Sushruta

• Welcome Message
• Editorial Message
• Foreword by BAPIO President
• Back to blame: Dr Bawa-Garba could have been any specialty trainee
• The case for changing the narrative in health and social care
• The BAPIO South West Leadership Initiatives: – Creating a novel and effective force!
• National Conference on Women Leadership 
• Quality improvement in the NHS 
• Children with Acquired Brain Injury (ABI)  - What do we owe them?
• Beyond Bawa-Garba: We deserve better 
• In pursuit of Sun, Solitude and Self - Trek to the Everest Base camp
• BAPIO Written Submission: Williams’ Review Indian Healthcare Sector 
• Honours and Awards 
• Kerala Flood Disaster: BAPIO fundraising appeal
• Remembrance: Vicky Osgwood
•  
• Sponsors
• Birnbeck Insurance Service, 
• Jet Electrical Services, 
• Oatens,
• J’s Autofast, 
• The Hangar-Bristol
• Gulf Medical University

cite as: Bamrah JS, Mehta R. Back to Blame. Dr. Hadiza Bawa-Garba could have been any specialty trainee. Sushruta 2018 vol11(issue1) 9-12 DOI: 10.38192/11.1.3

Introduction

The death of Jack Adcock in 2011 made headlines all around the world for many reasons. He was a 6-year-old child, admitted to Leicester Royal Infirmary (LRI) in February 2011 who died of sepsis and pneumonia 11 hours later. The paediatric registrar Dr. Hadiza Bawa-Garba had failed to diagnose his condition, resulting in criminal proceedings and her erasure from the medical register in 2017.

This article gives a glimpse of the controversial case, tries to relate this to all medical specialties, and offers some guidance on how to avoid a similar situation developing.

Dr. Bawa-Garba’s background

Dr. Bawa-Garba had dedicated her life to improving patient health from an early age. As a young student, from the age of thirteen, she had volunteered in Africa. During her holidays, after school and at the weekends, she had worked at hospitals and AIDS clinics. She continued her charitable work as a medical student and later as a doctor by raising funds for benevolent causes and awareness of matters, mainly HIV/AIDS and organ donation. She used her unique position to provide necessary and effective health information to women in underprivileged communities.

She received a first-class degree in Physiology and Pharmacology from the University of Southampton, where she also received the Physiology Society Prize and went onto study medicine, receiving outcomes of ‘Merit’ and ‘Excellent’ in many modules including in her finals. She continued to perform over and above average by contributing to excellent audit projects and guidelines, of high enough standard to be incorporated in working databases. She was popular with patients, families, nurses, and fellow medics.

Events of 11th February 2011

On 11th February 2011, Jack was referred to LRI by his GP and admitted to a Children's Assessment Unit. He had a known heart condition and Down’s syndrome. He presented with diarrhea, vomiting, and difficulty breathing.

He was treated by Dr. Bawa-Garba, an ST5 specialist registrar. She had recently returned from maternity leave and was alone in charge of the emergency department and the Children's Assessment Unit on the day. Rota gaps had meant that she had to cover the work of two other doctors and the on-call consultant was lecturing off-site and was unavailable to her.

She was in an unfamiliar setting, leading an inexperienced team, and covering the workload of three doctors (absent registrar and consultant, and her role) as well as that of her SHO during the afternoon who was delegated to do telephone calls for results due to computer system breakdown. She was covering multiple areas, spanning four floors in the hospital, as well as being tasked with advice on paediatric patient matters external to her direct cover ward areas and the wider community. The nursing team was also hard-pressed to make full observations and due to pressures on beds patients were moved between ward areas and given medications without Dr. Bawa- Garba’s awareness.

Jack had a complex clinical picture. Even senior experienced doctors undertreat severe sepsis in over 60 % of cases in the first twelve hours in the UK. She prescribed fluids, oxygen, and antibiotics in line with guidelines, and her initial treatment was acknowledged as good by the investigators of the case.

Jack died of a cardiac arrest as a result of sepsis at 9.20 pm.

Legal proceedings:

On 2 November 2015, agency nurse Isabel Amaro was sentenced to a 2-year suspended jail sentence, having been found guilty of manslaughter by gross negligence. Her monitoring of Adcock's condition and record-keeping were criticised. She was subsequently struck off the nursing register. The ward sister Theresa Taylor was also charged but acquitted.

On 4 November 2015, Dr. Bawa- Garba was found guilty of manslaughter by gross negligence. 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 Dr. Bawa-Garba for 12 months on 13 June 2017. The General Medical Council’s (GMC) successful appeal to the High Court resulted in her being struck off the medical register on 25 January 2018. There were national outrage and a tsunami of protests from doctors across the world to the

case. A crowdfunding campaign by ‘Team Hadiza’ ensued, resulting in over £350,000 being raised to support her in her fight against erasure. A separate legal team was appointed, and legal evidence was also submitted by BAPIO and the BMA as interested parties to the case.

The Master of the Rolls Sir Terence Etherton sat in judgment, along with Lord Chief Justice Lord Burnett and Lady Justice Rafferty1. In another twist to the tale, after the final hearing, he pronounced on the 13th August 2018 that the High Court had been “wrong to interfere with the decision of the tribunal.” Sir Terence Etherton further stated that “The tribunal was an expert body entitled to reach all those conclusions, including the important factor weighing in favour of Dr. Bawa-Garba that she is a competent and useful doctor, who presents no material continuing danger to the public, and can provide considerable IT failure, the Trust’s paediatric observation priority score tool was not sufficiently robust or easy to interpret, test results were relayed by telephone but no abnormal results were flagged up, there was a failure by nursing staff to recognise abnormal observations and record and monitor according to clinical need, the Trust process for handover between medical and nursing staff was poor, and there was a failure to communicate to the child’s family the importance of not giving enalapril.

Dr. Bawa-Garba did commit several errors; principally, it was felt that the abnormal results should have been obvious to her, she had not alerted the on-call consultant to them, she had misdiagnosed the condition, and she had mistaken Jack for another child and stated he was not for resuscitation when he had a cardiac arrest (though this

10 October 2018 useful future service to society.”

He instructed the GMC to restore her on the medical register.

E-portfolios:

Since 2012, several concerns have been highlighted including in 2016, that for junior doctors "A large number of doctors are required to 'reflect' on Serious Incidents (SIs) and Significant Event information as part of their training. This could, therefore, create a significant administrative burden and result in cases of double jeopardy.”

As required, Dr. Bawa-Garba kept reflective learning material in an e-portfolio as part of her training, including relating to the treatment of Adcock. However, a major contentious issue that arose, in this case, was the use of this material, although to what degree has been disputed. Her defense team has stated that her e-portfolio was not used in the 2018 case. The contention amongst others is that although the e-portfolio was not used explicitly in the 2015 case, it had been seen by expert witnesses and so ‘you cannot unsee what you have seen’. The GMC’s stance has been consistent, that doctors’ reflections should be legally privileged.

Systemic failures:

A catalogue of clinical and administrative mishaps occurred on the day that Jack was admitted. Dr. Bawa-Garba had just returned from maternity leave and did not have an induction which would have familiarised her with hospital procedures. There were rota gaps, an inexperienced nursing team was quickly recognised, and not attributed to his eventual death). The Trust’s SI report identified 93 failures, of which six were attributed to Dr. Bawa-Garba.

The response from doctors:

There has been outrage amongst doctors and doctors’ organisation about the final verdict to erase Dr. Bawa-Garba from the register2. 7,500 doctors signed a petition sanctioning the GMC, and the BMA’s GP committee passed a vote of ‘no confidence’ in the GMC.

Doctors attending the Royal College of Paediatrics and Child Health’s AGM in Glasgow unanimously passed a motion stating: “This College considers [that] the criminal prosecution of dedicated doctors for gross negligence manslaughter, following systemic errors, impairs the advancement of safe healthcare for patients.”

A group of 159 paediatricians wrote in The BMJ that they “are confident to employ Bawa-Garba with supervision in a training position upon her reinstatement to the medical register and pending her employment in a substantive post that will facilitate her return to work when she is reinstated.”

The President of the Royal College of Physicians and Surgeons of Glasgow, David Galloway, stated: “I think that the profession has lost confidence in the General Medical Council. Doctors on the ground, especially younger doctors, are facing an overstretched service with sub-optimal staffing that presents patient safety concerns. This is against the background of this tragic case and they, inevitably, feeling exposed.”

The BMJ stated: “We’ve received correspondence from readers around the world expressing their concerns about system failures, using e-portfolios in legal proceedings, and the threat to the duty of candour.”

Nick Ross, the journalist and TV pundit said: “I fear the time has come to hold the GMC to account. Can it show how this case has improved patient safety and standards in medicine, or - surely the only alternative - has it acted as an erudite and urbane kangaroo court?”

BAPIO accused the GMC of racial discrimination and victimising a trainee rather than understanding the pressures in the NHS. It called for the CPS to bring

charges of corporate manslaughter on the Trust and referred the consultant on call that day, Dr. Stephen O’ Riordan, to the GMC and the Medical Council of Ireland for investigation of his conduct.

Most significantly, Jeremy Hunt, Secretary for State for Health, posted a tweet expressing concern about the unintended consequences of the verdict and launched a rapid review immediately, which is chaired by Professor Sir Norman Williams, ex-President of the Royal College of Surgeons (England). The review will make public its conclusions this summer.

The real fear amongst doctors, and indeed other health professionals, following the conviction and erasure of Dr. Bawa-Garba and nurse Amaldo, is that genuine mistakes will be criminalised by the courts, thus jeopardising any learning from SIs. Furthermore, the likelihood is that many will be tempted to hide their mistakes rather than being candid, causing longer-term harm to patients and the health service.

Amongst the most prominent critics are two individuals who in our view truly stand out both regarding criticisms of the GMC’s handling of the case. Jenny Vaughan, a neurologist, the co-founder of an organisation ‘Manslaughter and Healthcare’ an online resource(www. manslaughterandhealthcare.org. The UK), stated: “The GMC’s actions here are purely punitive against a paediatrician who trusted the investigation process. Tragically, a child has died, but there are no winners in a system that blames tragic outcomes on a trainee. There was a catalog of errors in this case, and patient safety will never be improved unless everyone promotes an open learning culture.”

Jonathan Cusack, who supervised Dr. Bawa-Garba and lead on a debriefing for staff affected by Jack’s death, said that trainee doctors working in Leicester were concerned and angry about the conclusions of the trust’s investigation and the subsequent legal process. “Trainees felt that their colleague was being scapegoated and taking the blame for a series of system failings,” he said.

Implications for training – avoiding the pitfalls:

The first issue is that if any doctor finds himself/herself struggling under the demands of pressure, it is vital that you call the senior manager responsible or, in the case of a trainee the consultant supervisor, to ensure that they have the support and advice they need to overcome any crisis or demand.

If essential, limit yourself to the emergency work that requires immediate action.

In the case of consultants who are on call, our advice is that they must give the trainee(s) on duty a call to ensure that they are made aware by them personally to call in the event of any issues. It offers a personal touch that cannot be achieved by simply having a name on the rota, which in some instances will be wrong anyway.

In the event of an SI, doctors would be advised to raise a DATIX entry on this, which will then generate a formal response from the Trust. Junior doctors must also additionally do Exception reporting to ensure that this event goes formally through the Guardian of Safe Working. Portfolios are now under more scrutiny than ever, and until there is absolute clarity we would urge caution in being candid about SIs. This is also true for appraisal documentation. The principle here is one that the insurance companies adopt, of not accepting any blame for an accident until the matter has been legally looked at. This is rather unfortunate but as it currently stands at present, all portfolios on paper or e-notes can potentially be used as evidence during trials.

The case demonstrates the need to have professional indemnity and ensure that anyone affected is suitably supported. It threatens to change the course of medical history, with the prospect that genuine mistakes will be played out in court and punished criminally.

No specialty training is immune to this sort of event, particularly those that are patient-facing where risks are an everyday occurrence and the mixture of rota gaps, agency staff, multiple demands, poor IT back up are common. All those working in this crisis-ridden NHS must be aware at all times of the robustness of the system that they work in, or they risk facing similar consequences to Dr. Bawa-Garba in the event of the death of a patient from mistakes that might have been made for genuine reasons.

Finally, trainees need to be aware that this is a highly unusual case and therefore it is unlikely, though sadly not impossible, for such a case to arise in the future. Ultimately, the public has faith that doctors act in good faith and so having the fear factor rule the practice of medicine is likely to cause more harm than good. Risk-taking remains part of perfecting the art of that practice and should rightly remain so for the future. Provided, of course, that safeguards are built into this. It remains to be seen whether the less discerning member of the public can differentiate between harm or neglect arising through wilful acts as opposed to honest mistakes.

References:

1. Hadiza Bawa-Garba v General Medical Council. (2018) EWCA CIV 1879 https://www.judiciary.uk/judgments/bawa-garba-v- general-medical-council/

2. BMJ coverage https://www.bmj. com/Bawa-Garba

cite as: Singhal P. The case for changing the narrative in health and social care. Sushruta 2018 vol 11 (issue 1) 13-14 https://www.sushruta.net/vol-11-1-oct-2018 accessed (insert date)

Given our current challenges, how can we contribute to make a difference to patient care and service efficiencies? In other words, how can we all work towards changing the narrative and acting in different ways to make a difference to our patients, colleagues and organisations alike.

Whilst not overstating the case, our NHS is being challenged from several angles. Many colleagues are under serious work pressures, are stressed, suffer with low morale, some are voting with their feet and many more are reporting burnout. And yes, some of our patients are not having the timely care that they deserve? Many of our organisations are in financial distress; many are in special measures and Turnaround Regimes.

The pressure points are being reported from several sources. For instance The Royal College of Physicians (2017) Survey Report NHS reality check: Delivering care under pressure involving 2,100 Doctors indicated that:

• 78% say demand for their service is rising.

• Over half of physicians believe patient safety has

deteriorated.

• Over a third say the quality of care has lowered.

• 84% have reported staffing shortages in their team.

• 82% believe the workforce is demoralised.

Prof Jane Dacre, President of the RCP, commented 'I am sure these figures will not come as a surprise to anyone in the room. The physicians I know, and I include myself, are optimistic, positive, can-do people who produce ‘work round’ solutions to intransigent problems. However, they are being pushed to their limits and no longer are optimistic about the future.”

Similarly the Guardian [11 Feb 2017] reported on a survey of 2,300 trainee anaesthetists and found that “six out of seven – 85% – are at risk of becoming burned out, despite only being in their 20s and 30s. Respondents identified long hours, fears about patient safety, the disruption of working night shifts and long commutes to their hospital as key reasons for their growing fatigue and disillusionment.”

No doubt you will be able to point to similar findings or reports or know of colleagues with similar experiences. But here is the good news. Yes, we are pressured and face many challenges, but we are not and should not be helpless. Several commentators have argue that staff at the front line know the solutions. I believe the time is right for us all to play our part in helping to change the narrative and as a consequence act differently. It is time that we build on the massive good will of most of our colleagues and it is time to liberate energies and mobilise collectively to add value.

So what do I mean by narrative? Collins English Dictionary defines narrative as a 'story or account of a series of events.” All of us and leaders at different levels need to change the narrative by sharing stories that can engage and mobilise others to action.

Steve Denning is a leadership thought leader, author and guru. A short while ago, a colleague asked him why leadership story telling was important. He came up with a long list. I am including 2 accounts here.

Story telling is a key leadership technique because it’s quick, powerful, free, natural, refreshing, energising, collaborative, persuasive, holistic, entertaining, moving, memorable and authentic. Stories help us make sense of organisations. Story telling can inspire people to act in unfamiliar, and often unwelcome, ways. Mind-numbing

cascades of numbers or daze-inducing PowerPoint slides won’t achieve this goal. Even logical arguments for making the needed changes usually won't do the trick but creative story telling does. We know that there are different types of stories and Steve Denning has shown how stories can:

1. Spark action (the original springboard story)

2. Communicate who we are (identity stories)

3. Communicate who the company is (corporate identity and branding)

4. Proclaim and transmit values (value stories)

5. Foster collaboration (community-building stories)

6. Tame the grapevine (political stories)

7. Share knowledge (tacit knowledge stories)

8. Lead people into the future (inspirational and vision stories)

Similarly, Dr Helen Bevan, Chief Transformation Officer at Horizons NHS has been at the forefront of promoting the work of Prof Marshall Ganz from Harvard whose work on the power of stories for creating change and mobilising for action offers great potential in the NHS. Prof Ganz has argued that “Stories not only teach us how to act – they inspire us to act. Stories communicate our values through the language of the heart, our emotions. And it is what we feel – our hopes, our cares, our obligations – not simply what we know that can inspire us with the courage to act.”

Prof Ganz has proposed that a public story includes three elements as follows:

• A story of self: why you were called to what you have been called to.

• A story of us: what your constituency, community, organisation has been called to its shared purposes, goals, vision.

• A story of now: the challenge this community now faces, the choices it must make, and the hope to which “we” can aspire.

Story telling from board level all the way down to the front line is vital at engaging and mobilising all of our people for sustaining action that can bring about a better patient and staff orientated NHS. They can serve to develop better collaboration within and across organisations as well as laying the basis for delivering on effectiveness and productivity. It can help to create a work climate that enables us to be more caring, supportive and compassionate to our colleagues.

Some encouraging signs:

The good news is that there are some encouraging signs in which Clinicians, Leaders and Managers are stepping up at taking a lead on changing the narrative. Writing in BMJ (BMJ 2017;359:j4304), Dr David Oliver has argued why it is useful for Challenging the victim narrative about NHS doctors BMJ 2017; 359. Despite the challenges being faced, he has suggested that doctors “are not hapless victims. We have to be realistic as to what we can achieve. We must also use our considerable hard power, soft influence and status to the best effect to preserve and improve patient care.”

On similar lines, a recent tweet from Mr Ross Fisher, a paediatric surgeon at Sheffield Children's Hospital, “I’m the Consultant on call today. I gathered the whole team together and reiterated that we work as a team, that mine is the ultimate responsibility, that if they have concerns they escalate and NO-ONE gets thrown under the bus.

These are the kinds of narratives and stories that lead to action, which needs no one’s permission. Imagine then the work place culture if more and more Consultants were to take a lead from Mr Fisher’s example?

2018 marks the 70th anniversary of the establishment of the NHS. It is a time to celebrate the wondrous achievements of the service. It is also a time to make a Call to Action, given our challenges, to invite everyone to play their part in the making of a sustainable NHS. Our starting point is to change the narrative to build a better NHS for patients and staff.