A doctor responsible for the death of a six year old boy has been struck off by two senior High Court judges today after being convicted of gross negligence manslaughter.
The judges allowed an appeal by the General Medical Council - GMC - against a ruling that the doctor should only be suspended and be allowed back to work within a few months.
They heard how 40-year-old Doctor Hadiza Bawa-Garba had carried on working for several years after the death.
Lord Justice Goss, who sat with Mr. Justice Ouseley had described it as a 'tragic'case.
Mr. Justice Ouseley said: 'This is a sad and distressing case both for the parents of the six-year-old boy who died significantly sooner than he would otherwise have done, and for Dr. Bawa-Garba who, with an otherwise unblemished record, has had to come to terms, over a period of several years, with her very serious failings in his care.
'She has had to face trial, after being told that she would not be charged; she has been convicted of manslaughter by gross negligence, and given a two-year prison sentence, albeit suspended.
'I say that her failings caused the young patient to die 'significantly sooner than he would otherwise have done'.
He said her failures significantly contributed to his death.'
Quote
Who was on duty the day Jack died?
When Jack was admitted to the infirmary’s Children’s Assessment Unit at 10am on February 18, 2011, trainee paediatrician Dr Bawa-Garba — who moved to Britain from her native Nigeria in 1994 and qualified as a doctor in 2003 after studying medicine at the University of Leicester — was doing the work of two doctors and covering two wards as another registrar had failed to show up for work.
This was her first such placement in general paediatrics at the hospital and she was on her first day back after maternity leave.
‘It appears that a team of inexperienced medical and nursing staff were thrown together, reliant upon each other through the exhausting 13-hour shift, but who had not worked together in some cases, without any team introductions, adequate handover or consistent IT support,’ says Lyvia Dabydeen, a consultant paediatric neurologist at King’s College Hospital NHS Foundation Trust. Dr Bawa-Garba worked for the consultant while she was at Leicester Royal Infirmary and Dr Dabydeen wrote a testimonial of support for her tribunal.
She asked, in a response to an investigation into the case last month by trade publication the British Medical Journal (BMJ): ‘How did this even happen?’
Why didn't she act on test results?
Blood tests taken from Jack shortly after his arrival revealed abnormally high levels of urea and creatinine, suggesting kidney problems and contradicting Dr Bawa-Garba’s diagnosis of gastroenteritis.
Yet Bawa-Garba — who took three hours to examine x-rays that revealed Jack had a chest infection and required antibiotics — failed to do anything about the blood tests.
According to Jonathan Cusack, a neonatologist at the infirmary who became Dr Bawa-Garba’s supervisor as part of her re-training following Jack’s death, a computer failure meant she was told Jack’s results over the phone rather than reading them on screen, making her more susceptible to ‘cognitive error’.
He explains: ‘Normally with blood samples abnormal numbers flash up in red and they’re easy to see.’ Instead, he says, ‘she was given 15 to 20 numbers at speed which she was writing down. She was under pressure and didn’t think about what those numbers meant.’
Yet Bawa-Garba wasn’t the only professional to ignore the blood test results. The court heard that Stephen O’Riordan, duty consultant paediatrician that day, had written them down at evening handover but chose not to review Jack.
Cusack adds: ‘If, as has often been claimed, it should have been obvious to a trainee that Jack had sepsis, surely it should have been obvious to a consultant, too? And yet she was criticised for not acting on it and nobody else was.’
Drug that added to Jack's death
In hospital Jack — who had a known heart condition — was given his regular dose of Enalapril, which lowers blood pressure. Yet the drug should not be given to those suffering from septic shock and in court it was agreed that it was a contributing factor to Jack’s death, with Bawa-Garba criticised for not making it clear in his notes he should not be given it.
‘Enalapril makes the blood vessels dilate, which reverses the body’s normal defence to sepsis,’ explains Dr Cusack, who adds, however, that Bawa-Garba would have been unaware of the hospital culture at the time that contravened national guidelines and allowed drugs to be given without a prescription.
‘She knew it wasn’t a good idea for Jack to take Enalapril and chose not to prescribe it.’
Disaster of 'do not resuscitate' note
That evening Jack suffered a septic shock which led to a ‘crash call’ to doctors at around 8pm to revive him. But on entering Jack’s room Bawa-Garba confused him with another patient who had a ‘Do Not Resuscitate’ instruction on his notes and called off resuscitation.
‘It’s not even as if they looked alike,’ said Jack’s mother Nicola at the time. ‘How do you get two children mixed up when one has Down’s and the other hasn’t?’
Yet it was claimed in court that Bawa-Garba’s terrible mistake had no impact on Jack’s condition, which was too advanced for resuscitation to help. It was, however, highlighted by the judge, Mr Justice Nicol, as an example of Bawa-Garba’s lapsed standard of care.
What happened after Jack died?
According to the BMJ investigation, Bawa-Garba was asked to meet duty consultant paediatrician O’Riordan five days after Jack’s death, where — as part of her training — she was asked what she should have done differently. She apparently admitted her failings and O’Riordan typed up notes of her ‘reflection’, which were eventually fed into the inquiry, and later, into the police investigation.
Doctors who believe Bawa-Garba should be allowed to return to work say this process was a betrayal. ‘Trainees keep a log of training to assess what they’ve learned,’ says Dr David Nicholls, who organised the doctors’ petition. ‘That these reflections are being used in court cases is an abuse of their education.’
Did Bawa-Garba return to work?
Yes. Within weeks she had returned to the hospital in a supervised role, where she remained until her trial in 2015. ‘She never shied away from her mistakes and went out of her way to learn from her errors,’ says Dr Cusack, who says her progress in later reviews was rated as ‘above average.’
Why didn't she say sorry to family?
Nicola Adcock maintains that Bawa-Garba has yet to apologise while the tribunal found that although she had ‘expressed condolences’ to Jack’s family, they had seen no evidence to suggest she had apologised.
However, Dr Cusack, said she was ‘genuinely devastated’ but was prevented from saying sorry by the legal process. ‘When a case is part of a Coroner’s Inquest she would have been banned from talking to the family,’ says Dr Cusack. ‘Calling up to apologise would have been discouraged. She has since apologised through her lawyer.’
What did hospital chiefs conclude?
The hospital’s serious untoward incident inquiry was completed in August 2012 and recommended some 90 changes following Jack’s death. As well as those relating to Bawa-Garba’s conduct, there were also, says Dr Cusack, ‘multiple systemic failures’.
He says they included ‘medical and nursing staff shortages, IT system failures which led to abnormal laboratory test results not being highlighted, the deficiencies in handover, accessibility of the data at the bedside and the absence of a mechanism for an automatic consultant review.’
Why did charge take so long?
Initially, the Crown Prosecution Service claimed there were no grounds to charge an individual doctor because there were so many different failings.
Yet at the inquest, in July 2013, experts debated the criteria for manslaughter and apparently decided there were sufficient grounds to prosecute.
The case was re-conferred to the CPS which still didn’t charge Dr Bawa-Garba until December 2014. ‘The time taken demonstrates the complexity,’ says Dr Cusack.
Why do doctors dispute verdict?
‘The prosecution’s job is to find one person responsible but in healthcare multiple processes are responsible for error,’ says Dr Cusack, who gave evidence at the trial at Nottingham Crown Court in November 2015.
He claims expert witnesses were stopped by prosecution barristers from discussing the improvements Leicester Healthcare Trust made after Jack’s death that would have highlighted just how many other factors were to blame.
‘Clearly there are doctors who wilfully cause harm and of course they should be stopped,’ he says. ‘But I don’t believe manslaughter applies to someone who has an otherwise unblemished record and has made a medical error in a case where there are multiple other failures.’
The findings of the tribunal
It wasn’t until Dr Bawa-Garba’s two-day tribunal hearing at the MPTS in Manchester this June that other factors contributing towards Jack’s death became more widely known.
In mitigation, the tribunal considered that Jack’s death, ‘took place in the context of wider failings.’ They said there was no evidence to suggest her actions were ‘deliberate or reckless’ and therefore, instead of striking her off, suspended her for 12 months.
So why did the GMC disagree with them?
The GMC claimed public trust in the profession will be harmed if a doctor can continue after being convicted of homicide by a public court, that Dr Bawa-Garba should have ‘had sepsis in mind as a possible diagnosis’; that her mistakes are irredeemable and the only appropriate sanction is erasure from the medical profession.
Is the GMC's position a consistent one?
Not according to consultant cardiologist Peter Wilmhurst, who has written that the ‘decision of the GMC to take a tough stance against Dr Bawa-Garba contrasts with the GMC’s leniency when dealing with doctors whose conduct is more worrying’ adding that: ‘The GMC took no action against 100 doctors placed on the Sex Offenders Register (SOR) for accessing child pornography.’
Previously, GMC chief executive Charlie Massey said: ‘There are a small proportion of doctors on the medical register with convictions, some dating back many years and pre-dating our right to appeal Medical Practitioners Tribunal decisions.
‘Any doctor who receives a custodial sentence is automatically referred to the tribunal and for convictions such as serious segxwal offences, we will now always call for the doctor to be struck off the register.’
Wilmhurst, citing several other cases — some of which he reported to the GMC himself — concluded: ‘The GMC should deal forcefully with doctors who are deliberately and repeatedly dishonest rather than a conscientious doctor who made a single clinical error.’
How did Jack's mother take the decision?
After the tribunal Nicola claimed on Facebook that she was ‘disgusted’ by the decision not to strike off Dr Bawa-Garba.
She had vowed to ‘do whatever is necessary for my son and to stop parents having to go through the sort of thing my family has gone through.’
She added of the doctors rallying in support of Dr Bawa-Garba: ‘They didn’t know my son. Some of them will be parents — they must be able to understand my feelings and why I wouldn’t want her (Bawa-Garba) to be in charge of a child of mine.
‘Public confidence will be gone if she starts working with children again. Everyone makes mistakes. But would you really want someone convicted of gross negligence manslaughter treating your child?’
Why doctors believe the hearing matters
Those who fought to stop Dr Bawa-Garba being struck off were not doing so simply to save the career of a paediatrician they feel has been unfairly blamed, but because they believed if the GMC win their appeal it will set a precedent for a dangerous culture of cover-up.
When Jack was admitted to the infirmary’s Children’s Assessment Unit at 10am on February 18, 2011, trainee paediatrician Dr Bawa-Garba — who moved to Britain from her native Nigeria in 1994 and qualified as a doctor in 2003 after studying medicine at the University of Leicester — was doing the work of two doctors and covering two wards as another registrar had failed to show up for work.
This was her first such placement in general paediatrics at the hospital and she was on her first day back after maternity leave.
‘It appears that a team of inexperienced medical and nursing staff were thrown together, reliant upon each other through the exhausting 13-hour shift, but who had not worked together in some cases, without any team introductions, adequate handover or consistent IT support,’ says Lyvia Dabydeen, a consultant paediatric neurologist at King’s College Hospital NHS Foundation Trust. Dr Bawa-Garba worked for the consultant while she was at Leicester Royal Infirmary and Dr Dabydeen wrote a testimonial of support for her tribunal.
She asked, in a response to an investigation into the case last month by trade publication the British Medical Journal (BMJ): ‘How did this even happen?’
Why didn't she act on test results?
Blood tests taken from Jack shortly after his arrival revealed abnormally high levels of urea and creatinine, suggesting kidney problems and contradicting Dr Bawa-Garba’s diagnosis of gastroenteritis.
Yet Bawa-Garba — who took three hours to examine x-rays that revealed Jack had a chest infection and required antibiotics — failed to do anything about the blood tests.
According to Jonathan Cusack, a neonatologist at the infirmary who became Dr Bawa-Garba’s supervisor as part of her re-training following Jack’s death, a computer failure meant she was told Jack’s results over the phone rather than reading them on screen, making her more susceptible to ‘cognitive error’.
He explains: ‘Normally with blood samples abnormal numbers flash up in red and they’re easy to see.’ Instead, he says, ‘she was given 15 to 20 numbers at speed which she was writing down. She was under pressure and didn’t think about what those numbers meant.’
Yet Bawa-Garba wasn’t the only professional to ignore the blood test results. The court heard that Stephen O’Riordan, duty consultant paediatrician that day, had written them down at evening handover but chose not to review Jack.
Cusack adds: ‘If, as has often been claimed, it should have been obvious to a trainee that Jack had sepsis, surely it should have been obvious to a consultant, too? And yet she was criticised for not acting on it and nobody else was.’
Drug that added to Jack's death
In hospital Jack — who had a known heart condition — was given his regular dose of Enalapril, which lowers blood pressure. Yet the drug should not be given to those suffering from septic shock and in court it was agreed that it was a contributing factor to Jack’s death, with Bawa-Garba criticised for not making it clear in his notes he should not be given it.
‘Enalapril makes the blood vessels dilate, which reverses the body’s normal defence to sepsis,’ explains Dr Cusack, who adds, however, that Bawa-Garba would have been unaware of the hospital culture at the time that contravened national guidelines and allowed drugs to be given without a prescription.
‘She knew it wasn’t a good idea for Jack to take Enalapril and chose not to prescribe it.’
Disaster of 'do not resuscitate' note
That evening Jack suffered a septic shock which led to a ‘crash call’ to doctors at around 8pm to revive him. But on entering Jack’s room Bawa-Garba confused him with another patient who had a ‘Do Not Resuscitate’ instruction on his notes and called off resuscitation.
‘It’s not even as if they looked alike,’ said Jack’s mother Nicola at the time. ‘How do you get two children mixed up when one has Down’s and the other hasn’t?’
Yet it was claimed in court that Bawa-Garba’s terrible mistake had no impact on Jack’s condition, which was too advanced for resuscitation to help. It was, however, highlighted by the judge, Mr Justice Nicol, as an example of Bawa-Garba’s lapsed standard of care.
What happened after Jack died?
According to the BMJ investigation, Bawa-Garba was asked to meet duty consultant paediatrician O’Riordan five days after Jack’s death, where — as part of her training — she was asked what she should have done differently. She apparently admitted her failings and O’Riordan typed up notes of her ‘reflection’, which were eventually fed into the inquiry, and later, into the police investigation.
Doctors who believe Bawa-Garba should be allowed to return to work say this process was a betrayal. ‘Trainees keep a log of training to assess what they’ve learned,’ says Dr David Nicholls, who organised the doctors’ petition. ‘That these reflections are being used in court cases is an abuse of their education.’
Did Bawa-Garba return to work?
Yes. Within weeks she had returned to the hospital in a supervised role, where she remained until her trial in 2015. ‘She never shied away from her mistakes and went out of her way to learn from her errors,’ says Dr Cusack, who says her progress in later reviews was rated as ‘above average.’
Why didn't she say sorry to family?
Nicola Adcock maintains that Bawa-Garba has yet to apologise while the tribunal found that although she had ‘expressed condolences’ to Jack’s family, they had seen no evidence to suggest she had apologised.
However, Dr Cusack, said she was ‘genuinely devastated’ but was prevented from saying sorry by the legal process. ‘When a case is part of a Coroner’s Inquest she would have been banned from talking to the family,’ says Dr Cusack. ‘Calling up to apologise would have been discouraged. She has since apologised through her lawyer.’
What did hospital chiefs conclude?
The hospital’s serious untoward incident inquiry was completed in August 2012 and recommended some 90 changes following Jack’s death. As well as those relating to Bawa-Garba’s conduct, there were also, says Dr Cusack, ‘multiple systemic failures’.
He says they included ‘medical and nursing staff shortages, IT system failures which led to abnormal laboratory test results not being highlighted, the deficiencies in handover, accessibility of the data at the bedside and the absence of a mechanism for an automatic consultant review.’
Why did charge take so long?
Initially, the Crown Prosecution Service claimed there were no grounds to charge an individual doctor because there were so many different failings.
Yet at the inquest, in July 2013, experts debated the criteria for manslaughter and apparently decided there were sufficient grounds to prosecute.
The case was re-conferred to the CPS which still didn’t charge Dr Bawa-Garba until December 2014. ‘The time taken demonstrates the complexity,’ says Dr Cusack.
Why do doctors dispute verdict?
‘The prosecution’s job is to find one person responsible but in healthcare multiple processes are responsible for error,’ says Dr Cusack, who gave evidence at the trial at Nottingham Crown Court in November 2015.
He claims expert witnesses were stopped by prosecution barristers from discussing the improvements Leicester Healthcare Trust made after Jack’s death that would have highlighted just how many other factors were to blame.
‘Clearly there are doctors who wilfully cause harm and of course they should be stopped,’ he says. ‘But I don’t believe manslaughter applies to someone who has an otherwise unblemished record and has made a medical error in a case where there are multiple other failures.’
The findings of the tribunal
It wasn’t until Dr Bawa-Garba’s two-day tribunal hearing at the MPTS in Manchester this June that other factors contributing towards Jack’s death became more widely known.
In mitigation, the tribunal considered that Jack’s death, ‘took place in the context of wider failings.’ They said there was no evidence to suggest her actions were ‘deliberate or reckless’ and therefore, instead of striking her off, suspended her for 12 months.
So why did the GMC disagree with them?
The GMC claimed public trust in the profession will be harmed if a doctor can continue after being convicted of homicide by a public court, that Dr Bawa-Garba should have ‘had sepsis in mind as a possible diagnosis’; that her mistakes are irredeemable and the only appropriate sanction is erasure from the medical profession.
Is the GMC's position a consistent one?
Not according to consultant cardiologist Peter Wilmhurst, who has written that the ‘decision of the GMC to take a tough stance against Dr Bawa-Garba contrasts with the GMC’s leniency when dealing with doctors whose conduct is more worrying’ adding that: ‘The GMC took no action against 100 doctors placed on the Sex Offenders Register (SOR) for accessing child pornography.’
Previously, GMC chief executive Charlie Massey said: ‘There are a small proportion of doctors on the medical register with convictions, some dating back many years and pre-dating our right to appeal Medical Practitioners Tribunal decisions.
‘Any doctor who receives a custodial sentence is automatically referred to the tribunal and for convictions such as serious segxwal offences, we will now always call for the doctor to be struck off the register.’
Wilmhurst, citing several other cases — some of which he reported to the GMC himself — concluded: ‘The GMC should deal forcefully with doctors who are deliberately and repeatedly dishonest rather than a conscientious doctor who made a single clinical error.’
How did Jack's mother take the decision?
After the tribunal Nicola claimed on Facebook that she was ‘disgusted’ by the decision not to strike off Dr Bawa-Garba.
She had vowed to ‘do whatever is necessary for my son and to stop parents having to go through the sort of thing my family has gone through.’
She added of the doctors rallying in support of Dr Bawa-Garba: ‘They didn’t know my son. Some of them will be parents — they must be able to understand my feelings and why I wouldn’t want her (Bawa-Garba) to be in charge of a child of mine.
‘Public confidence will be gone if she starts working with children again. Everyone makes mistakes. But would you really want someone convicted of gross negligence manslaughter treating your child?’
Why doctors believe the hearing matters
Those who fought to stop Dr Bawa-Garba being struck off were not doing so simply to save the career of a paediatrician they feel has been unfairly blamed, but because they believed if the GMC win their appeal it will set a precedent for a dangerous culture of cover-up.
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