A doctor’s mistake, and the potential consequences for healthcare in Britain

The recent case of Hadiza Bawa-Garba, a British hospital doctor convicted of manslaughter and subsequently barred for life from practising after causing the death of a child through her errors and omissions brings to mind one fundamental factor: Jack Adcock’s death was, at least in part, the result of failures in communications.

Matthew Syed in The Times painstakingly relates the circumstances of the death of the 6-year-old back in 2011. Before discussing the case itself, he talks about the aftermath of three aircraft accidents that happened in the United States because pilots were so busy attending to a critical problem that they ignored other factors that led to the planes crashing:

When cognitive load is high, decision-making can be compromised. “Situational awareness” is the term used to describe the capacity of a crew to keep track of the multiple factors that together impinge on safety, the various pieces of the jigsaw that collectively provide perspective. When multiple demands are placed on a team, situational awareness can be undermined; pieces of the jigsaw (even seemingly obvious ones like the alarm) are missed.

This is why the aviation industry did not respond to these crashes and near-misses by blaming the professionals involved, but by learning key lessons. It led to a reformed approach to teamwork, the introduction of new checklists and a range of other changes, including strategic checks and balances. These accidents were tragic, but they also acted as a pivot to make air travel safer.

He goes on to describe the circumstances of Jack’s death, and in particular the demands on Dr Baba-Garwa’s attention:

– The consultant and another senior doctor responsible for the paediatric ward were absent

– She was required to work for 13 hours without a break

– She was responsible for six wards over four floors

– She carried out a series of life-saving interventions over the period, continually moving from patient to patient

– The IT system was down for four hours, so one of the doctors she supervised had to phone for blood results, making her unavailable

Nonetheless, a jury in 2015 found that her mistakes were sufficiently bad that they found her guilty of manslaughter. She was given a two-year suspended jail sentence. Earlier this week the Appeal Court upheld the General Medical Council’s application to have her name erased from the medical register, after an earlier tribunal ruled that she should be allowed to return to practice after a one-year re-training period.

It’s a complicated case, and if you’re sufficiently interested, you might want to read the Appeal Court judgement. Also read Matthew Syed’s article, which is both a mitigation and a warning about the dangers of a blame culture in the National Health Service.

I share his concerns. Medical negligence cases in the UK and in the United States are normally dealt with through civil lawsuits. Criminal prosecutions are very rare, and usually deal with deliberate acts – such as those of the mass murderer Dr Harold Shipman – as opposed to errors and omissions. Dr Bawa-Garwa was by testimony of her peers and supervisors an extremely competent doctor. Her career was ruined by one set of failures made in a short-staffed hospital amid a firestorm of competing claims to her attention. She continued to practice to a high standard without incident during the four subsequent years it took for a tribunal to suspend her.

I wonder whether public interest was served by this valuable resource being cast into the outer darkness.

Two other questions occur to me. First, if Jack hadn’t died, but the errors committed had been identical, would Dr Bawa-Garwa have been suspended? Second, if the doctor had been a male registrar with outstanding communication skills (think of Dr Ross, George Clooney’s character in ER), who apologised to the bereaved parents, would the same sanctions have been applied to him? In other words, did the fact that the offending doctor was female, black and a Muslim make it more likely that the parents would seek “justice” for their son?

I know that I’m entering dangerous territory here. I’m not accusing the parents of racism or Islamophobia. How could I? I don’t know them. I’m merely questioning whether an unconscious bias might have been at play in this case. How many of us, in our hearts, would not agree that we would be less nervous, for example (and this was not an issue in the case of Dr Bawa-Garba), if we were being treated by a doctor whose command of English was not as good as ours? No matter that the doctor concerned might be the best in the world, we might still be nervous. It’s the “not like me” factor at play.

Which leads me to a story about communications.

A few years ago, I was doing a workshop on the subject for a group of doctors, nurses and administrators in a highly-regarded Saudi hospital. One of the delegates, a consultant surgeon, spoke about an operation that went bad. A young girl was paralysed as a result.

After the operation, the surgeon asked his team to meet the parents and discuss the outcome, and the reasons for the failure of the operation, one of which was a critical error by the team.

In the meeting he explained the circumstances to the devastated parents without hiding any aspect of the operation. He told them how distraught they were at the outcome. He then asked the parents to speak about their daughter. The father stood up and spoke for half an hour. He was understandably emotional. He spoke about his daughter, her schooling, her hobbies and her aspirations in life, now severely circumscribed. The surgeon and his team didn’t interrupt them. They just listened.

When the father finally sat down, the surgeon offered his sincere apologies and sympathy for the child. He asked the father whether there was anything else they could do for the family. No, replied the father. He said that he was grateful to be listened to, that the fate of his daughter was the will of God, and that he would not be taking any action against the hospital.

Leaving aside the fatalism that is more common in Muslim countries – acceptance of the will of God – would the family’s attitude have been different if the meeting had not taken place? Almost certainly. The bereaved wanted more than anything else to be listened to. The surgeon, by his action, met that need. Not only did he listen, but he humanised his team in the perception of the parents. These were human beings, fallible like all of us, who made a mistake in an attempt to improve the daughter’s life.

I couldn’t teach that guy anything about communications. In fact I suggested that he should run the workshop instead of me.

Perhaps if Dr Bawa-Garwa had been part of that team, she would have been able to diffuse the understandable anger of Jack’s parents, and, in the process, overcome any unconscious bias on their part. But she would most likely argue that she didn’t have the time. Not even the time to express condolences to the family. Was that the mistake that had the greatest impact on her subsequent career?

Which brings me to another thought, again on communications. I’ve just finished an impressive and deeply moving book by a palliative care consultant, Katherine Mannix. In With the End in Mind, Dying, Death and Wisdom in an Age of Denial, she presents a collection of cases from her experience.

Her clear message is that in an age when we’re programmed to ignore or even deny the inevitability of death, effective communications can overcome the fear of death, not only on the part of the dying themselves, but also among their loved ones. Dr Mannix is not only an expert in palliative care – treating the symptoms, particularly pain, that can cause an agonising end. She is also a practitioner of Cognitive Behaviour Therapy (CBT). She uses her skills to help overcome the destructive loops of reasoning that make it more difficult for patients and loved one to accept the inevitable. The elimination of blame and recrimination, for example. The focus on living to the end rather than dying. Attention to the needs of the patient beyond desperate medical intervention that might prolong life, but that bring no quality in the living.

What’s abundantly clear from the book is that she and her colleagues work wonders, not only because of her clinical expertise, but through her superb communication skills.

Again, would she have been able to practice those skills so effectively if she had been in Dr Bawa-Garwa’s shoes on that fateful day? Perhaps not, but isn’t that an indictment of a system that allows a doctor just back from maternity leave to take on the responsibilities normally assigned to a consultant and a fully staffed team of doctors, and to have to work with a team of nurses – mainly from agencies – who have no experience of the paediatric ward in which they were placed as temporary staff? Not only that, but of a system that fails to equip all its clinical staff with the necessary skills to communicate effectively with patients, staff and loved ones?

To return to Matthew Syed’s article, there have been hundreds of comments by doctors arguing that standards of care cannot easily be improved if clinical staff are afraid that each mistake they make – and there are many in a huge organisation such as the NHS – will result in the end of their careers. Here’s one such comment:

Sir, Throughout my career as a consultant in intensive care I was regularly forced to make compromises in the care my team delivered (letters, Feb 9). There is no doubt that patients died as a result. If there are no beds available in intensive care, or too few doctors and nurses, then patients are refused admission, discharged too early or transferred elsewhere while potentially life-saving elective procedures are cancelled. Was I to blame for avoidable deaths or should I have downed tools in protest at being asked to do a job without being given the resources to make it possible?

You could argue that he was lucky, and Dr Bawa-Garwa wasn’t.

It seems blindingly obvious that in such situations, the emphasis should be on learning first, and consequences for those who make the errors second. Only in extreme cases should sanctions end careers. I’m not medically qualified, so I don’t know how Dr Bawa-Garwa’s actions rate on any kind of scale of negligence. Nor, I suspect, did the lay jurors who convicted her of manslaughter.

Any system that inhibits the honest and open investigation of errors and omissions with a view to improving clinical practice must be looked at with an extremely sceptical eye. The potentially devastating consequences of the case to the NHS – in terms of doctors covering their backsides by ordering tests to confirm their clinical judgements, difficulties in recruiting doctors in this branch of medicine because of the personal risk involved, and a time-consuming increase in paperwork – are spelt out in another Times article by Jenni Russell.

Finally, one more thought. The doctor’s career is over, unless further legal appeals succeed. Are there parallels?

Let’s say I’m driving down a motorway on a rainy night, trying to get home to my family, and I lose patience with a line of slow moving cars on the middle lane, and a couple of cars blocking the outside lane. I decide to overtake on the inside, and I crash into a truck that I didn’t see because of the poor visibility. I cause a pile-up, and people are killed and injured. I’m prosecuted, and convicted for dangerous driving. I go to jail for a couple of years, but eventually I get my licence back.

Is it fair that Dr Bawa-Garwa should never be allowed to resume her career after one fatal error, whereas I would be able to get my driver’s licence back? We both may have made one mistake that we will regret for the rest of our lives, but the doctor is unable to make amends by saving lives in the future.

Just a thought.

Many thanks to my wife, whose medical knowledge and interest in the case have been a great help to me in writing this piece.