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You can find the current article at its original source at https://www.theguardian.com/society/2018/aug/14/blaming-hadiza-bawa-garba-wont-protect-other-patients
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| Blaming Dr Hadiza Bawa-Garba won't protect other patients | Blaming Dr Hadiza Bawa-Garba won't protect other patients |
| (4 months later) | |
| The return to court this week of an emotive case involving the death of a child in hospital has caused me to reflect on my own experience as an NHS neurosurgeon, and on the fact that individuals will make mistakes but systemic issues that fail to prevent such mistakes must be addressed. | The return to court this week of an emotive case involving the death of a child in hospital has caused me to reflect on my own experience as an NHS neurosurgeon, and on the fact that individuals will make mistakes but systemic issues that fail to prevent such mistakes must be addressed. |
| We are all Hadiza Bawa-Garba. Any doctor could make the same mistake | |
| Jack Adcock died of sepsis in 2011. The circumstances of his death led to a conviction of manslaughter for the registrar doctor in charge of his case, Dr Hadiza Bawa-Garba, and an agency nurse, Isabel Amaro. Bawa-Garba and Amaro were subsequently permanently struck off the medical and nursing registers by the General Medical Council (GMC) and Nursing and Midwifery Council, respectively, preventing both from practising in this country. These decisions largely rested upon their convictions for manslaughter. | Jack Adcock died of sepsis in 2011. The circumstances of his death led to a conviction of manslaughter for the registrar doctor in charge of his case, Dr Hadiza Bawa-Garba, and an agency nurse, Isabel Amaro. Bawa-Garba and Amaro were subsequently permanently struck off the medical and nursing registers by the General Medical Council (GMC) and Nursing and Midwifery Council, respectively, preventing both from practising in this country. These decisions largely rested upon their convictions for manslaughter. |
| On 13 August, the court of appeal ruled that the GMC was wrong to permanently remove Bawa-Garba from the register after the Medical Practitioners Tribunal Service recommended she be suspended for a year. | On 13 August, the court of appeal ruled that the GMC was wrong to permanently remove Bawa-Garba from the register after the Medical Practitioners Tribunal Service recommended she be suspended for a year. |
| Bawa-Garba’s appeal was crowdfunded by many colleagues. Many worried about finding themselves in a similar situation – a doctor returning from maternity leave to an understaffed department, with an on-call consultant off site and IT failures that led to delays in accessing test results. Such situations are becoming increasingly common in an overstretched NHS. | Bawa-Garba’s appeal was crowdfunded by many colleagues. Many worried about finding themselves in a similar situation – a doctor returning from maternity leave to an understaffed department, with an on-call consultant off site and IT failures that led to delays in accessing test results. Such situations are becoming increasingly common in an overstretched NHS. |
| Some members of the public have argued against the medical profession, and feel doctors are “closing ranks” to protect their own. | Some members of the public have argued against the medical profession, and feel doctors are “closing ranks” to protect their own. |
| The details of the case have been eloquently argued by Professor Edwin Jesudason and by consultants at the hospital where Jack died. | The details of the case have been eloquently argued by Professor Edwin Jesudason and by consultants at the hospital where Jack died. |
| The indisputable fact is that a child died in traumatic circumstances that may have been avoided. | The indisputable fact is that a child died in traumatic circumstances that may have been avoided. |
| Part of the problem is that the reporting of such cases encourages blame to be pinned on one or two individuals rather than addressing the systemic faults that allowed such issues to arise. | Part of the problem is that the reporting of such cases encourages blame to be pinned on one or two individuals rather than addressing the systemic faults that allowed such issues to arise. |
| Jack’s death was blamed on two people, despite the many systemic faults that day that may have contributed. These faults were not properly addressed when Jack’s case was investigated by his hospital in Leicester. A similar case of sepsis, in New York, which resulted in the death of 12-year-old Rory Staunton, resulted in systemic change and no individual criminal conviction. | Jack’s death was blamed on two people, despite the many systemic faults that day that may have contributed. These faults were not properly addressed when Jack’s case was investigated by his hospital in Leicester. A similar case of sepsis, in New York, which resulted in the death of 12-year-old Rory Staunton, resulted in systemic change and no individual criminal conviction. |
| Where does the blame lie when something goes wrong at hospital? | |
| In my own specialty of neurosurgery, some patients who walk in with nothing more than a headache can be left unable to move, speak, think, feed or breathe for themselves. It has happened as a result of operations I have performed. One ghost that haunts me is that of 35-year-old Jill*. After I had operated on her brain tumour my then-consultant checked my work and left me to close. Jill woke up unable to speak or move her right side. She did not leave the hospital after surgery and died a month later, undoubtedly due to complications from my surgery. | In my own specialty of neurosurgery, some patients who walk in with nothing more than a headache can be left unable to move, speak, think, feed or breathe for themselves. It has happened as a result of operations I have performed. One ghost that haunts me is that of 35-year-old Jill*. After I had operated on her brain tumour my then-consultant checked my work and left me to close. Jill woke up unable to speak or move her right side. She did not leave the hospital after surgery and died a month later, undoubtedly due to complications from my surgery. |
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| I blamed myself, as many doctors do when complications occur. But no matter how bad I felt, it was nothing compared to the pain felt by Jill’s mother, her only close relative, who even now finds the memory of her daughter’s last days too hard to talk about. | I blamed myself, as many doctors do when complications occur. But no matter how bad I felt, it was nothing compared to the pain felt by Jill’s mother, her only close relative, who even now finds the memory of her daughter’s last days too hard to talk about. |
| Her loss drove her to set up a community counselling service for relatives of patients with long-term illness. Jill’s death also drove improvements in our pre-operative assessments of patients so that every scrap of information is wrung out of the technology available to us to try to prevent similar tragedies. | Her loss drove her to set up a community counselling service for relatives of patients with long-term illness. Jill’s death also drove improvements in our pre-operative assessments of patients so that every scrap of information is wrung out of the technology available to us to try to prevent similar tragedies. |
| Before writing this piece, I contacted Jill’s mother. Though she was stoical, I could hear the pain in her voice when she spoke of her daughter. However, just as strong was the need to use this pain to prevent others from suffering. She asked me to make sure that as many people could learn from her daughter as possible, to make her suffering meaningful. | Before writing this piece, I contacted Jill’s mother. Though she was stoical, I could hear the pain in her voice when she spoke of her daughter. However, just as strong was the need to use this pain to prevent others from suffering. She asked me to make sure that as many people could learn from her daughter as possible, to make her suffering meaningful. |
| Jill’s case illustrates the need to move beyond blaming individuals. To do so honours the memory of patients such as Jack far more than another standoff between patient advocates and the medical profession. | Jill’s case illustrates the need to move beyond blaming individuals. To do so honours the memory of patients such as Jack far more than another standoff between patient advocates and the medical profession. |
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| Jill’s case became a call to arms for me and my colleagues. All cases like hers and Jack’s must be, but this requires a societal shift to accept that individuals will make mistakes but systemic issues that fail to prevent such mistakes must be addressed, rather than ignored. Focusing on individuals prevents us from working to ensure these tragic cases never happen again. | Jill’s case became a call to arms for me and my colleagues. All cases like hers and Jack’s must be, but this requires a societal shift to accept that individuals will make mistakes but systemic issues that fail to prevent such mistakes must be addressed, rather than ignored. Focusing on individuals prevents us from working to ensure these tragic cases never happen again. |
| * Jill is a pseudonym | * Jill is a pseudonym |
| Health | Health |
| Leicester | Leicester |
| NHS | NHS |
| Doctors | Doctors |
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