Bawa-Garba and beyond: hope or despair?

In 2015 Dr Hadiza Bawa-Garba was found guilty of gross negligence manslaughter after mistakenly misdiagnosing sepsis as gastroenteritis in 6-year-old Jack Adcock, who subsequently died in 2011 at Leicester Royal Infirmary.

In light of the evidence against her, Dr Hadiza Bawa-Garba initially received a 24-month suspended sentence for gross negligence manslaughter.1 Imposing a one-year sanction, the Medical Practitioners Tribunal (MPT) argued that erasure from the register would have been ‘disproportionate‘.2 However, the GMC later appealed against the MPT’s decision stating that in order to protect ‘public confidence in the [medical] profession’, Dr Bawa-Garba should be erased from the medical register. The high court initially ruled in favour of the GMC3 but on 13th August 2018 the Appeal Court concluded that the High Court had been wrong to interfere with the original decision of suspension by the MPT.4 This verdict was unprecedented in many ways; notably due to the fact that Dr Bawa-Garba’s case was put before the Appeal court as a result of a massive crowd-funding initiative – with over £360,000 raised by over 11,000 supporters.In addition, both the British Medical Association (BMA) and the British Association of Physicians of Indian Origin (BAPIO) applied to intervene in the appeal in order to reflect the impact of her case on the medical profession.6,7

Timeline of the case:
• February 2011 – Jack Adcock, aged 6, a patient with Down’s Syndrome, died from sepsis at Leicester Royal Infirmary
• December 2014 – Dr Bawa-Garba and two nurses (Theresa Taylor and Isabel Amaro) were charged with gross negligence manslaughter
• November 2015 – Dr Bawa-Garba was found guilty of gross negligence manslaughter and given a two-year suspended sentence. The nurse Theresa Taylor was cleared of any wrongdoing
• August 2016 – Nurse Isabel Amaro is struck off the medical register
• December 2016 – Dr Bawa-Garba was denied permission to appeal against her conviction for gross negligence manslaughter
• June 2017 – The MPT suspends Dr Bawa-Garba for 12 months with the comment that erasure from the medical register would be ‘disproportionate’. In evidence, the MPT cited the plethora of hospital systemic failures that Dr Bawa-Garba was working in that day.
• January 2018 – The High Court ruled that Dr Bawa-Garba should be struck off the medical register to maintain public confidence in the profession
• March 2018 – Dr Bawa-Garba was granted leave to challenge her erasure from the medical register in the Court of Appeal
• August 2018 – The Court of Appeal ruled in favour of Dr Bawa-Garba after concurring that the original decision by the MPT of a one-year suspension from the register should stand

Since the details of Dr Bawa-Garba’s case became public there has been a global outpouring of support for her.8 Thousands of doctors across the UK have flocked to her side as they recognised the extremely challenging working conditions of that day.9 For example, Dr Bawa-Garba had worked long hours under extreme pressure, was stretched between caring for too many patients on too many wards, was only partially supervised, had only just returned from maternity leave, and (they feel) was also punished for being too honest about her failings through her reflective practice notes. These notes appear to have been taken down by the duty consultant as her Eportfolio was not admitted to trial in formal evidence.10

On the day that Jack was admitted to hospital, Dr Bawa-Garba made the duty consultant aware that Jack had been admitted with a PH of 7.084 and a high lactate during a handover meeting at 16.30. However, the duty consultant did not immediately review the patient as he told the court that Dr Bawa-Garba had failed to adequately ‘stress’ the abnormality of these results to him. He subsequently brought phone records to her trial to draw attention to the fact that Dr Bawa-Garba had not otherwise called him.11,12

In giving its judgment on the case the appeal court accepted that ‘no concerns have ever been raised about the clinical competency of Dr Bawa-Garba, other than in relation to Jack’s death’, and that ‘the risk of her clinical practice suddenly and without explanation falling below the standards expected on any given day is no higher than for any other reasonably competent doctor’.13,14

As a result of its appeal on the initial verdict, the GMC experienced intense and unprecedented criticism from the medical profession in the aftermath of this case, which highlighted issues that some say have gone unaddressed for far too long. The GMC pointed out that it has since commissioned an independent review into gross negligence manslaughter issues: ‘Doctors have rightly challenged us to speak out more forcefully to support those practicing in pressured environments, and that is what we are increasing our efforts to do’.15

However, pressure has been building from all sides of this tragedy. The case was recently explored in forensic but sensitive detail by Deborah Cohen on BBC Panorama, including interviews with Jack’s family and Dr Hadiza Bawa-Garba.16 The GMC have also attracted censure for their decision. Since the judgment various petitions have garnered huge support,17-20 with over 1500 healthcare professionals rejecting the idea that the GMC should use money from doctors’ fees to pay the legal bill for its failed bid to erase Dr Bawa-Garba from the medical register.18,19 The petition is still open for signature. A similar number have backed an initiative by The Doctors’ Association UK (DAUK) that calls for the GMC to reflect openly on its actions and refer itself to parliament via the Health Select Committee over its handling of the case.20 The Hospitals Consultants and Specialists Association (HCSA) have gone further and demanded the resignation of the CEO Charlie Massey as he has always made it clear that it was his personal decision to escalate the case to appeal the MPT verdict. The GMC have responded by stating that they accept the decision of the appeal court and as the regulator they have to make difficult decisions and that the case was ‘complex and unusual.’21

What do you think? Was Dr Hadiza Baba-Garba scapegoated because of the deficiencies of the system? What action with respect to conduct should be taken here by the GMC and/or parliament who they remain answerable to?  On a daily basis should the GMC make it easier to report rota gaps and other deficiencies in the system without fear of recrimination? Is the UK law currently fit for purpose in complex medical tragedies? How can trust be rebuilt between all sides so a patient safety culture can flourish in future?

To view the video of Dr Jenny Vaughan and Dr Hadiza Baba-Garba speaking out about the trial please click here. To view Dr Samantha Symington and Dr Cicely Cunningham of DAUK talking about the campaign of Learn not Blame please click here.

Dr Jenny Vaughan, FRCP, is a medical law campaigner and Consultant Neurologist. 

Professor Roger Kirby, FRCS, Medical Director, The Prostate Centre, London. 

References: 

1. BBC News. Leicester doctor guilty of manslaughter of Jack Adcock, 6 November 2015 (https://www.bbc.co.uk/news/uk-england-leicestershire-34722885; accessed 24 August 2018).

2. Medical Practitioners Tribunal. Dr Hadiza BAWA-GARBA 13 June 2017 appealed. Medical Practitioners Tribunal June 2017. (https://www.mpts-uk.org/static/documents/content/Dr_Hadiza_BAWA-GARBA_13_June_2017_appealed.pdf; accessed 24 August 2018).

3. Dyer C. Paediatrician convicted of manslaughter must be erased from register, rules High Court. BMJ January 2018 (https://www.bmj.com/content/360/bmj.k417; accessed 24 August 2018).

4. Haddock J, Qureshi M, Day C. Bawa Garba case: team Hadiza statement (http://54000doctors.org/letters/team-hadiza-statement-13aug2018.html; accessed 24 August 2018).

5. Haddock J, Qureshi M, Day C. Independent Legal Opinion on Dr Bawa-Garba Case (https://www.crowdjustice.com/case/help-dr-bawa-garba/; accessed 24 August 2018)

6. Wickware C. BMA applies to ‘intervene’ in Bawa-Garba appeal case. Pulse April 2018 (http://www.pulsetoday.co.uk/news/gp-topics/legal/bma-applies-to-intervene-in-bawa-garba-appeal-case/20036465.article; accessed 30 August 2018). 

7. Cook J. Doctors’ groups throw weight behind Bawa-Garba legal appeal. GP July 2018 (https://www.gponline.com/doctors-groups-throw-weight-behind-bawa-garba-legal-appeal/article/1488150; accessed 30 August 2018). 

8. Jha S. To Err is Homicide in Britain – The Case of Dr. Hadiza Bawa-Garba. The Health Care Blog January 2018 (http://thehealthcareblog.com/blog/2018/01/30/to-err-is-homicide-in-britain-the-case-of-dr-hadiza-bawa-garba/; accessed 24 August 2018).

9. Wickware C. No single root cause’ found after Bawa-Garba SUI investigation. Pulse March 2018 (http://www.pulsetoday.co.uk/your-practice/regulation/no-single-root-cause-found-after-bawa-garba-sui-investigation/20036369.article; accessed 24 August 2018).

10. Cohen D. Back to blame: the Bawa-Garba case and the patient safety agenda. BMJ November 2017 (https://www.bmj.com/content/359/bmj.j5534; accessed 24 August 2018).

11. MD. The GMC’s handy scapegoat. Private Eye August 2018 (http://www.private-eye.co.uk/columnists; accessed 24 August 2018).

12. Cohen D. Struck off for honest mistakes. BBC News August 2018 (https://www.bbc.co.uk/news/resources/idt-sh/the_struck_off_doctor; accessed 24 August 2018).

13. Vaughan J. The long road to justice for Hadiza Bawa-Garba. BMJ August 2018 (https://blogs.bmj.com/bmj/2018/08/14/jenny-vaughan-the-long-road-to-justice-for-hadiza-bawa-garba/; accessed 24 August 2018).

14. Cunningham C. The Court of Appeal was right to re-instate Dr Hadiza Bawa-Garba. The Guardian August 2018. (https://www.google.co.uk/amp/s/amp.theguardian.com/commentisfree/2018/aug/14/court-appeal-right-reinstate-dr-hadiza-bawa-garba; accessed 24 August 2018).

15. Massey C. Statement on Court of Appeal’s judgment on the Bawa-Garba case. GMC August 2018 (https://www.gmc-uk.org/news/media-centre/media-centre-archive/statement-on-bawa-garba-appeal; accessed 24 August 2018).

16. Cohen D.BBC Panorama 13 August 2018 (https://www.bbc.co.uk/news/resources/idt-sh/the_struck_off_doctor)

17. Wickware C. Appeal court rules in favour of Bawa-Garba appeal. Pulse August 2018. (http://www.pulsetoday.co.uk/news/hot-topics/bawa-garba/appeal-court-rules-in-favour-of-bawa-garba-appeal/20037269.article; accessed 24 August 2018).

18. Manslaughter and Healthcare (http://www.manslaughterandhealthcare.org.uk; accessed 24 August 2018).

19. Dyer C. Don’t use our fees to pay Bawa-Garba’s court costs, doctors tell GMC August 2018. BMJ August 2018 (https://www.bmj.com/content/362/bmj.k3612; accessed 24 August 2018)

20. Bostock N. Hundreds of doctors demand investigation into GMC’s ‘aggressive pursuit’ of Bawa-Garba. GP August 2018. (https://www.gponline.com/hundreds-doctors-demand-investigation-gmcs-aggressive-pursuit-bawa-garba/article/1491034; accessed 24 August 2018).  

21. Knapton S. Doctors demand resignation of GMC head over handling of Dr Hadiza Bawa-Garba case. The Daily Telegraph August 2018 (https://www.telegraph.co.uk/news/2018/08/27/doctors-demand-resignation-gmc-head-handling-dr-hadiza-bawa/; accessed 31 August 2018). 

 

Comments (15) Add yours ↓
  1. Simon Wessely Psychiatrist

    Well written blog By the way isabel Amaro was removed from the nursing not medical register. Is there a campaign to reinstate her ?

    September 1, 2018 Reply
    • Jenny Vaughan Consultant neurologist

      Sadly she was struck off by the NMC and they have said they won’t review that decision. I’m not even sure about the quality ( if any ) of her legal representation at that hearing. She has been offered support but not In the way Hadiza has which is sad.

      September 2, 2018 Reply
  2. Dr Wim Blancke MD FRCA FFPMRCA Consultant Anaesthetist

    Coincidentally, you might be interested in the content, speakers and the reasons for the International Conference being organised on Friday 26 October
    at the Royal Society of Medicine, London:

    https://www.rsm.ac.uk/events/anm02

    ‘When things go wrong – Consent, (Gross) Negligence and Manslaughter.’

    This one-day event is not only aimed at doctors, but at all healthcare professionals, our patients and their carers; i.e. ‘all we work with, and for’.
    We will constructively explore what happens when things go wrong, in the medical world, and with patients, and the current, correct legal meaning, definitions, interpretation and consequences in the UK of Consent, Negligence vs. Gross Negligence, and Manslaughter.
    Delegates will look at the issues at stake, and at the highest level, bringing together authorities, health care and legal professionals, regulators, the media, patients and their representatives.

    September 1, 2018 Reply
  3. Dr Umesh Prabhu Was MD in two acute Trusts for 14 years

    Dear Jenny,

    A very well written summary and I simply salute you.

    Please note that the NHS, and the UK generally, is a very fair country and if not we would not have had nearly 200,000 BME staff working in NHS and doing well. Many BMEs have reached leadership positions and I myself have had an amazing career. I have been talking about the impact of a culture of bullying, racism, discrimination on patient safety, staff wellbeing in the NHS over the last 15 years to BMA, BAPIO, BIDA, FMLM and the Royal Colleges. Sadly everyone gave me their valuable time but nothing much changed.

    We have tried to transform the culture of bullying and discrimination into a kind, caring and compassionate learning culture with a duty of candour. However, the sad reality is that we doctors have not taken interest in leadership and the NHS today has a ‘management culture’ This is not to criticise any managers, as most of them work hard under very difficult circumstances.

    Regarding Dr Bawa Garba, I am still not sure what is the next action to take? Thanks for all your hard work but it is the outcome that I and many others are keen to know.

    The system can only be changed if we are united – by challenging the system and changing it, or working within the system and changing it. Sadly, we as a profession never unite and so far the British Medical Association has failed to unite the members or the profession. I really admire your courage and all the hard work you have put in and I hope we will really see change now. Patients must be protected and all hard working staff must be supported.

    September 1, 2018 Reply
  4. C Brown Urologist

    I have followed this case with interest. I am encouraged by the recent outcome. No one works alone and system failure must always be taken into consideration. Increasingly medical, nursing and allied professionals from every specialty are being asked to do more, with less resource and patient care will suffer. There is a crisis in man power and rota gaps are common. Recently in my area a hospital had no middle grade or consultant on the on call rota and in an unprecedented move it was cross covered by another trust. There were no adverse incidents but if there were, the individual would first be in the firing line not the senior manager who arranged the cross cover.

    September 2, 2018 Reply
  5. Ben Challacombe Consultant

    Very sensible summary of the case and events surrounding it.
    The whole episode is so so sad with no winners and we are all so sorry for Jack;s death. clearly awful mistakes were made. but many junior doctors feel “here by the grace of God” when they think about this case. This is like the proverbial Swiss cheese disaster. This poor trainee was just back from maternity leave with no time to adjust, no induction, working in a new hospital to her, looking after 6 wards on 4 floors!. The lab system was down and results relayed verbally which is more difficult.
    Understaffed overworked unsupported. The people who should have been taken down after this are the managers responsible for the paediatric rota and staffing of the unit, AND the consultant who was told the results and did Nothing about it. He didnt even see the patient despite very high lactate and low pH. He has never apologised or offered any support to his own trainee which is shocking. That is not what our trainees expect from us and when he was required to step up he didnt. If you are the consultant on call in that situation you have to do something more. That is what really upsets me as a Consultant and trainer.
    Hopefully lessons have been learnt and doctors like Dr Bawa-Garba will have more support in the future.

    September 2, 2018 Reply
    • Jenny Vaughan Consultant neurologist

      Thanks Ben. Totally agree with all you say

      September 2, 2018 Reply
  6. Roger Kirby Professor of Urology

    Nearly 700 doctors have signed a petition asking the General Medical Council (GMC) to find alternative means of paying Hadiza Bawa-Garba’s legal costs rather than using doctors’ registration and licensing fees.

    The GMC faces a large legal bill, still to be assessed, after losing the appeal brought by the trainee paediatrician against a High Court ruling striking her off the medical register.1

    September 3, 2018 Reply
    • Jenny Vaughan Consultant Neurologist

      It’s over 2000 now Roger and we are going back to the GMC this week to nudge them for a response. It’s veey important that we all learn from errors ( including the medical regulator).

      September 3, 2018 Reply
      • Roger Kirby Professor Of Urology

        Thanks Jenny
        It seems to me that Doctors who are plunged regularly into the type of systemic chaos that prevailed on the fateful day of Jack’s death are now understandably panicked about the ramifications in the event of an avoidable tragedy. Not only, it seems to them, is there a risk of criminal sanction, as in David Sellu’s case, but the professional regulator – the GMC – will also seek to have doctors struck off completely for what are partially – if not mainly – failings caused by understaffing, lack of resources and defective working practices.
        What, it has been asked, is a doctor to do upon arriving at work to find themselves in Dr Bawa-Garba’s position? Do one’s best to help patients and risk the same fate? Or down tools citing unsafe working conditions?

        September 3, 2018 Reply
        • Matthew Bultitude Consultant Urologist

          Clearly a tragic case for all parties concerned. Clearly a medical regulator is needed but it is about time that this was centrally funded with clear aims rather than doctor funded with the thought that they protect doctors – clearly that is not the case here. You also have to wonder about compensation for doctors wrongly accused, careers ruined etc.

          I think the comment about “downing tools citing unsafe working conditions” is a fair one but difficult to do in practice. NHS staff face challenging circumstances everyday and could find reasons to do this all the time. Surely refusing to work and offer medical care is worse and would lead to more complications/ deaths and potentially expose healthcare professionals to further sanction, investigation or litigation. Perhaps what we should do is to file an incident form every time this happens so the difficult working conditions is highlighted and can be used as evidence if future litigation occurs. Difficult to do when so busy and challenged.

          September 4, 2018 Reply
  7. David Nicholl Dr

    I described the use of reflection in the Bawa Garba case as ‘dysfunctional’ in June (1), but we now know that her reflections- which in fact were based on O-Riordan’s notes, unsigned by Bawa Garba, were key to her cross-examination. As the prosecution QC stated; “List for us, please, all of the mistakes” (2).

    This is certainly dysfunctional in the sense of a trainee-trainer relationship, I will leave it for others more legally qualified as to whether this was dysfunctional in a legal sense. At the very least, there should be very clear guidance from The Academy of Medical Royal Colleges on the use of reflection to both trainees and Consultants that where any doctor who perceives that their reflections are being used inappropriately or they are being put under duress, that they should seek assistance from someone else outside of the trainee-trainer or appraisee-appraiser loop such as a College Tutor or Director of Medical Education.

    Finally as others have stated the GMC need to issue a meaningful apology. If I was to have made a serious mistake with one of my patients, my patient would expect me to apologise and state what I will do differently to ensure that the same error does not happen again. To date, the GMC has done no such thing- on reflections misleading not just the medical profession but also the Chair of the Health Select Committee (3). The GMC’s behaviour is frankly unprofessional.

    1. https://www.rcplondon.ac.uk/news/role-reflection-post-bawa-garba-era

    2. https://www.bbc.co.uk/news/resources/idt-sh/the_struck_off_doctor

    3. https://www.bmj.com/content/360/bmj.k481/rr-5

    September 3, 2018 Reply
  8. Mary O'Gorman Dr

    934 people signed a petition for Charlie Massey to go on Change .org too

    September 3, 2018 Reply
  9. Ngozi Edi-Osagie Consultant Neonatologist

    Dear Jenny, I have followed the case with interest and are thankful that there are people like you with drive and tenacity that have helped Hadiza. I was ecstatic that the wrong by the GMC has been put right. I’d like to see the GMC adopt a less adversarial way of dealing with things. I worry that there must be a number of other cases that haven’t had as much profile where doctors have been given disproportionate sanctions.

    September 4, 2018 Reply
  10. Gordon Muir consultant urologist

    Very few professions would accept working under conditions felt to be potentially dangerous. Doctors in the NHS do frequently, and working across sites in small units is a common cause of this.
    While consultants may feel able to refuse to operate under unsafe conditions, trainees are unlikely to refuse to work.
    There is a clear need for consultant leadership here, and an absolute need for hospitals to ensure that staffing levels are adequate and that systems exist to mitigate IT failures.
    If a system is unsafe it is up to the consultant in charge to divert patients regardless of pressure from management, and to support juniors to protect them.

    September 4, 2018 Reply

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