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

@Samcro mix ups do happen unfortunately. Possibly because patients are constantly moved around. It is difficult to keep track and mistakes happen.

If she had been to an arrest at the same bed not long before and a DNAR order made I can see why she would think it applied. And nobody wants to carry out a resuscitation on a child (or adult) who is not for resuscitation- it’s unpleasant, undignified and not peaceful. It was wrong but I see how it happened.

It’s being focused on as it’s emotive. But very unlikely to have caused this- resuscitation are seldom successful (except on tv sadly).

Not that I believe in baying for blood, but in light of all this, why aren’t UHL up for corporate manslaughter?

Devastated for Hadiza and the implications for medical practice in this country. This could have happened to any hard working conscientious doctor. I don’t know anyone that hasn’t faced a shift with these sort of issues. I was once a 3rd year SHO on nights, reg went home sick. I was the most senior medic. Consultant on call at home, had met me once but “knew I could handle it on my own”. There but by the grace of god go I...

I really feel we should add here that the poor poor parents weren’t to know either though, if theu did indeed give Jack his medication. If my child was on regular meds I can see how I might have done the same without giving it any thought. It’s horrible all round. People want things to be black and white and have someone specific to blame but it is rarely that simple

Or just what missduke ^^ said

I read the comments of the DM article. Full of people asking where she qualified, insinuating that she bought her medical degree abroad etc. The article itself states she graduated from the University of Leicester!

If she were white and male, she would not be receiving this treatment.

Regarding the DNR mix up, I just wanted to point out in case it's been missed - the Dr was covering multiple jobs that day (on her first day back from maternity leave, no induction, no access to IT systems as they'd all gone down - test results all having to be manually phoned for etc). And from what I recall she'd received a crash call for a DNR patient at the start of her shift (13hrs) earlier, and there had been multiple patient moves during those many hours which weren't logged - even if they had been able to give her access to those moves, it's not like she'd even had a Trust induction or IT access to access relevant information across 4 (yes, FOUR) wards she was being expected to cover.

It sounds like she went into that shift and it turned into a warzone, and she had absolutely no senior or oganisational support in place to help her deal with an utterly unmanageable situation.

I honestly don't know how this wasn't anything other than a terribly sad but preventable incident waiting to happen. It's a miracle something worse didn't occur (like with the baby with meningitis that she was dealing with).

If she were white and male, she would not be receiving this treatment.

I 100% agree with that.

Interesting that the trust/deanery didn’t stop her from working. They knew.

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'll admit I haven't practiced as a Nurse in over 10 years but this is terrifying practice. I'm only surprised there hasn't been more deaths due to this culture.

If she were white and male, she would not be receiving this treatment.

I agree.

I have seen it happen that relatives ask if a patient can have x drug. Not been seen by the doctor yet. Nurse says you can give it but we can’t. No advice to wait for doctor.

It’s a tricky situation for the nurse. Especially with vital heart meds like in this case and when all doctors busy elsewhere to ask

But if already been seen by a doctor and not prescribed it should have been locked in cupboard so no error could be made :(

I can't help wondering if Jack had continued to be given Enalapril during his illness (gastro) prior to hospitalisation and if this had contributed to his becoming so desperately ill in the first place.

In addition, it's worth remembering that all this happened in 2011. This was a time before the current campaign for sepsis awareness, standardisation of sepsis protocols etc.

Finally, a comment from beneath the article linked above

From personal experience, Dr Hadiza cared for my son while he was terminally ill. And we could not fault her, not one bit. She was attentive, not adverse to anything that we wanted to try, and fully supported us as a family. When my son finally passed, she came and asked if she could kiss him on his way.

I could weep for the bloody tragedy of it all.

Curious that her Consultant appears to have got away scot free. He has overall responsibility for his patient and doesn't need an "invite" from his Registrar to come and review them. He didn't know this junior doctor so didn't know the level of her knowledge or ability to cope in a crisis. Yet he chose to leave the unit to deliver training. He should have prioritised the clinical area over training. At the very least, he needs retraining and should no longer be approved as an Educational Supervisor.

I feel terribly sad for the parents but I find the glee they are exhibiting is rather tasteless. This is a Pyrrhic victory at most - they have lost a child, a young doctor has lost her livelihood and much much much more. This is not the time to guzzle champagne. Meanwhile the real perpetrators of this crime get off without censure and there will be little if no learning from this incident (and therefore potential prevention of future incidents) as the "evil" doctor who caused it is no longer a "danger to patients". I can understand that in their grief they need someone to blame but blaming the wrong person doesn't help anyone apart from the people who are truly responsible for this tragedy

Bore that has made me cry

Me too ONONARISTON

The reason this child died was because the unit was dangerously understaffed the Dr and the nurse may well have made mistakes but if there had been enough staff to share the burden they wouldn't have been in that position , i once as a nurse made a mistake with important section papers obviously it wasent life threatening but they were legal documents basically the wrong set of papers were filled out , I should have checked however on that day i was the only trained nurse on duty I was working a 13 he shift no one could cover my break so I didn't get one the phone inn the office was going constantly Drs and other staff were inn and out of the office patients were knocking on the office door needing my attention and I made a mistake the manager that investigated completely ignored all of that and said I needed more training .

I left nursing due to care of my disabled son. I’d done 26 yrs, altogether. I ended my career as a senior sister. There is NO WAY I would re-enter the profession.

And if there had of been adequate staff then someone could have sat and explained to Jack's parents exactly what was going to happen.and why he shouldn't have the enalapril that's assuming they did give it to him of course and we dont know if that's the case.

I agree that Dr Bawa Garba has been treated appallingly. Not knowing what else to do I wrote to the GMC. They are not protecting me by chasing away good doctors caught up in a collapsing system.
Anyway it's too late for the Dr concerned but it made me feel batter and if there's a petition to support this doctor and and others can someone post details.

The whole thing is just heart breaking. A doctor who from all reports was a good clinician in an impossible situation has lost her job. The general feeling I have (and is shared by every medical friend that I have had) is that this could have happened to anyone who was put in this situation.

There are so many things in this case that just make me angry.

I also can't understand how the paediatric consultant didn't deem it appropriate to review the patient after seeing the blood gas. Even if he wasn't asked to he is the senior clinician in this situation I don't understand how she has now got a manslaughter conviction and has been struck off and he is still working with an seemingly unblemished record. I have friends who have got in trouble when their juniors have made (less significant than this) mistakes which they weren't even informed of because they weren't deemed to be supervising them appropriately.

I also find the report of how she was taken to a police station and interviewed for hours on end two weeks after having her second baby (who was exclusively breast fed) very upsetting. This happened a long time after the event where was the urgency to interview her for hours on end when she had just had a baby who was away from her with no means of being fed.

I think that this doctor has been completely failed by the system. The GMC should hang their heads in shame.

Haven’t read the full thread as wanted to give my initial thoughts after reading the case, will go and read afterwards.

The patient had a blood ph of 7.0 on admission, this is not ok, the boy had acidosis and was in a critical condition. Even the “improved ph” of 7.24 was still dangerous. The 2 usual causes of acidosis are carbon dioxide retention or huge kidney process issues. Therefore leaving the chest X-ray for over 2 hours was a very poor standard of care given the above information.

The second issue is the administration of enalopril whilst not prescribed. This is really not ok either!

I understand the shift was in turmoil and the day was horrendous, but bearing in mind the above I think it’s absolutely right that both the doctor and the nurse should not be allowed to practice again.