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'Pharmacy waited years. Why make changes so quickly after Bawa-Garba?'

"Much of the review is applicable to prosecutions for dispensing errors"

The review Jeremy Hunt commissioned into the case of Dr Hadiza Bawa-Garba has implications for the whole of healthcare – and raised questions from David Reissner

Professor Sir Norman Williams has just sent the secretary of state for health and social care, Jeremy Hunt, his review of gross negligence manslaughter in healthcare, and the review makes a number of points that are important to all healthcare professionals.

His covering letter to Mr Hunt stresses the “profound effect” that a patient death, caused by a medical error, has on healthcare professionals.

Professor Williams also notes that the effect of healthcare professionals can be “compounded by an investigation which may seek to blame, rather than to understand the factors that have led to the tragedy, so that lessons can be learned to prevent future incidents”.

“At all stages of any investigation the stress levels for those involved, including the professionals, can be overwhelming,” he adds. “For healthcare professionals, a sense of fear pervades and patient safety is jeopardised as they become cautious about being open and transparent, impeding the opportunity for lessons to be learned.”

The review makes the following points:

  • Evidence suggested that a disproportionate number of black, Asian and minority ethnic professionals are involved in criminal and regulatory investigations. Professor Williams recommended looking into this, and suggested that fitness-to-practise panel members should receive equality and diversity training.
  • Although a key function of regulators like the General Pharmaceutical Council is to maintain public confidence in the profession, there is little understanding about the type of behaviours and failings that might lead to the public losing confidence in the profession and which therefore constitute grounds for regulatory action. The review panel called for a review on how public confidence is assessed, and for guidance to support consistent decision making.
  • There was concern that healthcare professionals who did not have legal representation in fitness-to-practise proceedings were more likely to be struck off – a point I also made in my recent blog.
  • The panel recommended that the Professional Standards Authority should look into the inconsistency of decisions by different healthcare regulators in relation to similar incidents.

Much of what the review says about manslaughter prosecutions is equally applicable to prosecutions for dispensing errors under section 64 of the Medicines Act 1968. This leaves me wondering why it took 10 years for pharmacists to get partial decriminalisation, but just four months after an outcry from the medical profession over Dr Bawa-Garba’s case, the secretary of state has accepted Professor Williams’ recommendations.

David Reissner is a consultant at law firm Charles Russell Speechlys


Margaret O'doherty, Community pharmacist

A feature of the Bawa-Garba case was senior doctors willing to admit they had made similar errors missing cases of sepsis. Because dispensing errors are a criminal act, pharmacists couldn’t admit making one and so their was much less outcry.


Leon The Apothecary, Student

Inconsistency is very worrying. Our entire legal system is based on setting precedent and treating similar cases the same to maintain fairness. If the PSA is not doing this in their decisionmaking, are they being fair?

Joy Wingfield, Manager

Need you ask, David? 'Twas ever thus!


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