Friday, February 23, 2018

To err Is homicide in Britain

The good that doctors do is oft interred by a single error. The case of Dr Hadiza Bawa-Garba, a trainee pediatrician in the NHS, convicted for homicide for the death of a child from sepsis, and hounded by the General Medical Council (GMC), is every junior doctor's primal fear…

Dr Bawa-Garba had just returned from a 13-month maternity break. She was the on-call pediatric registrar—the second in command for the care of sick children at Leicester Royal Infirmary. As a "registrar," she was both a master and an apprentice—a juxtaposition of roles necessary for the survival of acute care in the NHS. Because there aren't enough commanders, or consultants (attendings), in the NHS, trainees must fill their shoes, or else the NHS will collapse.

The captain of the ship and Dr Bawa-Garba's supervisor, Dr O'Riordan, was not in the hospital but teaching in a nearby city…

Normally, a registrar each is assigned to cover the wards, the emergency department, and the Children's Assessment Unit (CAU). On that day, Dr Bawa-Garba covered all three. She was new to the hospital but with no formal induction (ie, no explanation where things are and how stuff gets done in the hospital). She was expected to get along with the call and find her way around the hospital…

Triple booked, Dr Bawa-Garba was making critical decisions and also doing the scut work and teaching and supervising her team. To borrow an aviation analogy, she was flying the plane and serving food to the passengers.

At 10:30 am, she assessed Jack Adcock, a 6-year old boy with Down syndrome who was referred by the general practitioner (GP) for nausea, vomiting, and diarrhea….

Dr Bawa-Garba made a presumptive diagnosis of fluid depletion from gastroenteritis and administered an intravenous fluid bolus immediately and started him on maintenance fluids. She requested a chest radiograph; sent off bloods for blood count, renal function, and inflammatory markers; and drew blood gases, which showed that Jack was acidotic with a pH of 7 and a lactate of 11…

At 3 pm, she looked at the chest radiograph, which showed Jack had pneumonia. She prescribed Jack antibiotics, which were given at 4 pm. The radiograph had been exposed at 12:30 pm….

At 4:30 pm, she met Dr O'Riordan, her boss, in the hospital corridor. She showed him Jack's blood gas results and explained her plan of action. Her boss did not see Jack.

In the ward, Jack received enalapril. Dr Bawa-Garba had not prescribed enalapril, and she clearly stated in her plan that enalapril must be stopped—the drug lowers blood pressure and is absolutely contraindicated in shock. Nor was enalapril given by the nursing staff—they stick to the doctor's orders.

An hour after receiving enalapril, Jack had a cardiac arrest. After vigorous attempts at resuscitation, interrupted for a minute by Dr Bawa-Garba mistaking Jack for another child who was not for resuscitation, Jack was pronounced dead.

Jack died from streptococcal sepsis…

After Jack's death, Dr Bawa-Garba was distraught, and her consultant encouraged her to record her failings in her electronic portfolio. Trainees are encouraged to record their mistakes, predominantly for pedagogy. She could have, if she wanted, written about the system failures of that day. But that would have been making excuses, and you don't stick around in a field like pediatrics if you're the sort who points fingers at others.

Though the details of her reflections are not public, she is likely to have been merciless on herself. She likely admonished herself for not thinking about sepsis instantly, for not insisting that the chest radiograph be done immediately, for not reviewing the film sooner, for not starting the antibiotics immediately, and, most of all, for not being clear that under no circumstances was Jack to be given enalapril. It is likely she omitted that she was doing the work of three registrars that day, that she had a long hiatus from clinical medicine, that she was new to the hospital, that her consultant did not help out. In a cruel twist, her reflections, instead of purging her of guilt and delivering her from purgatory, would later deliver her to purgatory…

The first police inquiries did not find enough grounds for a prosecution. However, the Adcocks persisted—understandably, given their circumstances. And it's important to acknowledge that many people would have done exactly what the Adcocks did. You don't lose a 6-year-old child to sepsis and just shrug your shoulders.

Dr Bawa-Garba, and the two nurses who were caring for Jack, were charged with manslaughter. The case against the pediatric trainee was simple—she wasn't just clueless but grossly negligent. With the power of hindsight, Jack's case was dissected to the hilt. Sepsis, the deadly deceiver, became a diagnosis that any half-competent pediatrician should casually be able to detect…

Expert witnesses opined that had Jack received antibiotics within 30 minutes, rather than 6 hours, his chances of survival would have increased dramatically. There was tremendous certainty in the counterfactual. Diagnostic medicine is a fog of uncertainty until you know what the patient had. Dr Bawa-Garba was found guilty of manslaughter; the jury returned the verdict 10:2…

The problem with the law isn't that the law is an ass, it is that the law is an inconsistent ass. Jack's blood gases were deemed characteristic of sepsis. If they were so characteristic, why did Dr O'Riordan, the peripatetic consultant of the day and Dr Bawa-Garba's supervisor, not instantly diagnose sepsis when he saw the blood gases? It was Friday, 4:30 pm—the weekend was nigh. Why did he not immediately see Jack and transfer him to the intensive care unit?

If a trainee, an apprentice, who was doing the work of three registrars, can be found guilty of homicide for not understanding acid-base physiology, what does it say about the competence of her supervisor? How can she be criminally negligent and not he? This is neither scientific nor logical. Dr O'Riordan was either incompetent or lazy. Or there's another explanation: Perhaps sepsis in a child is difficult to diagnose, even for a seasoned consultant pediatrician.

Dr O'Riordan was not on trial, it was Dr Bawa-Garba. When asked why he did not see Jack, Dr O'Riordan said that Dr Bawa-Garba had not asked him to; she had not impressed upon him Jack's clinical urgency. This is deeply disingenuous. Every consultant must recall being a junior doctor—recall that trainees don't not ask for help because of their pride but because they're hesitant to ask for help, and they're hesitant not because they're afraid but because there's a culture of hesitancy, and that culture of hesitancy is a corollary to a culture in which apprentices are expected to make decisions independently, without which hospital medicine would abruptly halt. The onus is on the consultant to sniff out trouble…

Had Dr Bawa-Garba prescribed the fatal dose of enalapril, she ought to have been found guilty of manslaughter—that error is egregious. But she did not. And here, too, a failing, a mysterious failing, was internalized by the apprentice. It was deemed her fault for not anticipating that Jack would receive enalapril, even though it was not on his drug chart. She was guilty for not thinking about all the contingencies…

She was not surfing on the web whilst, unbeknownst to her, Jack's organs were being attacked by Streptococcus. She was performing lumbar punctures, attending to codes, taking referrals from GPs, managing several wards, all by herself…

I don't know how long it had been since his last meal when the Justice opined. But, with a bit of thoughtfulness, he might have arrived at an alternative interpretation—that Dr Bawa-Garba, hungry, exhausted, and overwhelmed, was at the end of her tethers. That doing the work of three registrars, which is difficult on any day, was particularly challenging in a new hospital after a year's break for a young mother who probably got little respite at home…

Like hyenas drawn to a carcass, the GMC began circling Dr Bawa-Garba. It was not enough that she was wrongly convicted of manslaughter. It was not enough that Health Education England withdrew her training number (ie, annulled her residency position). They wanted to make sure she could never practice medicine again. They wanted to erase her name from the medical register. Instead of rescuing the wounded soldier, they wanted to stab her whilst she was exsanguinating…

The GMC wasn't happy with mere suspension of Dr Bawa-Garba's medical license. They wanted her removed from their register. The GMC continued to pursue Dr Bawa-Garba's expulsion with extraordinary zeal. Finally, the high court sided with them, which opened the flood gates of the national angst of doctors in Britain.

The tribunal believed that Dr Bawa-Garba was remediable. The GMC did not. How was the GMC able to reason away the compelling evidence attesting to her competence? How did the GMC convince itself that she was a perennial threat to the public? What goes on behind the scenes at the GMC? I ask these questions not rhetorically but with incredulity. Is the prime regulatory body of doctors in Britain no longer fit to regulate? Who regulates the regulator?...

In the short term, junior doctors must, without compromise, be protected from manslaughter charges. This has to be built into the employment contract. The principle of respondeat superior must be installed. The hospital must assume complete responsibility for the actions of junior doctors, contractually. This'll put more skin in the game for the trusts, who will apply downward pressures on consultants.

The British public can't have it both ways. They can't simultaneously enjoy the thrift of a healthcare system with a tab of only 9% of the GDP, yet demand a structure needed to catch outliers. Such a structure costs. It'd have taken a village to save Jack. Jack died not because the village failed him but because the village did not exist….

If the British public insists on thrift, they must also accept the errors that come with thrift.


  1. I trained at one of the largest residency programs in the US and deeply remember the desperate nights of understaffing and overcrowding that were more the norm than not. I recall taking care of patients on guerneys in hallways drawing blood, placing the IV or central line and even placing chest tubes and performing lumbar punctures right there in the hallway because no one was available to help. I would be the assistant surgeon even as a medical student because the junior surgeons and interns were all in other operating rooms. I delivered many babies as a student because, again, the doctors were all with the high risk deliveries. A typical call lasted 40 hours with running up and down 18 floors of stairs the whole time because I never had time to wait for the elevator.

    Hearing about this case is so infuriating to me. No jury could ever understand the sacrifices we make on our own minds and bodies and spirits to put first another person’s child and mother and grandfather. If a physician is available for manslaughter convictions despite the inhuman sacrifices we make to love and care for everyone patient, I would imagine that fear would lead to young doctors refusing to come to work without ample staff support. If I were to show up at a hospital to find that I’m in charge of three stations instead of one, the best thing I could do for the whole system is to go home. To force my attending physician to cut short his teaching commitments. Why is he teaching when the hospital is so understaffed? Why aren’t patients diverted to other hospitals if possible when the hospital is understaffed? where are the administrators? How could anyone let this young doctor be placed in this predicament? The US made great changes to its rules on doctors-in-training two decades ago because of our awfully long work hours. Dangerous? Yes. Did it affect patient care? Of course. Did anyone get convicted of manslaughter? NO!

    Our movement started with a few students in Boston. Then Los Angeles. Then we went National. I hope that UK docs can find a similar way to protect doctors from taking the fall from system failures. My heart goes out to Dr. Bawa Garba.

  2. Having worked as a Junior Doctor (SHO through Locum Registrar) in the NHS for several years, I can only attest: Everything in this article is true and correct. I have been in many similar situations as Dr Bawa-Garba. The problem is not a "socialized system", but a culture of underfunding that is deeply engrained; and tacitly approved by the mixture of "Helper Syndrome" and macho attitudes that characterizes the medical professional in general.

  3. Agree. A total collapse of the “system” even IT was down. Did I miss something who and how was enalapril administered?

    Retired MD


    It was administered by the mother of the child, some 60 minutes before the arrest.

    Another reply:

    The parent. This is just an assumption, but it happens often on the wards when a parent simply continues the routine medications they've been doing at home because no one told them to stop,

    The article states it wasn't ordered and that no nurse gave it. That leaves only the well-intentioned parents.

    When admitting the patient, you need to specifically tell the parents not to continue home medications, that the nurse will do that and have the parents on board.

    I can guarantee you it was them, but I'm not sure why that wasn't revealed in the article.

  4. I was watching the General Medical Council take advantage of its relatively recently acquired right to appeal the result of a doctor’s fitness to practice hearing. The right of appeal was given to the GMC by an amendment to Section 40A of the Medical Act. As I watched the proceedings and the way the GMC argued the case, I wondered whether the GMC should have been given this right at all.

    Sat in the public gallery, I found myself sitting next to the doctor at the centre of the case, Dr Bawa-Garba. This lady is a junior doctor who has been convicted of manslaughter for her part in the NHS’ negligent treatment of Jack Adcock, a 6 year old boy who died of sepsis at Leicester Royal Infirmary in February 2011. In amongst a catalogue of system failures and having to do the job of two doctors during a double shift, Dr Bawa-Garba failed to spot the early signs of sepsis, did not act on significantly deranged blood results and delayed starting antibiotics after wrongly making an initial diagnosis of Gastroenteritis...

    I have a 6 year old son and a 4 year old daughter and cannot even come close to imagining the pain that would come as a result of losing one of them, or the suffering of Jack Adcock’s family. But as I sat there next to Dr Bawa-Garba, I could see first hand, another kind of suffering that may well be just as difficult to imagine or understand. Having suffered a bit myself as a result an NHS whistleblowing case, I wanted to show my support for a colleague in a very difficult situation. I find it hard to believe that a junior doctor has found themselves having to respond to legal action brought against them in the High Court by the General Medical Council - supposedly in the public interest, to challenge a decision by the MPTS not to strike them off the medical register...

    The Judgment from the Court of Appeal refusing Dr Bawa-Garba leave to appeal her conviction set out several factors that Dr Bawa-Garba relied on in her defence of manslaughter;

    · A failure in the hospital's electronic computer system that meant that ordered blood tests were delayed and not received from the hospital laboratory in the normal way and Dr Barwa-Garba was without the assistance of a senior house officer as a consequence.

    · 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. The consultant had overall responsibility for Jack.

    · A shortage of permanent nurses meant that agency nurses were being used more extensively.

    · The nurse involved had failed to properly to observe the patient and to communicate Jack's deterioration to Dr Barwa-Garba, 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, at 3 pm, when Jack was looking better.

    · The nurse did not tell Dr Bawa-Garba about Jack's high temperature 40 minutes earlier or the extensive changing of the nappies.

    · It was correct to be cautious about introducing too much fluid into the [patient] because of his heart condition

    The Crown Court also heard that, Dr Bawa-Garba’s Consultant, Dr O’Riordan was aware before Jack died that he had a serum pH of 7.084 and a blood lactate concentration of 11.4 mmol/L, which he wrote down in his notebook at evening handover. However, he did not perform a senior review of the boy because, he said, he was not specifically asked to by Dr Bawa-Garba. He said he would have expected her to “stress” these results to him.

  5. There is broad agreement that serious errors were made in Adcock's treatment. However, there has been a public debate about the background, context and pressures in which doctors work, and what happens when mistakes are made. The discussion centres on the issues of what systems and processes are in place that make mistakes less likely, and improve the chances of detecting them when they do occur. In the case of Bawa-Garba, the NHS Trust in question has recognised there were systemic failures and pressures which contributed to the death of a patient. Dr Jeeves Wijesuriya, the then junior doctors committee chair for the British Medical Association (BMA), argued that these systemic shortcomings were not adequately considered in the initial trial.

    At the end of January 2018, BMA council chair, Chaand Nagpaul, expressed concerns over doctors fears and challenges in working under pressure in the NHS. He explained that without clarity from the General Medical Council (GMC) and others, issues surrounding recording reflective learning would result in defensive practice and failure to learn from experience.

    The GMC released a FAQ about the case, covering issues such as what doctors should do if concerned about staffing levels and reflective practice.

  6. On 4 November 2015, Bawa-Garba was found guilty of manslaughter by gross negligence in Nottingham Crown Court before a jury directed by Justice Andrew Nicol. The following month, she was given a 2-year suspended jail sentence. She appealed against the sentence, but the appeal was denied in December 2016.

    The Medical Practitioners Tribunal Service suspended Bawa-Garba for 12 months on 13 June 2017. The General Medical Council successfully appealed and Bawa-Garba was struck off on 25 January 2018.

    On 13 August 2018, Bawa-Garba won an appeal against being struck off, restoring the one year suspension.

    Many healthcare professionals have raised concerns that Bawa-Garba is being unduly punished for failings in the system, notably the understaffing on the day.[