Statement from the Royal College of Physicians and Surgeons of Glasgow
Individuals must not be held accountable for complex systemic failure.
The controversy surrounding the court action taken by the GMC against Dr Bawa-Garba and her subsequent erasure from the Medical Register has generated several areas of concern for all doctors working in the UK. In view of the implications for patient safety, it is important that these are addressed as a matter of urgency. The process of the recent court case and its outcome have the potential to compromise patient safety in unforeseen ways.
As a College we wish to express our sympathy for all concerned in this tragic case, most of all to the family of Jack Adcock, a six year old boy who tragically died of sepsis in Leicester Royal Infirmary. We also offer our sympathy to the clinical staff upon whom responsibility for Jack’s care lay. It is also impossible not to feel frustration about the circumstances in which they were working.
The case against Dr Bawa Garba
In 2015 a paediatric registrar, Dr Hadiza Bawa-Garba, was convicted of manslaughter (as was a nurse involved in the case). She was given a 24 month suspended sentence at Nottingham Crown Court. As part of the proceedings, a reflective note Dr Bawa-Garba had created after the event was allegedly used in evidence against her. Dr Bawa-Garba was held responsible for a sequence of failings. She did not recognise the early features of sepsis in the child and as such appropriate antibiotic treatment was delayed. She appeared not to recognise the implications of seriously deranged blood gas results and failed to fully communicate the implications to her consultant. When the child suffered a cardiac arrest there was a further problem as the patient was wrongly identified as another child for whom a DNACPR order applied. A local investigation failed to find a single cause of the poor outcome but rather a complex systemic set of errors and failings.
Apparently Dr Bawa-Garba had recently returned to work following maternity leave. She was covering the work of another registrar, with her supervising consultant teaching on a different site, and the two junior colleagues, for whom she had supervisory responsibility, had no paediatric experience. She was expected to review unwell patients and perform procedures on six wards over four floors, field the GP calls and struggle without a functioning IT system. She was then blamed for failing to recognise, in the heat of the moment, that Jack was now in a bed previously occupied by a patient with a DNACPR order; that change had been made without her knowledge.
In June 2017 the Medical Practitioners Tribunal Service recommended that Dr Bawa-Garba be suspended from the Medical Register for 12 months rejecting an appeal from the GMC to strike her off the Register. The GMC applied for a judicial review of the MPTS decision in the High Court and argued that the tribunal was wrong in concluding that Dr Bawa-Garba be allowed to continue to practice when her suspension from the Medical Register ended. The GMC argued that the tribunal had allowed evidence of systemic failings to undermine Dr Bawa-Garba's personal culpability. The case made by the GMC was allowed in the High Court of Justice and on the 28th January 2018, the Court ruled that the doctor’s name be erased from the Medical Register, ostensibly to protect public confidence in the profession.
The Implications for Medical Practice in the UK
The social media storm which has resulted from this judgment has raised many areas of serious concern which will apply widely and have serious implications for the way in which doctors practice and reflect on their performance.
The GMC have recommended that trainees document and report their concerns about unsafe working conditions, though this would still leave them in the unenviable position of choosing between continuing to work in such circumstances, and facing the consequences if harm occurs; or refusing to work, and taking their chances. It should be noted that what happened to Dr Bawa-Garba occurred in 2012, and the increasingly stricken nature of the NHS has not gone undocumented by the media since that time. Systems and staff are stretched more than ever, and we should all feel fortunate that what happened to Dr Bawa-Garba has not happened to us. It is concerning that junior staff may now refuse to cover shifts for fear of being held responsible if an error occurs while they are undertaking extra work.
We believe that this case has significant implications for the supposed, ‘no blame’ culture in the NHS and for open learning from errors or near misses by way of reflective practice. Clearly, if such reflection may be used against an individual composing a frank and honest record, it is unlikely that such detailed reflection will ever be carried out. By using reflective practice in a punitive way, it will make doctors more defensive and less inclined to admit to, and perhaps learn from, their mistakes.
What can be done? Here are some practical suggestions:
- If you feel exposed by the level of staffing, availability of support, IT functionality or other systemic issues, you should immediately make that known to the consultant in charge.
- Please be aware of any additional relevant local reporting mechanisms that may apply and make sure you have the relevant contact details to hand.
- In as much as is possible, compose a careful and balanced written account of the risks in the situation and report that to senior clinicians and management.
- Consider reporting the concern directly to the College – specifically to the office of the President. Some doctors may be reluctant to directly involve their consultant in case this implies that they are unable to cope. The College is independent and will endeavour to respond quickly with appropriate suggestions, discussion and advice.
- In the meantime, if you do choose to write a reflective report, ensure that it is fully anonymised. Ensure that ePortfolio reflections contain no patient identifiable information. This will minimise but not eliminate the risk to patient confidentiality. Avoid emotive language, any suggestion of culpability or judgmental statements about any patient or staff who may be involved.
- Seek advice from senior colleagues or defense union representatives in cases considered to be potentially serious.
- Consultants should take a proactive role to ensure their trainees feel safe and supported and able to report incidents and clinical concerns. Reflective practice should still occur without trainees being exposed to legal action.
- Make an opportunity to discuss these issues with trainees you supervise in your role as an Educational Supervisor or Clinical Supervisor.
Finally for now:
- Consider becoming involved with the Royal College Buddy Scheme where you can be paired with another trainee in the same or similar specialty.
- The College will pick up other areas of concern arising from this case in meetings with the Council and Office Bearers as well as with the Academy of Medical Royal Colleges and the GMC and will issue additional advice in due course.