Does this doctor deserve to be guilty of manslaughter

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Does this doctor deserve to be guilty of manslaughter

Post by mr friendly guy » 2018-01-31 08:45am

The case of Dr Hadiza Bawa-Garba from the UK has been heard even in Australia among medical circles with some Aussie doctors voicing support for her. I had to do a bit of research so I will present some links and just post one of the articles. However each article seems to have information the other does not, so it makes the picture more clear.

Basically Dr Bawa-Garba was convicted of manslaughter of a child and then struck off the medical board (against the wishes of the Medical Practitioners Tribunal Service). Doctors are not happy given the circumstances,ie she was doing the jobs of several doctors at the time and there are problems to say the least with the system.

http://www.independent.co.uk/news/healt ... 84966.html

opinion piece here

http://www.pulsetoday.co.uk/your-practi ... 44.article
Dr Hadiza Bawa-Garba: What led to six-year-old Jack Adcock's death?
Junior doctor's conviction sparks outrage from medical community who raised concerns over apparent failure to consider exceptional pressures faced by NHS staff


Lucy Pasha-Robinson @lucypasha a day ago

The case of Dr Hadiza Bawa-Garba rocked medical circles after she was stripped of her medical licence following the death of a six-year-old boy with Down’s Syndrome.

The junior paediatrician was convicted of manslaughter by gross negligence and given a two-year suspended sentence for mistakes which led to Jack Adcock’s “needless death” in 2011.

But the decision has sparked anger from the medical community, with many raising concerns the High Court case failed to look at medical realities, including exceptional pressures faced by NHS staff and system-wide failings.

Here’s a timeline of the key events surrounding Jack’s death and Bawa-Garba‘s conviction:

18 February 2011

Jack is admitted to the Children’s Assessment Unit (CAU) at Leicester Royal Infirmary following a referral from his GP.

He has Down’s Syndrome, a known heart condition and has been suffering from diarrhoea, vomiting and difficulty breathing.

He is treated by Bawa-Garba, a specialist registrar in year six of her postgraduate training (ST6).

The trainee had recently returned from maternity leave and was solely in charge of the emergency department and acute Children’s Assessment Unit that day as there was no senior consultant available.

There was also an IT failure which led to delays in obtaining test results.

Bawa-Garba did make mistakes, including failing to ask a consultant to review Jack’s condition during the afternoon handover meeting and confusing him with another patient causing her to briefly put a stop to CPR – though this was not deemed to have contributed to his death.

She also failed to specify that the Enalapril medicine Jack took for his heart condition should be discontinued, and his mother gave him his evening dose at 7pm.

At 8pm, Jack “crashed” and Bawa-Garba responded.

At 9.20pm, Jack died of a cardiac arrest as a result of sepsis.

2 November 2015

Nurse Isabel Amaro, 47, of Manchester, is given a two-year suspended jail sentence for manslaughter on the grounds of gross negligence.

Prosecutor Andrew Thomas QC said her record-keeping was “woefully incomplete” and failed to monitor Jack’s vital signs.

He said: “The prosecution say that these were major failings which contributed significantly to the overall deficiencies in Jack’s care.

“If nurse Amaro had brought any of these to the attention of her senior nursing and medical colleagues, this should have led to urgent reassessment and initiation of further treatment to improve Jack’s condition.

“It was a needless death.”

She has since been struck off the register and is no longer able to work as a nurse or a midwife in the UK.

4 November 2015

At Nottingham Crown Court, Bawa-Garba is convicted of manslaughter on the grounds of gross negligence.

Mr Thomas said she has “failed to discharge her duty” as the responsible doctor.

“In short, she neglected her duty to care for Jack,” he said.

“It was not just a momentary lapse. The prosecution say that Jack’s care was neglected over a protracted period of time: her failings were compounded by a failure to go back and reassess Jack despite clear indications that his underlying condition was continuing.

“These were not just simple breaches of duty, but really serious breaches amounting to gross negligence.”

14 December 2015

Bawa-Garba is handed a two-year suspended sentence.

8 December 2016

Bawa-Garba’s appeal against her sentence is denied at the Court of Appeal.

13 June 2017

Bawa-Garba is suspended from working for 12 months by the Medical Practitioners Tribunal Service (MPTS). It rejects an application from the General Medical Council to strike her off the register, saying: “In the circumstances of this case, balancing the mitigating and aggravating factors, the tribunal concluded that erasure would be disproportionate.”

8 December 2017

The GMC appeals the MPTS ruling at the High Court. It argues it was “wrong” to allow Bawa-Garba to continue to practice medicine.

Jeremy Hunt

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Wouldn’t be appropriate for me as Govt Minister to criticise a court ruling, but deeply concerned about possibly unintended implications here for learning & reflective practice in e-journals. Am also totally perplexed that GMC acted as they did: patient safety must be paramount https://twitter.com/shaunlintern/status ... 6854221825
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25 January 2018

Bawa-Garba is struck off the medical register after a successful appeal by the GMC. Lord Justice Ouseley said: “The Tribunal did not respect the verdict of the jury as it should have. In fact, it reached its own and less severe view of the degree of Dr Bawa-Garba’s personal culpability.”

But Health Secretary Jeremy Hunt warns he is “deeply concerned” about the implications of the decision.

The medical community voice fears surrounding the impact of a “blame culture” in the NHS. Thousands of doctors sign a letter warning there will be wide-ranging consequences from the ruling which they say will make doctors working in the overstretched NHS more risk-averse and less likely to admit mistakes.

26 January 2018

Medics raise over £200,000 to fund an independent legal team to review Bawa-Garba’s case and potentially challenge the original ruling of causing manslaughter by gross negligence.

“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,” the medics in charge of the fundraising page wrote.

“It seems clear to us that even the most competent junior doctor would struggle to keep children safe under such conditions.”
Firstly lets go through some of the problems raised

1. The amount of duties she was saddled with.

Its said that she was doing the work of several doctors. Given she was somehow expected to run two units, ie Emergency and the Child Assessment unit, it seems quite plausible to me. In adult medicine there is emergency and medical admissions unit / acute assessment unit or whatever you want to call it. They are separate units and each are ridiculously busy, at least in my state. Its not inconceivable to me that these are ridiculously busy as well given what I hear from UK colleagues.

2. She didn't get the consultant to see the patient

This to me is disputable if this is a problem. The consultant sees everyone on a ward round, or in some cases patients who the junior staff are worried about. From other sources than the Independence, she was allegedly not worried at that time she spoke to the consultant because the child was supposedly better.

Again this is hard to prove in my mind whether this was negligence. Its quite possible the child was looking better and deteriorated suddenly or in the 1.5 hours since she spoke to the consultant (spoke at 6.30, child crashed at 8.00).

3. Doing resuscitation she got confused with another child who had a "do not resuscitation order," although this was corrected within 30 seconds to two minutes when another doctor realised it wasn't.

This could be a reflection of her or on the system with so many patients that she got confused. However ultimately the court found that this did not contribute to the death of the child as he was too far gone at that point. Of course if the child wasn't too far gone, it could have been fatal to lose that time not doing CPR. However that wasn't the case here.

4. The delay in getting antibiotics to the child
http://www.pulsetoday.co.uk/your-practi ... 44.article

Basically x-ray available at 12.30. She was unaware of it being available until 3pm. A lost of 2.5 hours. Antibiotics were prescribed but did not get administered until 1 hour later for a delay of 3.5 hours. Its questionable whether the last hour is her fault as doctors don't exactly stand over nurses waiting for them to administer antibiotics. I also don't think the initial delay is her fault either since she was missing a junior doctor who helps chase up these tests.

This delay could potentially cost the child his life since he ultimately had pneumonia which became sepsis (as the bacteria causing his chest infection spread to his blood).


5. the administration of enalapril

Now this would have definitely worsened the child's condition. Basically enalapril was given for his cardiac condition and it lowers blood pressure When a child becomes septic one of the features is a drop in blood pressure. Not a good combination when its given with a drug which lowers BP. Low blood pressure means less perfusion to vital organs, and if severe enough, you go into cardiac arrest.

Was it her fault that it was still given? Perhaps but this seems like a system fault (which the hospital has since corrected). Remember, she didn't prescribe it (which was the right decision), but she didn't tell the mother not to give it or made that known, so it was still given.

In the hospitals I worked in, all medications are recorded and administered from the hospital stores even if the patient has the drug with them when they present to hospital. The patient's own drugs are locked away until discharge. In the event the patient has some rare drug which the hospital may not necessarily have on hand, it can be given from the patient's own store, but the nurses must observe it being taken and record it being given so all staff know what has been administered. The way it worked in this UK hospital seems a bit different and sadly led to this mistake.

Consider how this would have been handled in a Western Australia hospital. If the doctor decide not to give enalapril for now, they could either

a) not write it on the medication chart, and the patient's own supply would be locked away, or

b) write it on the chart but indicate it would be withheld for a certain length of time or withheld pending a review. In the medical notes, the doctor would ideally write with hold enalapril, but if they forget to record all their thoughts, as long its withheld on the med chart, administration by the parents would be unlikely.

Apparently in this UK hospital, not writing it on the chart is not good enough, one has to actually state in the plan as well to prevent the parents giving the usual medication.

I think this system has problems.



********************************************************************************************************************************************
Based on these articles (and I concede I don't have all the information), I am going to say the only thing she did that was blatantly wrong was stopping the resus because she mistook the patient for another one who had a do not resuscitate order. However this did not lead to the death of the child, so she can certainly be disciplined over it, but its unfair to attribute the cause of death to her via manslaughter. Keep in mind she was working under very trying conditions to say the least.

My feeling is that we have a need to identify one cause, or maybe someone who is at fault, rather than the system which is a complex interaction between numerous factors.
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Re: Does this doctor deserve to be guilty of manslaughter

Post by B5B7 » 2018-01-31 11:14am

There was a manslaughter - by the Conservative Party.
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Re: Does this doctor deserve to be guilty of manslaughter

Post by Zixinus » 2018-01-31 11:55am

A question: was there any protest logged that she was severely overworked? That she was forced to work in a way that was severely against guidelines and regulations?
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Re: Does this doctor deserve to be guilty of manslaughter

Post by TheFeniX » 2018-01-31 12:52pm

Zixinus wrote:
2018-01-31 11:55am
A question: was there any protest logged that she was severely overworked? That she was forced to work in a way that was severely against guidelines and regulations?
I recall when Congress was trying to enforce limits on the amount of hours/work that can be dumped on residents and interns, the response from the... AMA I think, or some medical board was "mind your own business, we're doctors. Don't tell us how to do things." People were dieing needlessly and men/women with PHDs couldn't see reality.

I mean "The trainee had recently returned from maternity leave and was solely in charge of the emergency department and acute Children’s Assessment Unit that day as there was no senior consultant available. " kind of speaks for itself. Just back from maternity leave and put in charge of running two departments alone?

And someone died and they cover their ass by throwing one woman (and a nurse I think) under the bus. The system works.

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Re: Does this doctor deserve to be guilty of manslaughter

Post by Zixinus » 2018-01-31 05:27pm

I was just wondering whether there are rules that stuff like this does not happen.

But that kind of attitude with doctors is just typical.
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Re: Does this doctor deserve to be guilty of manslaughter

Post by mr friendly guy » 2018-01-31 06:37pm

Zixinus wrote:
2018-01-31 11:55am
A question: was there any protest logged that she was severely overworked? That she was forced to work in a way that was severely against guidelines and regulations?
Guidelines most probably cover hours worked. She wasn't necessarily working more hours, but just doing the job of several people at the same time.
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Re: Does this doctor deserve to be guilty of manslaughter

Post by Zaune » 2018-02-03 05:16am

Zixinus wrote:
2018-01-31 11:55am
A question: was there any protest logged that she was severely overworked? That she was forced to work in a way that was severely against guidelines and regulations?
Quite possibly, but I doubt it would have made much difference. The hospital was probably struggling to pay the staff they already had, never mind bring staffing levels up to within shouting distance of adequate.
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Re: Does this doctor deserve to be guilty of manslaughter

Post by Thanas » 2018-02-03 07:34am

She is guilty, but mitigating factors are so strong that she most likely does not deserve any punishment.
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Re: Does this doctor deserve to be guilty of manslaughter

Post by Alyrium Denryle » 2018-02-03 04:07pm

Thanas wrote:
2018-02-03 07:34am
She is guilty, but mitigating factors are so strong that she most likely does not deserve any punishment.
Yeah, I kinda look at it like:

"She's technically guilty because she made mistakes and someone died. However, anyone under those circumstances could have made the same or similar mistakes, and as a result we can't really hold her culpable. The situation was next to impossible. So what we're going to do instead is change hospital policies and procedures so this doesn't happen again."
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Re: Does this doctor deserve to be guilty of manslaughter

Post by Elheru Aran » 2018-02-03 04:11pm

Alyrium Denryle wrote:
2018-02-03 04:07pm
Thanas wrote:
2018-02-03 07:34am
She is guilty, but mitigating factors are so strong that she most likely does not deserve any punishment.
Yeah, I kinda look at it like:

"She's technically guilty because she made mistakes and someone died. However, anyone under those circumstances could have made the same or similar mistakes, and as a result we can't really hold her culpable. The situation was next to impossible. So what we're going to do instead is change hospital policies and procedures so this doesn't happen again."
If the healthcare manpower shortage is as bad in the UK as it is here though... good luck with that...
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Re: Does this doctor deserve to be guilty of manslaughter

Post by Alyrium Denryle » 2018-02-03 06:55pm

Elheru Aran wrote:
2018-02-03 04:11pm
Alyrium Denryle wrote:
2018-02-03 04:07pm
Thanas wrote:
2018-02-03 07:34am
She is guilty, but mitigating factors are so strong that she most likely does not deserve any punishment.
Yeah, I kinda look at it like:

"She's technically guilty because she made mistakes and someone died. However, anyone under those circumstances could have made the same or similar mistakes, and as a result we can't really hold her culpable. The situation was next to impossible. So what we're going to do instead is change hospital policies and procedures so this doesn't happen again."
If the healthcare manpower shortage is as bad in the UK as it is here though... good luck with that...
Well the Tory Scum have been slowly strangling the NHS so....
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Re: Does this doctor deserve to be guilty of manslaughter

Post by mr friendly guy » 2018-02-03 06:56pm

Some of the systems problems could be fixed. For example the accidental administration of the drug enalapril by the child's parents. This would unlikely happen in a Western Australia hospital as I explained in the OP. This could have been avoided if the hospital adopt similar procedures, and according to one of the sources, the hospital has since changed its procedure to prevent this.
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Re: Does this doctor deserve to be guilty of manslaughter

Post by LadyTevar » 2018-02-03 10:13pm

"The trainee had recently returned from maternity leave and was solely in charge of the emergency department and acute Children’s Assessment Unit that day as there was no senior consultant available. "
The trainee. THE TRAINEE.
She was not even a full employee and they thought it was ok to put her in charge of TWO units without supervision?!?! She's a TRAINEE, she was just back from pro-longed maternity leave, she probably had "baby-brain" from lack of sleep, and they expected her to work without a senior or junior consultant to back her up?!? No wonder she for flustered and made mistakes!
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Re: Does this doctor deserve to be guilty of manslaughter

Post by mr friendly guy » 2018-02-03 11:57pm

LadyTevar wrote:
2018-02-03 10:13pm
"The trainee had recently returned from maternity leave and was solely in charge of the emergency department and acute Children’s Assessment Unit that day as there was no senior consultant available. "
The trainee. THE TRAINEE.
She was not even a full employee and they thought it was ok to put her in charge of TWO units without supervision?!?! She's a TRAINEE, she was just back from pro-longed maternity leave, she probably had "baby-brain" from lack of sleep, and they expected her to work without a senior or junior consultant to back her up?!? No wonder she for flustered and made mistakes!
Trainee most probably means different things to doctors than what the everyday usage of the word means.

She was a registrar so she was qualified. What the trainee is referring to, is that she is being trained to become a specialist but hasn't reached it yet. As a medical registrar I was confident of handling most problems I would have encountered given a hospital's resources. She appeared to assigned too many tasks.
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Re: Does this doctor deserve to be guilty of manslaughter

Post by Titan Uranus » 2018-02-07 04:29pm

Well, the entire NHS has massive systemic problems as I understand it, especially in regards to training. If I remember correctly 100 hour weeks are the average for junior doctors, which is why fully half of them leave the country for the rest of the Anglosphere. But all of the current senior doctors came through that system and so see it as a hardening experience, a way of weeding out the uncommitted, unfortunate but necessary, and various other mentally comfortable alternatives to changing the system.

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Re: Does this doctor deserve to be guilty of manslaughter

Post by Elheru Aran » 2018-02-08 10:41am

100 hour weeks. That's 20 hours every 5 days, assuming they get 2 days off a week, or if they worked every day, 14+ hours.

That, I'm preeeeeeeetty sure, wouldn't be legal in the US. Medical staff do pull some long shifts, but usually it's something like 4 days of 12-hour shifts alternated with 3 days off or whatever.

I can understand the whole 'running the gauntlet' notion... but with levels of overwork like that, you're just begging for more incidents like the OP.
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Re: Does this doctor deserve to be guilty of manslaughter

Post by Simon_Jester » 2018-02-08 02:37pm

It may not be legal in the US but it's very far from unheard of.
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Re: Does this doctor deserve to be guilty of manslaughter

Post by Elheru Aran » 2018-02-08 05:27pm

I reiterate that this is a bad thing. Overworked medical professionals=Mistakes Happen.

Now there's no real easy fix to the problem, because the main cause is manpower shortages due to the ruinious cost of medical education. Becoming a RN is bad enough, MD means hundred-thousand-dollar debts. When you couple that with the fact they're overworked, and everybody knows, then that makes it an even less attractive option. I have an acquaintance who was looking at medical school. He ended up becoming a vet instead, because it was cheaper and the patients get along with you much better.

So in an ideal world the solution is twofold: re-assess and reinforce labor laws, particularly in regard to hours worked, and make medical education at all levels more financially accessible and offer incentives such as tax breaks, scholarships, grants, and whatnot to draw in more students.
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