“Leicester doctor convicted over death of six-year-old boy.”
That was the headline splashed all over the newspapers back in 2014, outcry that concluded the four-week trial of Dr Hadiza Bawa-Garba. Following a series of errors, Jack Adcock suffered what was described as “truly, exceptionally bad treatment” at the hands of Dr Bawa-Garba.
Instinctively I was reminded of the Harold Shipman case and got that gut-wrenching feeling of: “Not again – just how are these supposedly qualified professionals permitted to practice and no one suspects a thing? It’s just not possible.”
Only when you start to uncover the details of the case do you realise there’s more to it – much more. Jack, a six-year-old with Down's syndrome and suffering from a pre-existing heart condition, died of sepsis in 2011 at Leicester Royal Infirmary. There was understandable uproar at the time and talk of systemic failings of not only Dr Bawa-Garba, but two other nurses involved in Jack’s care.
Typically and inherently woven into the DNA of human nature, the need to make individuals accountable for the cause of such a devastating and traumatic incident took hold. Despite there being a number of circumstances surrounding the case, the public, the General Medical Council (GMC) and the judicial system needed to hold someone responsible for this little boy’s death. In December 2015, Dr Bawa-Garba was convicted of manslaughter and served a two-year suspended sentence. In June 2017, the Medical Practitioners Tribunal Service said she should be suspended for 12 months, and rejected an appeal for her to be struck off the register. In January 2018, the GMC successfully appealed the decision, to ensure Dr Bawa-Garba was struck off the medical register and prevented from practising in the country again, ever.
While there were clearly some failings from Dr Bawa-Garba, what was fittingly described as a “perfect storm” led to the death of Jack and no one individual could or should have been held accountable. This was not a deliberate and malicious case of intent to harm or even neglect, but systemic failings of an already strained medical team, a weak and dysfunctional infrastructure, poor supervision and lack of clinical management; fundamentally a system with so many cracks it was only a matter of time before it crumbled.
Healthcare professionals, each and every day, make instinctive clinical decisions about patient care, often working under pressure, with little support, relying on years of experience and expertise to kick in when presented with complex patients on complex medication. In spite of these challenges, pharmacy teams deliver an exceptional level of service and support to patients with proportionately low errors in dispensing. From April 16 this year, a pharmacy professional or unregistered member of staff has a defence against a criminal sanction for an inadvertent dispensing error if they meet a set of conditions.
A breakthrough for the profession? The jury’s still out, as it is likely that should a dispensing error occur, the person responsible could still face a court appearance and, even more significantly, be subjected to the onslaught of condemnation and denigration from those not appraised of the full facts. What does that do to a person?
And while Dr Bawa-Garba had her sentence overturned this month in a ground-breaking and emotive appeal, her seven-year fight to regain her credibility as a doctor and clear her name must have fundamentally changed her, forever.
How is it that in many other ‘high profile’ sectors, such as the aviation industry, rigor and process is rife in analysing high impact errors and a thorough and critical path of learning implemented at all levels over many decades? In contrast, the criteria and robustness for review across the healthcare industry is much more generalised – aiming for ‘the highest standards’ is an admirable sentiment, but preventable deaths remain stubbornly high.
Instead of blame, persecution and prosecution, we should promote and foster a culture of sharing of errors across all levels of primary and secondary care. We need to honestly and actively recognise failures in a system and identify development needs, rather than ‘turning a blind eye’ for fear of recrimination. We must collectively move away from the reluctance to admit, document or examine circumstances where errors occur or recognise where pressure points are ultimately putting patients at risk.
Perhaps the case of Dr Bawa-Garba is the turning point for organisations, industries and governments to focus more efforts on learning from failings, rather than criminalising what is fundamentally a systemic breakdown. This is a breakdown that should never – unless there has been a deliberate and considered intent to cause a human being harm – result in an individual being criminally liable.
Of course this is a moral juxtaposition and I’m sure Jack’s parents would have a very different view. In these types of scenarios there are no winners, least of all for the people involved – for whom their lives are inextricably changed forever.
Jeremy Meader is managing director of pharmacy support group Numark