I was fortunate enough to get through my career as an Oral and Maxillofacial Surgeon without ever finding myself in court defending my practice. Not everyone is so fortunate and indeed some deserve to go the distance. The fact is that the majority of medical errors, even serious ones, do not result in litigation and the majority of cases that do are the result of a perceived lack of empathy rather than malpractice on the doctor’s part.
When a case does get to court the evidence is something like this …
On 18th February 2011 Jack Adcock was admitted to Leicester Royal Infirmary with a history of severe gastro enteritis. He had previously had an AVSD repair, doing well, on enalapril. He had a temperature of 37.7 degrees centigrade, dehydration and shock. A Blood gas showed a Ph, 7.0, base deficit, -14, lactate 11 mmols. He was prescribed a fluid bolus and maintenance fluids. Blood tests including CRP were undertaken and a chest x –ray ordered. There was a delay of two and a half hours in review of chest x-ray during which time Jack showed some recovery, playing with the radiographer, drinking juice from his beaker, improvement in blood gas, to ph 7.24. Jack was moved off the Children’s Assessment Unit (CAU) to the wards, where an unprescribed dose of enalapril was administered. Approximately one hour later he suffered a collapse from which he was very sadly unable to be resuscitated.
Which I’ve taken from a description of the case against Dr Hadiza Bawa-Garba. This is translated for the jury but just think how much information is packed in that single paragraph, multiply that by a large number of paragraphs and think about the volume of information that a jury has to process to arrive at its verdict. The medical defence organisations do their best to keep us out of trouble and I was often reminded that should a case go to court a matter that a trained doctor would regard as a lay down misere could very easily go either way.
Dr Bawa-Garba was a junior doctor just back from maternity leave. She had an unblemished record and had done good work for charitable causes. Young Jack was a much-loved six-year-old with a lot of medical problems stemming in the main from Down Syndrome.
On the day that Jack died …
- The medical team was relatively new due to the February change over
- Dr Bawa-Garba had not received an induction to the hospital
- Another registrar did not attend work
- Her supervising consultant was rostered elsewhere
- The hospital computer system was down
- A senior house officer was diverted to chasing test results by phone
- When the computer did come on-line abnormal results were not flagged
On this day: Dr Bawa-Garba, a trainee paediatrician, who had not undergone Trust induction, was looking after six wards, spanning 4 floors, undertaking paediatric input to surgical wards 10 and 11, giving advice to midwives and taking GP calls.
Quite how long Dr Bawa-Garba was on duty is unclear but it is clear that she was involved in two instances of resuscitation 11 hours apart.
For large numbers of the medical profession who have read this account, the clinical circumstances surrounding Jack’s death sound exceptionally horrific, with Dr Bawa-Garba struggling against all odds to keep her young patients safe and undertaking the roles of 3 or 4 doctors in the absence of her supervising clinical consultant. It seems clear to us that even the most competent junior doctor would struggle to keep children safe under such conditions.
Appropriate tests were performed, results eventually received , a proper diagnosis made appropriate treatment was administered. Jack showed initial improvement but then collapsed. Resuscitation was unsuccessful.
When she eventually discussed the case with her consultant Dr Bawa-Garba was encouraged to write a full and frank account of the events which she did. The logic behind this is obvious – no one learns from mistakes or system failures that are hidden. On the other hand what is good for the community may not be good for the doctor. There were errors in Jack’s management.
The crucial error was the administration of enalapril, a medication used to treat high blood pressure, diabetic kidney disease, and heart failure. Jack’s blood pressure was in his boots. Dr Bawa-Gaba did not order the enalapril but she failed to make it clear to Jack’s mother that it should be stopped. Mum gave Jack his regular dose by mouth.
Four years after the event Dr Bawa-Garba and two nurses were found guilty of manslaughter. Dr Bawa-Garba was given a two year suspended prison sentence. The independent Medical Practitioners Tribunal Service (MPTS) ruled that she was a competent doctor who made mistakes in the context of serious systemic failures, and recommended that she should be allowed to continue to practise medicine. The General Medical Council (GMC) appealed the MPTS’s decision, and on 25 January 2018 the High Court allowed the GMC to permanently erase Dr Bawa-Garba from the medical register.
This is a dire miscarriage of justice.
You can do something about it and maybe help do some good. Visit this site www.crowdjustice.com.
bobmcgee 