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| Where does the blame lie when something goes wrong at hospital? | Where does the blame lie when something goes wrong at hospital? |
| (3 months later) | |
| Who is to blame when something goes wrong in a hospital and a patient suffers injury or a setback, or even dies, as a result? Is it an individual or team or, given the complexity of healthcare, have the flaws been in a wider system, and hinged on available resources, not just clinical decisions? | Who is to blame when something goes wrong in a hospital and a patient suffers injury or a setback, or even dies, as a result? Is it an individual or team or, given the complexity of healthcare, have the flaws been in a wider system, and hinged on available resources, not just clinical decisions? |
| Dr Hadiza Bawa-Garba’s role in the death of six-year-old Jack Adcock in 2011, and especially the series of legal and disciplinary processes that triggered, would have sparked renewed debate about these profound and troubling questions at any time. | Dr Hadiza Bawa-Garba’s role in the death of six-year-old Jack Adcock in 2011, and especially the series of legal and disciplinary processes that triggered, would have sparked renewed debate about these profound and troubling questions at any time. |
| But they came against the backdrop of the understaffing that is increasingly visible across the NHS, the trainee paediatrician’s conviction for gross negligence manslaughter and erasure from the medical register, and her insistence that Jack’s death involved inadequacies in her hospital over which she had no control, as well as her own admitted failings. | But they came against the backdrop of the understaffing that is increasingly visible across the NHS, the trainee paediatrician’s conviction for gross negligence manslaughter and erasure from the medical register, and her insistence that Jack’s death involved inadequacies in her hospital over which she had no control, as well as her own admitted failings. |
| Often referred to as blood poisoning or septicaemia, the World Health Organisation says sepsis arises when the body’s “response to any infection injures its own tissues and organs”. The NHS says it is a “rare but serious complication of an infection” that, while treatable, is difficult to diagnose and life-threatening if not caught quickly because it can lead to multiple organ failure. | Often referred to as blood poisoning or septicaemia, the World Health Organisation says sepsis arises when the body’s “response to any infection injures its own tissues and organs”. The NHS says it is a “rare but serious complication of an infection” that, while treatable, is difficult to diagnose and life-threatening if not caught quickly because it can lead to multiple organ failure. |
| NHS information differs, depending on the age of the sufferer. In children under the age of five, people should look for whether they appear “mottled, bluish or pale”, whether they are “very lethargic or difficult to wake” and if the child is “abnormally cold to touch”. Fast breathing, a rash that does not fade and fits or convulsions are also warning signs. | NHS information differs, depending on the age of the sufferer. In children under the age of five, people should look for whether they appear “mottled, bluish or pale”, whether they are “very lethargic or difficult to wake” and if the child is “abnormally cold to touch”. Fast breathing, a rash that does not fade and fits or convulsions are also warning signs. |
| In anyone older, early symptoms include: a “high temperature (fever) or low body temperature” and chills, as well as fast breathing and heart rate. One of the problems associated with sepsis is that it is often mistaken for the flu, so sufferers are advised to seek medical help if they get those symptoms after having had an infection or an injury. | In anyone older, early symptoms include: a “high temperature (fever) or low body temperature” and chills, as well as fast breathing and heart rate. One of the problems associated with sepsis is that it is often mistaken for the flu, so sufferers are advised to seek medical help if they get those symptoms after having had an infection or an injury. |
| The NHS says there are about 123,000 cases of sepsis in England a year, with about 37,000 a year dying as a result. | The NHS says there are about 123,000 cases of sepsis in England a year, with about 37,000 a year dying as a result. |
| Under normal circumstances, the immune system fights infection where it exists in the body but, if the immune system is weak or the infection severe, infection can spread. That causes the immune system to “go into overdrive”, the NHS says. This leads to inflammation, which is usually helpful in the fight against the infection, affecting the whole body, damaging tissue and interfering with blood flow. That can lead to low blood pressure and, consequently, less oxygenation of organs. | Under normal circumstances, the immune system fights infection where it exists in the body but, if the immune system is weak or the infection severe, infection can spread. That causes the immune system to “go into overdrive”, the NHS says. This leads to inflammation, which is usually helpful in the fight against the infection, affecting the whole body, damaging tissue and interfering with blood flow. That can lead to low blood pressure and, consequently, less oxygenation of organs. |
| Bawa-Garba’s case assumed huge significance for medical practice, patient safety and also the chances of the NHS recruiting and retaining the number of junior doctors it needs to care for patients properly, many of whom were alarmed by her being “scapegoated”. | Bawa-Garba’s case assumed huge significance for medical practice, patient safety and also the chances of the NHS recruiting and retaining the number of junior doctors it needs to care for patients properly, many of whom were alarmed by her being “scapegoated”. |
| As one of them – Dr Rachel Clarke – put it, Bawa-Garba suffered “persecution and scapegoating. Bawa-Garba made mistakes, but her unit was understaffed, chaotic, lethal bedlam. She was hung out to dry”. | As one of them – Dr Rachel Clarke – put it, Bawa-Garba suffered “persecution and scapegoating. Bawa-Garba made mistakes, but her unit was understaffed, chaotic, lethal bedlam. She was hung out to dry”. |
| The three appeal court judges referred several times to the “systemic failings” evident at Leicester Royal Infirmary in explaining their decision to overturn Bawa-Garba’s ban on working as a doctor. | The three appeal court judges referred several times to the “systemic failings” evident at Leicester Royal Infirmary in explaining their decision to overturn Bawa-Garba’s ban on working as a doctor. |
| Jack, who had Down’s syndrome and a heart condition, was admitted to the hospital in February 2011. | Jack, who had Down’s syndrome and a heart condition, was admitted to the hospital in February 2011. |
| Bawa Garba was on her first shift back after maternity leave, and was the most senior doctor in charge of the children’s assessment unit. The consultant who should have been around for her to discuss Jack with was covering another department, because of gaps in the medical rota. | Bawa Garba was on her first shift back after maternity leave, and was the most senior doctor in charge of the children’s assessment unit. The consultant who should have been around for her to discuss Jack with was covering another department, because of gaps in the medical rota. |
| Two of the three nurses on duty were from an employment agency. Problems with the hospital’s IT system meant she did not receive the result of blood tests she had ordered for six hours. And she was very busy dealing with other sick children, one of whom had to have a lumbar puncture. Doctors across the NHS encounter similar circumstances in their units worryingly often. | Two of the three nurses on duty were from an employment agency. Problems with the hospital’s IT system meant she did not receive the result of blood tests she had ordered for six hours. And she was very busy dealing with other sick children, one of whom had to have a lumbar puncture. Doctors across the NHS encounter similar circumstances in their units worryingly often. |
| Jack ultimately died of sepsis, a virulent blood-borne infecton that is acknowledged to be both a major cause of avoidable death but also very hard to detect. Bawa-Garba is by no means the only health professional to miss what turned out to be signs of it. | Jack ultimately died of sepsis, a virulent blood-borne infecton that is acknowledged to be both a major cause of avoidable death but also very hard to detect. Bawa-Garba is by no means the only health professional to miss what turned out to be signs of it. |
| The appeal court pointed out that “the full context of Jack’s death” involved the decision-making of other staff at the hospital, as well as these “systemic failings”, not just Bawa-Garba’s conduct. | The appeal court pointed out that “the full context of Jack’s death” involved the decision-making of other staff at the hospital, as well as these “systemic failings”, not just Bawa-Garba’s conduct. |
| That is what the paediatric registrar had argued all along in her appearances in court and also during both a medical practitioners’ tribunal hearing and the General Medical Council’s subsequent appeal against the MPT’s decision that a one-year suspension from practising was the right punishment. | That is what the paediatric registrar had argued all along in her appearances in court and also during both a medical practitioners’ tribunal hearing and the General Medical Council’s subsequent appeal against the MPT’s decision that a one-year suspension from practising was the right punishment. |
| The tribunal decided that Bawa-Garba’s conduct in Jack’s case was neither deliberate nor reckless and that she posed no danger. Yet the GMC, which regulates doctors, still decided that public confidence in the profession meant she should be struck off. Its standing with doctors is a major casualty of the Bawa-Garba saga. | The tribunal decided that Bawa-Garba’s conduct in Jack’s case was neither deliberate nor reckless and that she posed no danger. Yet the GMC, which regulates doctors, still decided that public confidence in the profession meant she should be struck off. Its standing with doctors is a major casualty of the Bawa-Garba saga. |
| It is hard to quantify the short- and long-term damage done in terms of the chilling effect on all levels of doctors across the NHS at seeing the paediatrician being convicted and banned. | It is hard to quantify the short- and long-term damage done in terms of the chilling effect on all levels of doctors across the NHS at seeing the paediatrician being convicted and banned. |
| But the case again shows that lapses in patient safety are often not as simple as errors of individual judgement. As Chaand Nagpaul, the chair of the British Medical Association, put it: “Lessons must be learned from this case which raises wider issues about the multiple factors that affect patient safety in an NHS under extreme pressure rather than narrowly focussing only on individuals.” | But the case again shows that lapses in patient safety are often not as simple as errors of individual judgement. As Chaand Nagpaul, the chair of the British Medical Association, put it: “Lessons must be learned from this case which raises wider issues about the multiple factors that affect patient safety in an NHS under extreme pressure rather than narrowly focussing only on individuals.” |
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