‘How can she live with herself? Yes, she made catastrophic blunders — but was she also a scapegoat for a hospital in chaos?
IN February 2011 Nicola Adcock took her son Jack to Leicester Royal Infirmary with sickness and diarrhoea.
But following a misdiagnosis of gastroenteritis by Dr Bawa-Garba plus a catalogue of further errors, the sixyear-old, who had Down’s syndrome and a heart condition, died. The landmark case prompted doctors to rally around the paediatrician. They claimed that, while she made errors, she had been made a scapegoat for systemic failings in the NHS. So how did this junior doctor – who has described herself as ‘wholeheartedly sorry’ – come to be convicted of manslaughter in the first place?
A TRAGIC DEATH IN AN OVERSTRETCHED DEPARTMENT
Firstly, after Jack’s admission, came Dr Bawa-Garba’s misdiagnosis of gastroenteritis. On her first day back from maternity leave, she was on a 13-hour shift, doing the work of two doctors because one hadn’t turned up. She was also reliant on a faulty IT system. It took her three hours to examine X-rays that would have revealed Jack needed antibiotics and she failed to raise the alarm at his abnormal blood tests. But, said Jonathan Cusack, a neonatologist at the infirmary who became her supervisor as part of her re-training following Jack’s death, a computer failure meant she was told Jack’s results over the phone rather than reading them on screen, making her more susceptible to ‘cognitive error’. He explained: ‘Normally with blood samples, abnormal numbers flash up in red and they’re easy to see.’
Instead, he said, ‘she was given 15 to 20 numbers at speed which she was writing down. She was under pressure and didn’t think about what those numbers meant.’
Yet Dr Bawa-Garba wasn’t the only professional to ignore the blood test results. The court heard that Stephen O’Riordan, duty consultant paediatrician that day, had written them down at the evening handover but chose not to review Jack. Dr Cusack added: ‘If, as has often been claimed, it should have been obvious to a trainee that Jack had sepsis, surely it should have been obvious to a consultant, too?’
A BETRAYAL AND A BOTCHED INVESTIGATION
Five days after Jack died, Dr BawaGarba was asked to meet Dr O’Riordan in the hospital canteen and encouraged to admit her mistakes as part of her ‘reflection’ – a process essential for medical training which doctors insist should stay confidential.
Yet Dr O’Riordan typed up her notes which were eventually fed into an inquiry and police investigation. ‘Trainees keep a log to assess what they’ve learned,’ says Dr David Nicholl, who organised a doctors’ petition backing Dr Bawa- Garba. ‘That these are being used in court cases is an abuse of their education.’
Dr Bawa- Garba returned to work and the hospital’s serious untoward incident inquiry – completed in 2012 – found widespread faults in the hospital, including staff shortages and IT system failures. Ninety changes were recommended, making it abundantly clear Dr Bawa-Garba – who moved to the UK from her native Nigeria in 1994 and qualified as a doctor in 2003 – was far from the only one at fault.
A HIGHLY CONTENTIOUS CRIMINAL CONVICTION
At first, the Crown Prosecution Service claimed there were no grounds to charge an individual doctor. Yet at the inquest, in July 2013, experts apparently decided there were sufficient grounds to prosecute. The case was re- conferred to the CPS which still didn’t charge Dr Bawa- Garba until December 2014. Doctors insist it is wrong to criminalise medical error as it will make staff too scared to work in case they make mistakes, and because in healthcare multiple processes are nearly always responsible for error.
And at Dr Bawa-Garba’s trial, it is claimed, expert witnesses were stopped by the prosecution from discussing the improvements Leicester Healthcare Trust made after Jack’s death that would have shown how many other factors were to blame.
Dr Bawa-Garba was given a two-year suspended jail sentence, as was nurse Isabel Amaro, who was on duty that day. ‘Clearly there are doctors who wilfully cause harm and of course they should be stopped,’ says Dr Cusack, who gave evidence at the trial. ‘But I don’t believe manslaughter applies to someone who has an otherwise unblemished record and has made a medical error in a case where there are multiple other failures.’
A MEDICAL PROFESSION AT WAR
At Dr Bawa-Garba’s tribunal hearing in June last year, the hospital’s failings became more widely known and the Medical Practitioners Tribunal Service – whose job is to decide whether a doctor is fit to practise – found there was nothing to suggest her actions were ‘deliberate or reckless’. Instead of being struck off, Dr Bawa- Garba was suspended for 12 months.
Jack’s mother wrote on Facebook that she was ‘disgusted’. The General Medical Council said public trust would be harmed if a doctor continued to work after being convicted of homicide. To the dismay of 800 doctors who begged it to reconsider, the GMC appealed the MPTS ruling, won its appeal at the High Court – and in January Dr Bawa-Garba was struck off.
A NEW LAWYER FOR A FIGHTBACK
Thousands of furious senior doctors raised more than £300,000 through crowd-funding to help Dr Bawa-Garba pay for an appeal. As support for her grew, then-health secretary Jeremy Hunt ordered a review into whether gross negligence manslaughter laws should apply in the context of healthcare. In February, she instructed a new law firm – Tim Johnson Law – and this March was given leave to appeal.
Following yesterday’s judgment Jack’s mother said she was ‘devastated’ by a decision that has made a ‘mockery of the justice system’. GMC chief executive Charlie Massey fully accepted the Court of Appeal’s judgment. ‘As the independent regulator responsible for protecting patient safety we are frequently called upon to take difficult decisions, and we do not take that role lightly,’ he said.