Understaffed and under pressure-just who is responsible for patient death in today’s diseased NHS?
Where will the blame culture lead us? At some stage in the future will we think it worth checking the entire cast of doctors working for the GMC in a regulatory capacity for potential errors they may have been a party to, at some or any stage during their career? I doubt any doctor will be free from errors or omissions. They are usually the stimulus for greater anxiety and over careful management when faced with future situations. If we cannot have, as many respected commentators have mentioned, a ‘safe space’ to discuss these traumatic occurrences and debrief, learn and move forward, then what use is clinical governance? I grew up hearing stories of 4-day weekends sustained by milky coffee and courage, working alongside junior doctors who were likely burnt out; one even suicidal. All anecdotal, of course. As a medical student I tried to grasp the concepts of audit and risk management, only to later find myself and one colleague covering over 400 acute medical patients as night SHO’s. If Admissions was busy, the wards suffered and groaned while one or both of us diverted to clerking. The Registrar was seen flitting between wards and Admissions, certainly not responsible for chasing blood results or x-ray review, at least in the first instance. The House Officer would chase bloods, or the lab ring in worrisome findings. How can a registrar covering Children’s Assessment Unit, Accident and Emergency and the wards in a much busier teaching hospital in Leicester, be responsible for one tragic occurrence? No one can imagine the loss felt by the grieving family, but wouldn’t the healing thing to do be the explanation of what happened through a mediator, explaining that the tragic death was multifactorial and that Dr Bawa-Garba was not the cause? Surely we work as an MDT, and any death in such circumstances would be attributable to the MDT as a whole breaking down, perhaps through institutional problems such as poor staffing levels and inadequate senior support.
Rather than wreck the lives, reputations and careers of those onshift when a death occurs, the trust simply needed to arrange in-house reflections that culminated in better staffing, increased senior cover and re enforcement of early warning scoring systems to identify peri-arrest scenarios. It appears there are now 2 registrars in the Leicester Royal Infirmary doing the same, which speaks volumes. Isn’t this the very purpose of clinical governance-find errors, make changes, re-review the changes, feedback to patients and their families. Could not a series of meetings between the trust and the patient’s family, with mediators present, have averted this tragic hounding of one individual? Dr Bawa-Garba has been described as an ‘excellent doctor’ according to two consultant colleagues, Dr A and Dr D, as written in the recordings of the MTPS tribunal (1). Indeed, she worked for a further 4 years for the same employer-the inference would be that she was safe, which both the above-mentioned Consultants agreed verbally within this recording. What a great shame that this situation was allowed to go this far. GMC: do the honourable thing and prove your doubters wrong. Reinstate this doctor.
When a patient dies whilst on-shift, what are doctors’ feelings and thoughts? It is easy to blame a shell-shocked, possibly over-reflective doctor for the death of a patient. It is harder to pin down blame when faced with gross institutional failures. We live by the Multidisciplinary team, but abandon our colleagues as soon as a whiff of blame surfaces, perhaps from a grieving family lashing out. Without apportioning blame, a little analysis reveals many factors, as one would expect. Nursing and junior medical staff issues surface such as the unfortunate lack of repeating the blood gases despite being requested by Dr Bawa-Garba of her junior, the administration of enalapril despite it not being prescribed by Dr Bawa-Garba, or the seeming absence of early warning scores failing to cascade progressively senior clinician review by the nursing team. One point on the mention of bloods not being seen in the tribunal notes available online struck a chord-as a PRHO and then SHO in acute medicine, I reviewed the blood results of admitted patients rather than my registrar.
Let’s talk about why individual doctors may allow this type of allegation to be levelled against them, without necessarily being able to rebut effectively what was not their fault. A study of over 7,000 doctors to investigate health and psychological welfare after a complaint found their anxiety and depression scores increased with the severity of the complaint, most emphatically after GMC referral (2). No surprise there. 38% felt bullied, and they were twice as likely to have experienced thoughts of self-harm. I wonder whether one eventually starts to believe the anger within the grief of family bereaved, and acquiesce to the blame being levelled. In a study on paediatric registrars’ responses to child death, 91% of registrars think of a particular baby or child who died, and many of these thoughts related to doubt about management and unresolved issues (3). Potential reasons why the courtroom scene played out in this fashion..
Now to the conviction-many would argue that this is not gross negligence, but could well be a gross injustice. Cases that involve the tragic loss of life through supposed medical negligence should require, in my humble opinion, a specialist jury-one trained in medicine, perhaps. Certainly one able to accommodate situations where there could be a systems failure rather than individual culpability, however shell-shocked the defendant. Juries faced with the sad death of a child may be more likely to be sympathetic to the family in grief-we are only human, after all. Further analysis needs to be done in this field, and research is scanty, however what is known is that there is subconscious prejudice when a jury deals with BME defendants (4).
(2) Tom Bourne et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open. Volume 5, Issue 1. Found at http://dx.doi.org/10.1136/bmjopen-2014-006687
(3): A Baverstock. Specialist Registrars’ emotional responses to a patient’s death. Arch Dis Child. 2006 Sep; 91(9):774-776 doi: 10.1136/adc.2005.076760
Rapid Response:
Understaffed and under pressure-just who is responsible for patient death in today’s diseased NHS?
Where will the blame culture lead us? At some stage in the future will we think it worth checking the entire cast of doctors working for the GMC in a regulatory capacity for potential errors they may have been a party to, at some or any stage during their career? I doubt any doctor will be free from errors or omissions. They are usually the stimulus for greater anxiety and over careful management when faced with future situations. If we cannot have, as many respected commentators have mentioned, a ‘safe space’ to discuss these traumatic occurrences and debrief, learn and move forward, then what use is clinical governance? I grew up hearing stories of 4-day weekends sustained by milky coffee and courage, working alongside junior doctors who were likely burnt out; one even suicidal. All anecdotal, of course. As a medical student I tried to grasp the concepts of audit and risk management, only to later find myself and one colleague covering over 400 acute medical patients as night SHO’s. If Admissions was busy, the wards suffered and groaned while one or both of us diverted to clerking. The Registrar was seen flitting between wards and Admissions, certainly not responsible for chasing blood results or x-ray review, at least in the first instance. The House Officer would chase bloods, or the lab ring in worrisome findings. How can a registrar covering Children’s Assessment Unit, Accident and Emergency and the wards in a much busier teaching hospital in Leicester, be responsible for one tragic occurrence? No one can imagine the loss felt by the grieving family, but wouldn’t the healing thing to do be the explanation of what happened through a mediator, explaining that the tragic death was multifactorial and that Dr Bawa-Garba was not the cause? Surely we work as an MDT, and any death in such circumstances would be attributable to the MDT as a whole breaking down, perhaps through institutional problems such as poor staffing levels and inadequate senior support.
Rather than wreck the lives, reputations and careers of those onshift when a death occurs, the trust simply needed to arrange in-house reflections that culminated in better staffing, increased senior cover and re enforcement of early warning scoring systems to identify peri-arrest scenarios. It appears there are now 2 registrars in the Leicester Royal Infirmary doing the same, which speaks volumes. Isn’t this the very purpose of clinical governance-find errors, make changes, re-review the changes, feedback to patients and their families. Could not a series of meetings between the trust and the patient’s family, with mediators present, have averted this tragic hounding of one individual? Dr Bawa-Garba has been described as an ‘excellent doctor’ according to two consultant colleagues, Dr A and Dr D, as written in the recordings of the MTPS tribunal (1). Indeed, she worked for a further 4 years for the same employer-the inference would be that she was safe, which both the above-mentioned Consultants agreed verbally within this recording. What a great shame that this situation was allowed to go this far. GMC: do the honourable thing and prove your doubters wrong. Reinstate this doctor.
When a patient dies whilst on-shift, what are doctors’ feelings and thoughts? It is easy to blame a shell-shocked, possibly over-reflective doctor for the death of a patient. It is harder to pin down blame when faced with gross institutional failures. We live by the Multidisciplinary team, but abandon our colleagues as soon as a whiff of blame surfaces, perhaps from a grieving family lashing out. Without apportioning blame, a little analysis reveals many factors, as one would expect. Nursing and junior medical staff issues surface such as the unfortunate lack of repeating the blood gases despite being requested by Dr Bawa-Garba of her junior, the administration of enalapril despite it not being prescribed by Dr Bawa-Garba, or the seeming absence of early warning scores failing to cascade progressively senior clinician review by the nursing team. One point on the mention of bloods not being seen in the tribunal notes available online struck a chord-as a PRHO and then SHO in acute medicine, I reviewed the blood results of admitted patients rather than my registrar.
Let’s talk about why individual doctors may allow this type of allegation to be levelled against them, without necessarily being able to rebut effectively what was not their fault. A study of over 7,000 doctors to investigate health and psychological welfare after a complaint found their anxiety and depression scores increased with the severity of the complaint, most emphatically after GMC referral (2). No surprise there. 38% felt bullied, and they were twice as likely to have experienced thoughts of self-harm. I wonder whether one eventually starts to believe the anger within the grief of family bereaved, and acquiesce to the blame being levelled. In a study on paediatric registrars’ responses to child death, 91% of registrars think of a particular baby or child who died, and many of these thoughts related to doubt about management and unresolved issues (3). Potential reasons why the courtroom scene played out in this fashion..
Now to the conviction-many would argue that this is not gross negligence, but could well be a gross injustice. Cases that involve the tragic loss of life through supposed medical negligence should require, in my humble opinion, a specialist jury-one trained in medicine, perhaps. Certainly one able to accommodate situations where there could be a systems failure rather than individual culpability, however shell-shocked the defendant. Juries faced with the sad death of a child may be more likely to be sympathetic to the family in grief-we are only human, after all. Further analysis needs to be done in this field, and research is scanty, however what is known is that there is subconscious prejudice when a jury deals with BME defendants (4).
References:
(1) MPTS Public record of determinations page 6, found at https://www.mpts-uk.org/static/documents/content/Dr_Hadiza_BAWA-GARBA_13...
(2) Tom Bourne et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open. Volume 5, Issue 1. Found at http://dx.doi.org/10.1136/bmjopen-2014-006687
(3): A Baverstock. Specialist Registrars’ emotional responses to a patient’s death. Arch Dis Child. 2006 Sep; 91(9):774-776 doi: 10.1136/adc.2005.076760
(4): found at http://www.thejuryexpert.com/2012/05/subtle-contextual-influences-on-rac...
Competing interests: Empathy