. Lack of accountability means changes aren’t made. Again and again and again.

I actually think the outcry over this is more likely to lead to positive changes for patient safety than any of the thousands of unecessary deaths that came before.

Well if she thought it was the same patient she had seen earlier with a DNAR that makes sense. Yes of course someone should have checked notes before stopping CPR- my point is that is a team error not an individual one.

I absolutely agree that care for patients with learning disabilities should be improved. I’ve worked closely with advocates in this field to deliver Grand Rounds and other educational lectures to colleagues on more than one occasion.

However holding 2 people entirely responsible for a systems error doesn’t help anyone- it actually makes it worse. People think it’s just a few bad apples who have been weeded out and don’t address the massive systematic failures that occurred.

This was a case of negligence at an institutional level and should have been treated as such. We all in the health sector should learn from such cases and put in systems to prevent similar cases in future.

This doctor is not a monster, Shipman was a monster, patterson is a monster, however she has not demonstrated a good duty of candour, she has apparently not once apologised to Jack's parents.

Maybe that lack of empathy with Jack's parents made her come accross as unrepentant.

Hmm I kind of take your point devilish, that even if I don’t feel it is right that this doctor has (IMO) been scapegoated, it does provide a rather horrifying cautionary tale and maybe the publicity around it will be a catalyst for change. But isn’t it more likely that it will just terrify lower ranking medics (in itself unhelpful- no one performs their best when scared) without impacting on those who should be responsible for changing the systems in place? For example looking into systems regarding the administration of a patient’s regular meds while being treated?

I think the perceived lack of apology is a bit of a red herring here.

I certainly have no doubt her medical defence organisation and her employing Trust would have advised her not to enter into any contact/correspondence or dialogue with the family, even if it was to express how sorry she was for the way events turned out.

I don't know, I just imagine this would have been a likely scenario- there was a Trust investigation happening, inquest by the coroner and eventually a criminal investigation going on.

I'm sure she would have been advised- or maybe not as the case may be?

I'm a GP and this kind of thing terrifies me. She has been thrown under a bus completely. I too am looking for a way out of medicine as its unsustainable in its current condition. So so sorry for this poor lady.

theredjellybean she will have been told by her defence union not to in case it appears an admission of guilt!

@ONONARISTON

Absolutely systems need looking into!

My question would be- how the hell did the patient receive a drug that was not even prescribed for him??!!

It sounds like the doctor made the correct decision to withhold a number of his regular medications due to his sepsis and failing kidneys.

I'm baffled.

You often hear cases where important drugs are prescribed and then do not get given for several hours (or even days!).

But a case where a medication was specifically withheld, for very good clinical reasons- yet the patient still received a dose, possibly precipitating his cardiac arrest?

Easier to punish a scapegoat then to highlight and deal with the underlying problems :(

@theredjellybean she will have been told by her counsel not to apologise. I’m sure she feels awful for the mistake and angry at the institution which allowed it happen.

I was involved in a case at around her stage where there was no gross negligence but a political will from the hospital to make a point about the death of a patient (more regarding place of death than more of death if that makes sense). Even though it was only an inquest, and there was no question that the death was unavoidable the case had a huge impact on me. I was terrified on every call for the rest of the year I worked there, I became obsessed with documentation, I stayed at work hours late to make sure I did everything myself rather than trust someone else. I was absolutely miserable for that whole year and certainly wouldn’t have felt comfortable whistleblowing if I saw unsafe practices as the hospital had amply demonstrated that it did not care for its staff. I did return at a more senior level to speak with the CEO about my experiences and concerns. I strongly felt that the culture of blame made the hospital far more unsafe.

I think this case creates similar fears for everyone in the health service.

But the guidance to doctors from the gmc is very clear that under a duty of candor you should apologise when mistakes have been made and that this is not seen as an admission of guilt.
The guidance highlights that culturally making an apology maybe perceived differently by doctors who have qualified outside of the UK. However if you are registered with the gmc you are expected to follow their guidance.

The doctor in question can apply to get her registration back after 5 years, but (and doctors here can correct me if I'm wrong) it will be pretty difficult to get her training number back, won't it? 5 years is a long time in medicine, especially at ST6 level, I would have thought. It really is such an awful thing.

I understand the Dr made mistakes, although an earlier post made it appear as though her mistakes were not contributory to the death of the poor child and it was the medicine he was given without her knowledge that played the biggest part?

Even so, if she was negligent then surely so was the CAU registrar who went on training, leaving their ward without adequate cover.

The consultant who did not attend, leaving someone under qualified to do their job.

The person in charge of rotas who allowed this doctor to cover four wards.

But mostly the person in charge of the hospital who allowed all of this to happen.

TurquoiseDress

"My question would be- how the hell did the patient receive a drug that was not even prescribed for him??!!"

Apparently, one of the systematic failings that was discovered at the hospital, was that there was a cultural norm, that the doctor was unaware of, that medications that were normally prescribed for the patient, but had not been prescribed by the admitting doctor, could be given without prescription. The admitting doctor had decided not to give the enalapril, because it is an antihypertensive, and he was already underfilled, but she didn't document that she had decided to omit it, because she assumed that by not prescribing it, it would be omitted. In that hospital, to ensure it wouldn't be given, it would need to be documented that his usual drugs should not be given. Absolutely barmy in any other hospital, because legally, nurses can't prescribe drugs unless they are prescribers, they can only administer drugs that are prescribed.

I should qualify, that there are certain Patient Group Directives, which allow nurses to give 'one-off' doses of certain drugs/fluids without referring to a doctor, whilst waiting for a doctor's attendance. Examples would be a single dose of paracetamol for pain, or a 50 ml bag of saline as an antibiotic flush, parrafin wax for dry lips, etc. However, if the patient required paracetamol on an occasional or regular basis, the doctor would have to prescribe it either PRN, or 4-hourly.