Dr Hadiza Bawa-Garba Case Study
Definitions
Blame Culture: Blaming the mistake on the individual - this is often considered as an unfair perspective.
Just Culture: Blaming the mistake on the system and how it is set up - this is now a strongly encouraged stance.
Do Not Attempt Resuscitation (DNAR): A medical order that indicates a person should not receive cardiopulmonary resuscitation if their heart stops beating.
Suspended Sentence: A sentence where the offender doesn’t have to go to prison provided they commit no further offences and comply with any requirements imposed.
Reflections: These are personal written notes about an event to help a doctor reflect and improve their medical practice.
DAYTIX: This is a type of incident reporting software used in many hospitals. A doctor can fill out the form and the incidents will then be flagged, analysed, and (if systematic) resolved.
Timeline of the Case Study
This is a case study which highlights just culture (argued for by the Medical Practitioner’s Tribunal Service), against blame culture (argued for by the GMC). It was a very shocking case as many doctors could sympathise with Dr Bawa-Garba and her actions due to the staffing pressures, yet she was tried for manslaughter by gross negligence. The event in question occurred on the 18th February 2011:
10:30am: Jack Adcock was admitted to the Children’s Assessment Unit at the Leister Royal Infirmary following a GP referral. He was born with a heart condition and Down syndrome and was struggling to breathe. Dr Bawa-Garba gave him fluids and ordered a blood test and x-ray.
12:30pm: The x-ray came back showing evidence of a chest infection. She wasn’t informed about this and didn’t see it until 3:00pm.
3:00pm: After seeing the x-ray, she immediately prescribed him antibiotics.
4:15pm: Although massively delayed (as computer systems were down), the blood test results were returned.
4:30pm: The consultant arrived on the ward and, during the handover, Dr Bawa-Garba didn’t ask the consultant to review Jack.
7:00pm: Dr Bawa-Garba forgot to record the cessation of Jacks heart medication in his patient notes and so his mother gave him a dose.
8:00pm: Jack went into cardiac arrest. She mistook him for a patient with a DNAR and temporarily stopped the resuscitation. This decision was corrected within 2 minutes.
9:20pm: Jack died of pneumonia.
4th November 2015: She is convicted of manslaughter by gross negligence by the Nottingham Crown Court and is given a 24 month suspended sentence.
Over the next years, the Medical Practitioners Tribunal Service rejected the GMC’s application to strike her off the medical register and reduced her suspended sentence to 12 months. The GMC takes the MTPS to court and wins the case; Dr Bawa-Garba is struck of the Medical Register. There were concerns that her reflections were used in court which lead to a public outcry from doctors and reviews into how the GMC treats black and minority ethnic doctors differently. The Professional Standards Authority (the regulator of the GMC) accuses the GMC for striking Dr Bawa-Garba off the medical register “without merit” and she appeals to the High Court’s decision. The appeal is successful and judges agree with the MPTS to suspend rather than erase her from the medical register. She returned to work in 2019 as a lower grade and under close supervision for the first year.
The Doctors Association UK began the “Learn Not Blame” campaign which argued that we should look at how the system needs correcting (just culture) rather than the individual (blame culture). They argued that striking Dr Bawa-Garba off the register won’t bring Jack back and the UK is better off with another practicing doctor.
Who’s To Blame?
Dr Bawa Garba
She failed to see the x-ray came in at 12:30pm and, therefore, delayed jack’s antibiotics by two and a half hours.
She temporarily stopped Jack’s resuscitation by confusing him for another patient.
She failed to record the cessation of Jack’s heart medication.
Leicester Royal Infirmary
She was returning after maternity leave and didn’t have the appropriate support and training on re-entry.
There were very few senior nurses and no one informed her jack was deteriorating.
The computer systems were down so the blood tests were delayed.
The consultant didn’t start working until 4:30pm.
She was covering the role of two doctors on her shift.
Furthermore, a later investigation found that the resuscitation had no cause to Jack’s eventual death. Paired with her exemplary record, it is clear the institution failed Jack and Dr Bawa Garba should remain a practising doctor.