On the morning of 18 February 2011 Jack Adcock, a six-year-old boy, was brought into Leicester Royal Infirmary with diarrhoea and vomiting. He died eleven hours later. The paediatric registrar looking after him, Dr Hadiza Bawa-Garba, was convicted in November 2015 of manslaughter by gross negligence, and in January this year she was struck off the medical register. Jack had Down’s syndrome and had previously undergone surgery to repair a congenital heart condition. When he arrived at the infirmary, after 12 hours of D&V, he was described as being unresponsive. Initial blood tests showed high levels of lactate and acid in his blood, which can be the result of shock, a secondary condition in cases of sepsis or dehydration. Bawa-Garba attributed it to dehydration caused by gastroenteritis and treated Jack with IV fluids. His bloods improved (although not back to normal values), he woke up, and he was observed drinking and playing. While waiting for the results of further blood tests and a chest X-ray, Bawa-Garba went to see the many other patients she was responsible for that day, including a baby who needed a lumbar puncture for possible meningitis. Bawa-Garba, who was in her sixth year of specialist training, was doing the work of two doctors, covering the children’s assessment unit (CAU) and referrals from A&E and GPs while the other registrar was away on a training day (no cover had been provided). The on-call consultant for the CAU was not in the hospital until the afternoon. The rest of the team consisted of two far more junior doctors who were beginning their paediatric rotations – one of them spent the whole afternoon on the phone to the laboratory getting blood results because the IT system was down.
The results of the blood tests Bawa-Garba requested when Jack first arrived didn’t come back for six hours because of the IT issues. Bawa-Garba didn’t see the chest X-ray until three hours after it had been done. It showed pneumonia and she prescribed antibiotics. It was a further hour before the antibiotics were administered by the agency nurse Isabel Amaro, who wasn’t trained in paediatrics. She too has been convicted of manslaughter for not adequately monitoring Jack or alerting Bawa-Garba to his deterioration. The prosecution argued that Bawa-Garba hadn’t reviewed the X-ray and blood results quickly enough, that she should have started the antibiotics earlier and should have ‘escalated’ her concerns about Jack to the on-call consultant, Dr Stephen O’Riordan, who was informed of Jack’s case and results at the usual 4.30 p.m. handover but didn’t review him (he has suffered no repercussions). O’Riordan has stated that he wasn’t asked to review Jack, but it would be reasonable to assume that a doctor of his seniority and experience would have made his own assessment of the seriousness of Jack’s condition: a consultant will often review a worrying case without being expressly asked to do so, and the Royal College of Paediatrics and Child Health recommends a consultant review of every new patient within 12 hours of admission. On the day of Jack’s death, the CAU was so busy that Bawa-Garba worked her 13-hour shift without a break. It is also worth noting that she had only just come back after maternity leave, she was working in a hospital that was new to her and she had received no induction from the trust.
At 7.45 p.m. Jack’s heart stopped and a crash call was put out alerting the medical team, including Bawa-Garba. Forty-five minutes earlier Jack had been given his regular medication, enalapril, a drug used to treat high blood pressure, by his mother. Bawa-Garba had specifically not prescribed the enalapril as it can precipitate cardiac arrest in a patient who already has low blood pressure due to shock (at her trial she was criticised for not making it clear to the mother not to administer it). Resuscitation was started, but briefly stopped because Bawa-Garba thought a ‘do not attempt resuscitation’ order was in place. The inquest ruled that this interruption did not contribute to Jack’s death as his condition was by then too far advanced. Jack was declared dead at 9.20 p.m.
The coroner investigating Jack’s death raised concerns with the police and they questioned Bawa-Garba, but the CPS decided there wasn’t enough evidence to prosecute. After a medical expert witness stated at the inquest that he felt Jack’s death had been preventable, the police reopened their investigation. Four years after Jack’s death, Bawa-Garba was convicted of ‘gross negligence manslaughter’, which is defined as a ‘truly exceptional degree of negligence’. She received a suspended sentence of two years’ imprisonment and was ordered to pay £25,000 to the prosecution. In 2017 the Medical Practitioners Tribunal Service imposed a 12-month suspension from the medical register, concluding that Bawa-Garba did not pose a continued risk to patients. This was challenged by the General Medical Council in the High Court – an unprecedented move – and the judge agreed to her permanent erasure from the medical register.
Jack’s case raises a number of serious issues for clinicians. Bawa-Garba did not provide exemplary care. She did make mistakes. Perhaps she would not have done so in a fully staffed, supportive environment. It’s worth noting that no other complaints were made about her in the years she worked as a doctor before Jack’s death, or in the four years following it. The University Hospitals of Leicester NHS Trust conducted a 14-person investigation into Jack’s death before her conviction and no single cause was identified. Their report made 23 recommendations, including increased consultant presence on the CAU and a review of the paediatric early warning system that identifies deteriorating patients. At the tribunal, evidence was given regarding the staff shortages, IT failures and the lack of automatic consultant review of sick patients, yet the trust has faced no penalties.
Perhaps it is time for the Department of Health and NHS trusts to take responsibility for making medical staff work in an environment that puts patients at risk, instead of criminalising individuals. Working a fully staffed rota is a rarity nowadays. I have done so for less than two of the last 12 months. A recent survey by the Guardian found that only 2 per cent of healthcare workers think there are always enough staff to provide a safe service for patients. Empty shifts are covered either by agency workers, who may be unfamiliar with the hospital, or by doctors who feel pressured into working extra shifts (and in doing so break their contractual maximum of 72 hours a week). Too often shifts are left unfilled, even for extended periods such as maternity leave, making it impossible to provide the recommended standard of care. If there is no cover the other doctors working that day are expected to manage their colleagues’ work on top of their own, and in cases like Bawa-Garba’s that means one doctor trying to do the work of two.
Doctors make mistakes. In a system working as it should the number of mistakes is minimised. But when the system isn’t working, should doctors go in to work and do their best even though their errors may lead to criminal charges? What does ‘gross negligence’ mean in a health service under such strain? The treatment of Bawa-Garba has troubled the medical community (which has raised £360,000 in donations to help finance her legal efforts) partly because of the precedent it sets in bringing criminal charges against individuals when system failures were a significant factor in the patient’s death. Especially worrying in this respect is the use of Bawa-Garba’s own clinical reflections against her. All doctors record their reflections on serious incidents in their portfolios. We discuss them at meetings. The process allows everyone to learn from mistakes and is an important part of continuing professional development. We have also traditionally understood it as an expression of a culture in which medical errors are not considered in isolation (leading to blame of individual doctors) but as part of a complex system. If doctors’ reflections are used against them it will only encourage them not to discuss mistakes for fear of prosecution. A GP committee has already advised GPs to abstain from writing reflective pieces until adequate safeguards are put in place to protect them. We are moving towards a culture of defensive medicine, which is changing the way that doctors work.
There are concerns too among doctors about the GMC and its determination to strike Bawa-Garba from the medical register against the advice of its own tribunal. The GMC states that its role is to ‘protect patients … by supporting students, doctors, educators and healthcare providers’. Although the Health Service is nationalised, the GMC is funded by doctors, who pay around £400 each year in order to remain on the register. More than half this money is spent investigating complaints about them. It’s important for the public to have faith in the GMC, and in the doctors who care for them, but it is also proper to scrutinise NHS trusts and their failures to maintain public safety. Meanwhile, the Sentencing Council set up by the Ministry of Justice consulted last year on increasing the sentence for convictions of gross negligence manslaughter from a minimum of two years to a minimum of six. Doctors have been warned that no exemptions are being considered.
The case of Jack Adcock highlights systemic failings within the NHS, which seem to get worse every year. Without significant improvements, it is likely we will see an increasing number of cases in which patients are seriously harmed by an overstretched service. From the outside, Bawa-Garba’s mistakes may look exceptional; the courts, and the media, present a straightforward chain of events and point to individual failings. But doctors working in hospitals know that the reality of medicine is not that simple, and that errors, including serious ones, are not rare and are hugely exacerbated by problems with the system in which we work. It is not uncommon for a doctor not to see an X-ray for a few hours if there are many urgent cases. You assume you will be bleeped if a patient is deteriorating. You can’t produce thorough notes when a colleague is away and six people need things from you right away.
For a conviction of gross negligence manslaughter to be secured, the law in England and Wales does not require the demonstration of intent, recklessness or public interest, which sets the bar low for the conviction of healthcare workers. The feeling among doctors is that there is a sharpening focus on individual blame. This damages morale and shows a lack of understanding of our working practices. It will not lead to improvements. In Scotland there is no offence of gross negligence manslaughter and no doctor has been convicted of the nearest equivalent, culpable homicide. Those who are concerned about the use of the charge against doctors are waiting for the reports of two doubtful allies: Jeremy Hunt and the GMC have both promised investigations. Next month Bawa-Garba will appear before the Court of Appeal to fight her removal from the medical register. The hope is that in the future she may also be able to appeal against her manslaughter conviction.