Back to blame: the Bawa-Garba case and the patient safety agenda
BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5534 (Published 29 November 2017) Cite this as: BMJ 2017;359:j5534
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I fully understand that Jack’s family feel owed an apology from those involved in Jack’s care. However any censure on the part of professionals regarding the absence of an apology from Dr Bawa-Garba, a trainee registrar, specifically and separately from a Trust apology, either fails to acknowledge due process and Trust’s systems or is even, possibly, misleading
Bereavement follow up and counselling support should be led by those most senior. Full disclosure should be respectfully made, with duty of candour and proper apology. A trainee would not apologise separately from this without guidance from the department and permission from the Trust, who would need to check with the legal advisors to the hospital and patient experience and liaison service. All documentation would be checked. An apology from a trainee may lead to further questions. This in itself may be discouraged by the Trust. Indeed the fact that there were so many systems errors could lead the Trust to be even more defensive in this particular case. Certainly guidance to the trainee provided in hospital canteen as stated in the BMJ article would not be the way to go about ensuring appropriate communication with the family
Once a defence organisation is involved, the legal team may recommend that the Trainee does not communicate with the family for fear of exacerbating a situation, seeming to canvass or admitting responsibility where it may not be so
Thus Dr Bawa-Garba’s hands will have tied in terms of her ability to communicate her remorse and yet as with so many things, in this case, such as the lack of records of observations by hard pressed staff and the illegal administration of a drug she suspended, this has been held against her by those who should know the process and system better
Competing interests: No competing interests
I am very sorry that Jack Adcock died and I am sorry for the distress that his death caused his family.
I have read that Dr Bawa-Garba is a conscientious doctor who made mistakes in the care of Jack Adcock. Had she not made those mistakes he might have survived. There were also system problems and others made mistakes.
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. The GMC took no action against 100 doctors placed on the Sex Offenders Register (SOR) for accessing child pornography - they remained on the Medical Register without even the requirement to inform their patients that they were on the SOR. The GMC allowed a consultant gynaecologist to remain on the Medical Register without restrictions when he was placed on the SOR. The GMC allowed doctors to remain on or return to the Medical Register after a period of suspension after one performed inappropriate private surgery, including total colectomy, for personal gain; after one gave desperate patients with cancer expensive private treatments that have no scientific basis; after several defrauded charities and medical insurance companies, and a doctor who appeared before two separate Fitness to Practise Panels that found that he repeatedly committed research misconduct.
The GMC should deal forcefully with doctors that are deliberately and repeatedly dishonest rather than a conscientious doctor who made a single clinical error.
Competing interests: I reported to the GMC some of the doctors referred to in this response.
Thank you for bring this unfortunate and sad incident to our attention and presenting an unbiased view.
I am disappointed by the fact that this 'trainee' doctor has been targeted. Disappointed that the system and society (is this the justice that is being delivered by fellow human beings?) has made decisions that in my view are unfair to this doctor, especially as it has been suggested that the unfortunate death of the patient was multifactorial.
I am equally disappointed regarding GMC's stance on this issue. GMC need to protect both patients and doctors, and in particular, treat all doctors, with fairness.
Competing interests: No competing interests
This article (and the series of pieces the BMJ and rapid responses) provokes 2 recurring questions:
1. How on earth did Dr Hadiza Bawa-Garba ever get convicted of gross negligence manslaughter?
It is possible that the judiciary, just like the medical profession, are fallible and there has been a miscarriage of justice - this, however, is a question to be addressed on another day.
2. What can I do as a clinician do speak up to raise awareness of this case?
a) You can sign this letter which I will be submitting (on December 2nd) to a broadsheet newspaper to make the public aware of this case via https://www.gopetition.com/petitions/letter-to-the-media-re-gmc-and-dr-h...
b) If you are able attend the Royal Courts of Justice on Thursday December 7th but act respectfully, this was a tragic case.
c) Take a selfie to show how you support a #LearnNotBlame culture https://twitter.com/djnicholl/status/934083721141149696 and not the #BlameNotLearn culture that the GMC by its very actions appear to seek to promote.
Remember the GMC has specific guidance on raising concerns about patient safety and it would appear in this instance by taking these actions, it is the GMC itself which is a risk to patient safety by bringing the practice of medicine into disrepute.
"All doctors have a duty to act when they believe patients’ safety is at risk, or that patients’ care or dignity are being compromised."
https://www.gmc-uk.org/guidance/ethical_guidance/raising_concerns.asp
As such I am taking the GMC's guidance by acting against the GMC.
Competing interests: No competing interests
It is staggering that the concept of a single person being the cause of medical error is still so pervasive in 2017. Lessons learned from industrial processes (from airlines to atomic energy) are clear that only when enough small things have aligned can there be enough momentum for tragedy to occur. Any one individual does not have the capacity to change all of these, and therefore the last person holding the ball cannot be held responsible.
It is also terrifying that my personal reflections may end up being used against me, as has happened to Dr Bawa-Garba. Many trainees (and consultants) feel the e-portfolio is a broken tool, that turns learning experiences into tick-box exercises. The precedent set by this case is surely going to make trainees think twice before documenting candid self-examinations of their performance.
Losing a patient is, unfortunately, an inevitable part of our profession. It fills us all with dread, and is a heavy burden on the shoulders of every one of us. Even when we could have done no more, we beat ourselves up with all the "what ifs" and "why didn't I...". Criminal and professional sanctions may provide short-term succour to the bereaved, and nice clean headlines in the tabloids, but do so at the cost of honesty and improvement at every level of the health service.
When our understanding of human factors and the chain of error has never been clearer nor more widely taught, and when the moral of the workforce is at its deepest nadir, this is the time for the medical leadership, and national leadership to step forward and end this brutal miscarriage of justice. As Dr Vaughan said in this article "there are no winners in a system which blames tragic outcomes on a trainee... Patient safety will never be improved unless everyone promotes an open learning culture."
Competing interests: No competing interests
It is a shame that yet again another foreign doctor has been 'named and shamed' and is on the verge of erasure from the GMC register. This is in the background of evidence that there have been layers of mistakes that could have averted the tragedy - and not solely as an individual, as has been publically proclaimed by the hospital trust itself after a thorough investigation..
Hafiza like any other trainee at her level had requested help and advice and was not provided the same. Many other added on complexities- human and environmental, also had confounded the progression of the condition that led to sad untimely death of the child.
Despite MPTS guidance and several senior paediatricians advice against it, it appears like the GMC is pent on ruthlessly striking her off the register, with no consideration given to her exemplary past track record or the inadequate working conditions around her. It is almost made to feel to us that the episode was as if a pre-meditated murder.
Whenever errors happen in the NHS, as is well known even if we uphold 'No Blame' culture as a virtue, it is never implemented fully or fairly. It is also clear that the decisions made are even more unfair if the melanin pigment is in abundance in the one implicated. There is ample statistics in the GMC to show the grossly disproportionate number of referrals to GMC and the ones convicted and erased from the GMC register also disproportionately being higher from the BME community.
On a daily basis one loses faith in various systems around us, with the one we had on the GMC crumbling minute by minute.
Once again we are proven that 'Fairness is only skin deep'.
Competing interests: No competing interests
Re: Back to blame: the Bawa-Garba case and the patient safety agenda
The case of Dr Hadzia Bawa-Garba has been described to illustrate the issues of the development of a blame culture, the use of a junior doctor’s educational reflective practice in court and senior supervision. [1] It is understood that failures in care are often a result of wider system errors, rather than individuals. [2] Appropriate clinical supervision is a key element of postgraduate medical training, and should be tailored to the individual training needs of the trainee. [3] In the acute setting, supervision falls to the admitting consultant, who has overall clinical responsibility for the patient and the multidisciplinary team caring for that patient. [4]
The General Medical Council requires doctors to reflect openly and honestly on all aspects of their clinical practice and comply with investigations [5] Doctors have a duty of candour to admit errors and apologise, as well as offer remedy. Principally, doctors and healthcare professionals should foster a blame-free culture whereby incidents and near-misses are discussed to learn, develop and improve patient safety. [6]
In November 2016, the Academy of Medical Royal Colleges (AoMRC) issued guidance on entering information on e-portfolios. [7] This guidance is chiefly concerned with the anonymity of patient data. The exclusion of patient identifiable data, the use of gender neutral descriptors and limiting the details of the event are simple. However, in significant cases it is impossible to guarantee anonymity in good quality reflection, and is acknowledged by the AoMRC when they state: “Occasionally it will be unavoidable as the condition of a particular patient will be unique, but try and minimise the patient identifiable information that you provide”. The AoMRC further advises to take advice from a senior, experienced colleague when writing reflection about cases that may be contentious or result in an investigation. This guidance has been supported and reiterated by Health Education England and medical defence organisations. [8,9,10]
ASiT is concerned that the use of junior doctors' educational reflections in court will have a significant negative impact on patient safety, the duty of candour and indeed on surgical training. Trainees will be reticent to reflect openly and honestly for fear of their reflections being used against them, thereby undermining the process entirely. Trainees may lose confidence in their supervision and training. This could, over time, erode the trainee-trainer relationship and prevent organisations from improving patient safety. ASiT is concerned that there are future implications for trainees, and that there could be a development of a defensive culture to education and training.
ASiT feels that more robust guidance should be issued on trainee reflection and supervision and that there should be to legislative change to foster a supportive culture of learning and patient safety.
References
[1] Cohen D. (2017) Back to blame: the Bawa-Garba case and the patient safety agenda. BMJ:359:j5534 doi: 10.1136/bmj.j5534
[2] Francis R, (2013) The report of the Mid Staffordshire NHS Foundation Trust public enquiry. Executive Summary. Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil... Accessed 09.12.17
[3] General medical Council (2011) The trainee doctor. Available at https://www.gmc-uk.org/The_Trainee_Doctor_1114.pdf_56439508.pdf Accessed 09.12.17
[4] Academy of Medical Royal Colleges (2014) Guidance for taking responsibility: Accountable Clinicians and Informed Patients. Available at https://www.aomrc.org.uk/wp-content/uploads/2016/05/Taking_Responsibilit... Accessed 09.12.17
[5] General Medical Council (2013) Good medical practice. Available at https://www.gmc-uk.org/Good_medical_practice___English_1215.pdf_51527435... Accessed 09.12.17
[6] General Medical Council and Nursing and Midwifery Council (2015). Openness and honesty when things go wrong: the professional duty of candour. Available at https://www.gmc-uk.org/static/documents/content/DoC_guidance_english.pdf Accessed 09.12.17
[7] Academy of Medical Royal Colleges (2016) Guidance for entering information onto e-portfolios. Available at http://www.aomrc.org.uk/wp-content/uploads/2016/11/Academy_Guidance_on_e... Accessed 09.12.17
[8] Health Education England (2016) Position statement on trainees’ written reflections. http://www.stfs.org.uk/sites/stfs/files/2016%203%20(23rd)%20HEE-EM%20Letter%20-%20Statement%20on%20Trainee%20Reflections%20(2).pdf Accessed 09.12.17
[9] Medical Defence Union (2015) New guidance on e-portfolio reflective notes. Available at https://www.themdu.com/guidance-and-advice/latest-updates-and-advice/new... Accessed 09.12.17
[10] Medical and Dental Defence Union of Scotland (2017) Can reflective practice be “incriminating”? Available at https://www.mddus.com/resources/publications-library/insight/q2-2017/can... Accessed 09.12.17
Competing interests: No competing interests