By Erika Koutroumpa,
The standard of care is the benchmark that determines whether the professional obligations of healthcare professionals to patients have been met. It is based on what a reasonable person would do in similar circumstances. However, if systemic failures and lack of resources prevent a doctor from providing quality healthcare, should they be held accountable for the fate of the patient, and to what extent? These were some of the questions that were raised by the Bawa-Garba case.
The patient was 6-year-old Jack Adcock, a child with Down syndrome who had a heart defect, for which he was being treated with medication. He was prone to illness, coming in and out of hospitals often. On February 18, 2011, he was sent to the Children’s Assessment Unit (CAU), following his GP’s referral. He was lethargic, had difficulty breathing, presented nausea, diarrhea, and cyanosis (blue lips), all of which also happened to be septic shock symptoms.
Adcock was being treated by Dr Bawa-Garba, a 6th year trainee in pediatrics. Before the events of the case, she had an exemplary record but was new to the hospital and had just come back from a one-year maternity leave. On that day, the doctor was covering the shift of one of her superiors, who had double booked himself with teaching engagements, leaving her as the most senior member that day. Since the hospital was understaffed, she was doing the work for two people at the same time, working overtime and treating other emergency cases in between checking in with Jack. With a lack of senior doctors, Dr Bawa-Garba had nobody to report to, and due to the scarcity of nurses, there was no one to inform her of the patient’s worsening condition.
The doctor had initiated treatment for gastroenteritis and gave the patient a bolus, seeing that he had lost a lot of fluids. Jack was also to be taken off his heart medication, but this had been omitted from the notes, and nor were his parents informed of this. Blood tests and a chest x-ray were ordered, but due to system failures, the doctor was not notified of their arrival. Hence, the blood test results were reported to the doctor 5 hours late and even though the x-ray results were available from 12.30 pm they were not seen until 3 pm. In the meantime, the doctor was treating other severe cases, but Jack’s condition was worsening- his blood pH was acidic, blood results showed elevated C reactive protein, an indication of infection, and the x-ray also showed an infection. As soon as the diagnosis had been made, Dr Bawa-Garba prescribed antibiotics to be given to the patient, but they were administered an hour later.
When Dr Bawa-Garba checked on Jack in between shifts his condition seemed to improve and showed no signs of the progression of sepsis. At 7 pm, the patient’s mother administered to him the heart medication, and only an hour later he suffered cardiac arrest. While trying to save him, Dr Bawa Garba mistook his notes for another patient with a do not resuscitate order, hence briefly halting the procedure before realizing the error. Despite the doctors’ efforts, Jack died that day at 9.20 pm, his cause of death being sepsis secondary to pneumonia.
When the parents enquired about their son’s death, they were told that a junior doctor had failed to recognize the severity of Jack’s condition and that he was not given the right care. Hence, in 2012 the GMC received a referral letter about Dr Bawa Garba from the deceased’s family and began investigating her misconduct. Initially, the doctor was told by the Crown Prosecution Service that she would not have charges brought against her, but this changed when she was taken to the High Court on 4th of November 2015, and was found guilty of manslaughter on grounds of gross negligence and was given a 2-year suspended sentence. The GMC chief appealed to the High Court to overturn the tribunal decision, and in January 2018 Dr Bawa Garba lost her right to practice in the UK.
The question asked in this case was how far below did Dr Bawa Garba fell from the standard of care. According to the expert witnesses, Jack’s death was multifactorial, but ultimately his life could have been saved if sepsis had been detected and antibiotics had been given to the patient earlier. The doctors who served as the witnesses of the two sides could not agree on the heart medication’s role in the case, but both agreed that the mistake during resuscitation did not play a factor. What was of pivotal importance, instead was both the string of miscommunication between hospital staff members as well as the systematic failures that played a part in delaying drug administration. The critical errors on Dr Bawa-Garba’s behalf seem to be not being alarmed by the C reactive protein spike earlier, not writing down the alterations she made on the patient’s medication and not communicating with her superior once he arrived at the hospital later during the day.
Doctors across the country were enraged by this case because Dr Bawa Garba was led to court partially due to issues inherently within the NHS itself- IT system not working, hospitals are understaffed, and consultants were not available. The University Hospitals of Leicester NHS Trust’s internal investigation on Jack’s death, conducted 6 months after the incident, was revealed on 19 March 2018, claiming that there was ‘no single root cause’ behind the death. Hence, many doctors felt that it could have easily been them instead of the former trainee in that courtroom. The reflective diary of the doctor was also another point of controversy- albeit it not being part of the formal evidence, it was used against her in the trial. Some clinicians also claimed that the reflections also exist for supervisors to notice any mistakes or points that the trainees have neglected to notice and that the supervisor also failed to fulfil his duties. This wrecked years of work within the NHS of cultivating transparency and openness regarding case handling, hence inhibiting clinicians from learning from their mistakes due to fear.
Thus, a crowdfunding campaign began, managing to raise over 335,000 GBP to support Dr Bawa-Garba to appeal the ruling, with the Court of Appeal ultimately ruling in favor of the defendant and restoring the Tribunal’s initial decision that she should be suspended instead of erasing from the medical register. On the one hand, the Tribunal claimed that giving a heavier punishment would be ‘disproportionate and punitive’, while on the other Jack’s mother Nicole claimed she “will cause public uproar” if the doctor was reinstated, as the doctor herself had made in her opinion too many mistakes during the handling of her son’s case. As a result of this case, the then secretary of Health Jeremy Hunt launched an investigation aiming to clarify basic human error from manslaughter in healthcare, and the GMC launched a separate one in 2018 to discover why ethnic minority doctors are more prone to complaints from employers than their white counterparts. While there have been efforts to try and avoid the errors of the past, it is felt by some that so far they have been moot.
To what extent can we expect doctors to be held accountable for delivering services below the standard of care when they have been set up for failure to begin with? How can we expect doctors to perform their best when they have unsuitable working conditions, where there is no teamwork between senior and junior staff, with the latter being left without guidance? These are some questions that urgently need to be answered not just in the UK but in healthcare systems with limited resources across the globe. The reaction towards this case’s outcome managed to serve as food for thought for policymakers and regulatory authorities in the country, but there is still a long way to go as far as improving working conditions are concerned. Regardless, a clear distinction should be made and medical manslaughter ought to be reserved specifically for cases of severe malpractice that goes beyond honest human error.
References
- “The inside story of a six-year-old boy’s death. And the trainee doctor who took the blame”, Deborah Cohen, BBC News. Available here
- “Can the Bawa-Garba case result in a stronger NHS safety culture?”, Richard Vize, 23 February 2018, The Guardian. Available here
- “Bawa-Garba Case”, The Medic Portal. Available here
- “Bawa-Garba: timeline of a case that has rocked medicine”, 10 April 2019, The Pulse. Available here
