Dr Bawa-Garba - Medical liability in team-based, underesourced health care settings:
One of the most highly challenged and emotive medical negligence cases to have hit the UK medical profession finally came to its conclusion in 13th of August 2018. The Court of Appeal ruled in favour of Dr Hadiza Bawa-Garba to practice medicine again, after being convicted of manslaughter by gross negligence. The Court of Appeal held that Dr Bawa-Garba’s situation needed to be looked at in the wider context and the mitigating circumstances, which we will come to discuss later in this blog. The case concerned the unfortunate death of Jack Adcock, a 6-year-old patient who died as a result of avoidable failures whilst under the care of medical professionals in Leicester Royal Infirmary. The debates surrounding this case have suggested overwhelmingly that the series of systemic failures leading up to Jack’s death were preventable. At the center of this case is Dr Hadiza Bawa-Garba, a junior doctor who was the primary doctor in charge of treating Jack. Whilst under the care of Dr Bawa-Garba, a series of ill-fated circumstances led Jack to receive inadequate medical attention and, unfortunately, eventually this led to his death.
Jack’s case highlights a number of key issues for health law and policy, not just in England, but beyond. How fit for purpose is medical negligence law, which focuses blame on individuals, and imagines a powerful doctor in charge of and hence responsible for everything that happens to a patient? How should the law take account of changes in medical practice, towards team approaches, which are more effective both for patients and for health systems? And how should the law compensate patients where failures arise from under-resourcing or other inadequacies or inefficiencies that essentially arise from governmental actions?
Aside from the very sad circumstances of a seriously ill patient dying under avoidable conditions, emotions have run high through the entire case due to the impact this has had on Dr Bawa-Garba. There are those who argue Jack died due to the deficits in the care Dr Bawa-Garba had provided herself, and that if she had taken a number of preventative measures whilst Jack was under her care (and ensuring those subsequently taking over her position were adequately instructed) Jack would have survived. There are others who argue that the circumstances of this case are much more complex , and the blame should not have been placed on Dr Bawa-Garba to the extent that it had at certain parts of her trial. Principally, the argument is that Dr Bawa-Garba and Jack Adcock were unfortunate victims of extensive systemic failures within the hospital.
Though the Court of Appeal’s verdict in August [SS2] is a sigh of relief to those who felt the law was punishing Dr Bawa-Garba for circumstances that were beyond her control, the way this case has been dealt with has caused widespread concerns for current and future medical professionals. The significant implications this has on medical negligence laws are also thought to be substantial. Such issues will be discussed in later blog posts in this series covering the case.
What happened on the day of Jack Adcock’s death?
Dr Hadiza Bawa-Garba, a junior doctor, was on duty on the 18th of February 2011 in sole charge of the pediatric emergency department and Children’s Assessment Unit (CAU) in Leicester Royal Infirmary. Dr Bawa-Garba had recently returned from maternity leave and had not received any formal introduction or training for her new job as a ST5 Specialty registrar (a doctor who is receiving advanced training in a specialist field of medicine, in this case the paediatric ward).
There are a few points worth noting about the circumstances during this particular shift. Along with receiving no formal induction, Dr Bawa-Garba did not have any other senior consultants working alongside her in the paediatric emergency department and CAU on the day. Essentially, she was covering the work of two other doctors.
Jack Adcock, the 6-year-old patient, was referred to the Leicester Royal Infirmary by his GP after presenting symptoms of diarrhea, vomiting and difficulty breathing. Jack had Down’s Syndrome and a known heart condition, and thus it was clear that Jack had a complicated medical history. The nursing staff in the CAU alerted Dr Bawa-Garba toJack’s medical condition after admission in the hospital, with Dr Bawa-Garba finding him to be dehydrated after a clinical examination and administrating him with fluid replacement. Blood tests were also taken and sent off for laboratory analysis and a chest x-ray was requested.
Dr Bawa-Garba ordered Jack to be given fluids (but not antibiotics) at 10.45am which Jack reacted to positively.
Unfortunately, there were a number of failures that had taken place subsequent to Jack’s admission to the hospital that caused his health to deteriorate without sufficient medical care. These included a delay in the receipt of the blood test results due to an IT failure (the blood test results were ordered at around 10.45am and were not received until after around 4.15pm). The chest x-rays were also not received until after 3.00pm (and Dr Bawa-Garba had not chased up the results of this either).
There were also a number of failures in Dr Bawa-Garba’s medical judgements. Though her initial suspicions were that Jack had a case of gastroenteritis, the chest x-ray results showed that in fact Jack had pneumonia. His blood test results showed he had a Group A Streptoccal infection (a bacterium which can colonise the throat, skin and anogenital tract) causing potential respiratory tract infections.
Dr Bawa-Garba prescribed antibiotics to Jack at 4.00pm and he was moved onto a ward.
There was a routine handover to a senior consultant later that day at 4.30pm. During the handover meeting Dr Bawa-Garba did not ask a consultant to review Jack’s condition. She did share abnormal laboratory results with him which he wrote down in his notebook. However, the consultant later felt that Dr Bawa-Garba had not “stressed” these results enough when handing over, at least not enough for him to take due note of the abnormality of the results. Furthermore, she had told the senior consultant that Jack’s condition had improved.
She had also omitted to state on the drug chart that Jack’s regular medicine of enalapril (for his heart condition) should be discontinued. This omission led Jack’s mother to eventually administered this medicine to Jack at 7pm, which induced Jack’s circulatory shock and death.
By 7.46pm, the sepsis caused by the pneumonia led to Jack suffering from organ failure, including heart failure. By around 8pm, Jack’s condition was fast deteriorating and he suffered a cardiac arrest. CPR was commenced. However a further failure caused by Dr Bawa-Garba mistakenly believing Jack to be another terminally-ill patient led her to request the ward team to stop performing further CPR for around 2 minutes. Realising her error, Dr Bawa-Garba ordered the team to recommence CPR.
Though efforts were made to resuscitate Jack, these attempts failed and Jack died at 9.20pm.
What was the lead-up to Dr Bawa-Garba’s sentence in the Court of Appeal?
Dr Bawa-Garba was initially temporarily suspended from practicing medicine but was reinstated later on the basis of her good record as a doctor. On the 4th of November 2015, she was charged with gross negligence manslaughter and found guilty by a jury in Nottingham Crown Court. The judge sentenced her to a two-year jail term suspended for two years. This led Dr Bawa-Garba to appeal to the Court of Appeal in December 2016, but to no avail (the full judgement of the Court of Appeal dismissing her application for leave to appeal can be read here):
Her criminal conviction led her to be suspended from practice for 12 months by the Medical Practitioners Tribunal on the 13th of June 2017. The General Medical Council (GMC) subsequently was successful in its appeal to the High Court for this 12-month suspension to be overturned and to instead erase Dr Bawa-Garba’s registration on 25th of January 2018. Dr Bawa-Garba later appealed to the Court of Appeal, with the Court finding that the Medical Practitioners Tribunal had made no error in its initial judgement and reinstated the 12-month suspension on the 13th of August 2018.
From the facts we can see that the circumstances surrounding Jack’s death were not as clear-cut as the typical medical negligence case. There has also been widespread sympathy for Dr Bawa-Garba, as she was described to have a good record and there no concerns about her clinical competency. Medical doctors, whopractise within hospitals day in and day out, have also empathized with the unfortunate situations, highlighting the unacceptable pressure that today’s NHS doctors are under.
This blog post has provided an overview of the facts of this case and the subsequent judgements passed down by the courts. The undisputed impact this has had on the medical profession will be discussed in the second blog post of this series – this will discuss the current law on medical negligence in the UK.