An Atypical Friday
Though far from usual, Friday, February 18, 2011, was not a typically unusual day in a British hospital. Dr Bawa-Garba had just returned from a 13-month maternity break. She was the on-call pediatric registrar—the second in command for the care of sick children at Leicester Royal Infirmary. As a "registrar," she was both a master and an apprentice—a juxtaposition of roles necessary for the survival of acute care in the NHS. Because there aren't enough commanders, or consultants (attendings), in the NHS, trainees must fill their shoes, or else the NHS will collapse.
The captain of the ship and Dr Bawa-Garba's supervisor, Dr O'Riordan, was not in the hospital but teaching in a nearby city. As horrendous as "attending not being in the hospital" sounds, this, too, is not atypical in the NHS. Dr Bawa-Garba's colleagues (ie, other registrars) were also away on educational leave. Normally, a registrar each is assigned to cover the wards, the emergency department, and the Children's Assessment Unit (CAU). On that day, Dr Bawa-Garba covered all three. She was new to the hospital but with no formal induction (ie, no explanation where things are and how stuff gets done in the hospital). She was expected to get along with the call and find her way around the hospital.
As anyone who has been a junior doctor in NHS can attest, the normal—the optimal—is unusual, and what is usual in British hospitals is remitting and relapsing chronic understaffing. The abnormal eventually becomes normal. You work through the anarchy. The anarchy is both the old normal and the new normal.
Though the analogy isn't exact, a registrar is the equivalent of a senior resident in the United States. Registrars are the principle decision-makers in hospitals—that is, they function as both a senior resident and an attending. I recall during my internship the relief I felt when a registrar came to see the patient. They exuded confidence and competence. Often, the registrar was more useful than the consultant.
Over the years, the distribution of responsibilities on trainee physicians has changed, and the registrar now assumes more of the work traditionally done by senior house officers (postgraduate years 2-5), who, in turn, have become interns. The house officers (interns) have become supernumerary. Formerly, the senior house officer was the busiest person in the hospital; it is now the registrar.
That day, Dr. Bawa-Garba was taking referrals from general practitioners and emergency physicians, surgeons and midwives, and responding to emergencies on the wards, along with the usual multiple inquiries which in hindsight turn out to be clinically irrelevant. She was also phoning pathology for results because the hospital IT system was down, and the results, let alone the abnormal results, weren’t automatically being populated in the electronic health record. She was performing skilled procedures like lumbar punctures because no one else in her team, which comprised an intern and a junior trainee, could. Triple booked, Dr. Bawa-Garba was making critical decisions and also doing the scut work, and teaching and supervising her team. To borrow an aviation analogy, she was flying the plane and serving food to the passengers.
A boy in shock
At 10:30 am she assessed Jack Adcock, a six-year old boy with Downs syndrome who was referred by the GP for nausea, vomiting and diarrhea. Jack was normally a lively chap, who had a past surgical history of a repaired atrioventricular canal defect, and was on enalapril. He was apyrexial, but looked dehydrated and sick. Dr. Bawa-Garba made a presumptive diagnosis of fluid depletion from gastroenteritis and administered an intravenous fluid bolus immediately, and started him on maintenance fluids. She requested a chest radiograph, sent off bloods for blood count, renal function and inflammatory markers, and drew blood gases, which showed that Jack was acidotic with a pH of 7 and a lactate of 11.
The metabolic profile confirmed her working diagnosis of shock from gastroenteritis but, judging from the tests she ordered, pneumonia was in her differential. After the initial fluid bolus, Jack seemed to be trending in the right direction, metabolically. The repeat blood gas showed he was less acidotic, with a pH of 7.24, heading towards a normal pH of 7.4.
At 3 pm, she looked at the chest radiograph which showed Jack had pneumonia. She prescribed Jack antibiotics, which were given at 4 pm. The radiograph had been exposed at 12:30 pm. Radiographs aren’t routinely interpreted by radiologists – there aren’t enough radiologists in the NHS. Jack was moved from the CAU to the ward. At 4:30 pm, she met Dr. O’ Riordan, her boss, in the hospital corridor. She showed him Jack’s blood gas results and explained her plan of action. Her boss did not see Jack.
In the ward, Jack received enalapril. Dr. Bawa-Garba had not prescribed enalapril, and she clearly stated in her plan that enalapril must be stopped – the drug lowers blood pressure and is absolutely contraindicated in shock. Nor was enalapril given by the nursing staff – they stick to the doctor’s orders.
An hour after receiving enalapril, Jack had a cardiac arrest. After vigorous attempts at resuscitation, interrupted for a minute by Dr. Bawa-Garba’s mistaking Jack for another child who was not for resuscitation, Jack was pronounced dead.
Jack died from streptococcal sepsis. His circulatory system put up a fight, and he so bravely maintained his blood pressure that he deceived everyone about the true nature of his critical condition. His body had been fighting the bugs for some time and by the time he was assessed in the CAU it was so knackered that it could not even mount a temperature. There is plenty of ruin in the circulation. And Jack might have prevailed. The fatal dose of enalapril took the sails out of his resistance, and precipitated circulatory collapse.
Reflections of an overworked trainee
When a patient dies a part of the doctor dies. Privately, many doctors express their grief by excessive introspection, reliving the events to ask what could they have done differently – arguably the more conscientious a doctor, the more self-critical. To render the death of a six-year-old otherwise healthy boy as inevitable is to make medicine less humane. This is the nature of a medical error – whether you’re at fault or not you have to learn from it, and by conceding that you may have been wrong, you achieve closure. Clinical medicine is arguably shaped less by science and more by the many errors and the near-misses doctors face personally, or hear about from their colleagues. Clinical medicine is affect heuristic writ large.
After Jack’s death, Dr. Bawa-Garba was distraught and her consultant encouraged her to record her failings in her electronic portfolio. Trainees are encouraged to record their mistakes, predominantly for pedagogy. She could have, if she wanted, written about the system failures of that day. But that would have been making excuses, and you don’t stick around in a field like pediatrics if you’re the sort who points fingers at others.
Though the details of her reflections are not public, she is likely to have been merciless on herself. She likely admonished herself for not thinking about sepsis instantly, for not insisting that the chest radiograph be done immediately, for not reviewing the film sooner, for not starting the antibiotics immediately, and most of all, for not being clear that under no circumstances Jack be given enalapril. It is likely she omitted that she was doing the work of three registrars that day, that she had a long hiatus from clinical medicine, that she was new to the hospital, that her consultant did not help out. In a cruel twist her reflections, instead of purging her of guilt and delivering her from purgatory, would later deliver her to purgatory.
To err is homicide
The trust led an internal inquiry which identified several system issues which contributed to Jack’s death. Medical errors can be caused by system issues and physician factors. The American patient safety movement has taken the high road and placed the blame for medical errors on systems. The Tort system targets both individuals and systems. The truth is that both can contribute – no matter how good a system is, it can’t raise a severely incompetent physician. The opposite is also true, particularly in the NHS – no matter how good a physician, they can be brow beaten by the system.
The British medicolegal system is not as primed with cash as the American system. Large payouts are uncommon. Jackpot justices are rare. Ambulance chasers are unheard of. There are no billboards advertising personal injury lawyers. Perhaps incidental to, or because of, the lack of large financial payouts for medical injuries in Britain, an unusually large number of physicians are prosecuted for manslaughter for patient death from medical error. Restitution of the deceased is, by definition, not possible, so families of the deceased press criminal charges against the physician for justice. The prosecution tries to prove that the physician was “criminally negligent” in erring.
To be fair in cases such as Jack’s, it is not easy going after systems. The system is innominate and faceless. Who do you prosecute – Leicester Royal Infirmary? NHS England? The government? The taxpayer? It is easier going after individuals. It is easier believing that a particular doctor “killed” the child, than a system failed to save the child. Thus, a black, Muslim, female physician wearing a headscarf, who should have been the face of NHS’s glory became the face for all its failings.
The first police inquiries did not find enough grounds for a prosecution. However, the Adcocks persisted – understandably given their circumstances. And it’s important to acknowledge that many people would have done exactly what the Adcocks did – you don’t lose a six-year old child to sepsis and just shrug your shoulders.
The Trial
Dr. Bawa-Garba, and the two nurses who were caring for Jack, were charged with manslaughter. The case against the pediatric trainee was simple – she wasn’t just clueless, but grossly negligent. With the power of hindsight, Jack’s case was dissected to the hilt. Sepsis, the deadly deceiver, became a diagnosis which any half competent pediatrician should casually be able to detect.
Jack’s care was meticulously decomposed. The delay in getting chest x-ray, the delay in reading the x-ray read, the delay in prescribing the antibiotics. Unwittingly, the court was exposing system failures, but Dr. Bawa-Garba was being held responsible for each failed component. It was as if she was all of NHS and all of NHS was her on February 18th.
Expert witnesses opined that had Jack received antibiotics within 30 minutes, rather than 6 hours, his chances of survival would have increased dramatically. There was tremendous certainty in the counterfactual. Diagnostic medicine is a fog of uncertainty until you know what the patient had. Dr. Bawa-Garba was found guilty of manslaughter – the jury returned the verdict 10:2.
Throwing the apprentice under the bus
Guilty of homicide for mistaking normalizing pH after a fluid bolus for hypovolemic rather than septic shock. The difference between jail and exoneration in Britain for a trainee physician is a multiple-choice question about a medical emergency.
The problem with the law isn’t that that the law is an ass, it is that the law is an inconsistent ass. Jack’s blood gases were deemed characteristic of sepsis. If they were so characteristic, why did Dr. O’ Riordan, the peripatetic consultant of the day, and Dr. Bawa-Garba’s supervisor, not instantly diagnose sepsis when he saw the blood gases? It was Friday, 430 pm – the weekend was nigh. Why did he not immediately see Jack, and transfer him to the intensive care unit?
If a trainee, an apprentice, who was doing the work of three registrars, can be found guilty of homicide for not understanding acid-base physiology, what does it say about the competence of her supervisor? How can she be criminally negligent and not he? This is neither scientific nor logical. Dr. O’ Riordan was either incompetent or lazy. Or there’s another explanation – perhaps sepsis in a child is difficult to diagnose, even for a seasoned consultant pediatrician.
Dr. O’ Riordan was not on trial, it was Dr. Bawa-Garba. When asked why he did not see Jack, Dr. O’ Riordan said that Dr. Bawa-Garba had not asked him to, she had not impressed upon him Jack’s clinical urgency. This is deeply disingenuous. Every consultant must recall being a junior doctor – recall that trainees don’t not ask for help because of their pride, but because they’re hesitant to ask for help, and they’re hesitant not because they’re afraid, but because there’s a culture of hesitancy, and that culture of hesitancy is a corollary to a culture in which apprentices are expected to make decisions independently, without which hospital medicine would abruptly halt. The onus is on the consultant to sniff out trouble.
And Dr. O’ Riordan should have sniffed out trouble. He knew she was new to Leicester Royal Infirmary. He knew, or should have known, that she had been away from clinical medicine for over a year, so probably wasn’t at the top of her clinical game. He knew she was working the work of three registrars. Why did the jury not consider these mitigating factors? Why could they not see that an apprentice had been thrown under the bus?
Had Dr. Bawa-Garba prescribed the fatal dose of enalapril, she ought to have been found guilty of manslaughter – that error is egregious. But she did not. And here, too, a failing, a mysterious failing, was internalized by the apprentice. It was deemed her fault for not anticipating that Jack would receive enalapril, even though it was not on his drug chart. She was guilty for not thinking about all the contingencies.
The jury heard how about Jack’s delayed treatment. But they did not hear about the other patients who were receiving care in the same hospital from Dr. Bawa-Garba. No patient is an island, least of all in the severely resource-constrained NHS. She was not surfing on the web whilst, unbeknownst to her, Jack’s organs were being attacked by streptococcus – she was performing lumbar punctures, attending to codes, taking referrals from GPs, managing several wards, all by herself.
The most unfortunate part of the whole episode was when Dr. Bawa-Garba called off the code confusing Jack for another patient whose code call she attended that morning. The mistake was picked up by another junior doctor. The resuscitation was interrupted by a minute though, sadly, it was too late for Jack by then. Justice Nichol, the sentencing judge, said of that episode that it indicated how far from Jack’s care she had departed.
I don’t know how long it had been since his last meal when the Justice opined. But, with a bit of thoughtfulness, he might have arrived at an alternative interpretation. That Dr. Bawa-Garba, hungry, exhausted, and overwhelmed, was at the end of her tethers. That doing the work of three registrars, which is difficult on any day, was particularly challenging in a new hospital after a year’s break for a young mother who probably got little respite at home. That her mistakenly stopping the resuscitation wasn’t a sign of her incompetence, but a sign she was decompensating despite a Herculean effort to stay together on that fateful day. That it had not, for a second, occurred to her that it was Jack who had coded because she felt that Jack’s clinical situation was on the mend.
The most merciless expert witness was none other than Dr. Bawa-Garba herself. Her electronic portfolio became her confession. She erred because she had confessed to erring. Her reflections on how she could be a better doctor became proof that she was a bad doctor. Her remorse, the cornerstone of being a compassionate doctor, was evidence that she should be behind bars. It was a scene from confessions in a medieval torture chamber. It was worse than a court for kangaroos. It was literally a case of “we find you guilty because you said you were guilty.”
The hyenas in the General Medical Council
The law, for all its failings, is the law. One can’t expect jurors to understand how trainees prop up the NHS, how any trainee could have been Dr. Bawa-Garba that day. But one does expect the General Medical Council (GMC), the regulatory body for physicians, to understand how the NHS works. GMC comprises physicians who were once junior doctors in the trenches.
Like hyenas drawn to a carcass, the GMC began circling Dr. Bawa-Garba. It was not enough that she was wrongly convicted of manslaughter. It was not enough that Health Education England withdrew her training number – i.e. annulled her residency position. They wanted to make sure she could never practice medicine again. They wanted to erase her name from the medical register. In stead of rescuing the wounded soldier, they wanted to stab her whilst she was exsanguinating.
It is easy to run out of adjectives which can be used in polite company for the GMC. But it is worth understanding this organization. To label them as “corrupt” misses the point – sure, power corrupts, but GMC’s pathology isn’t “power corrupts absolutely.” Though they seem as cold-hearted as a serial killer lack of empathy isn’t the issue.
Though the GMC’s purpose is to protect patients and guide doctors, it’s an organization which takes an uncompromising stance towards its own reputation, and the reputation of doctors in general in the public sphere. It has long taken the reputation of the medical profession personally. Meaning, if there is a chance that a physician, who has been investigated for fitness to practice, will bring the profession into disrepute, the GMC axes them from the register.
The GMC knows it can’t monitor quality in physicians, ex ante. So, it signals its own quality and purpose by taking a ruthless stance against the doctors. The GMC investigations are known to cause night terrors – many doctors have committed suicide whilst being investigated by the GMC.
For the GMC, Dr. Bawa-Garba was irresistable fodder. She had already been found guilty of manslaughter by a public court which led the GMC to apply elementary logic – “found guilty therefore guilty.”
Here are excerpts from a tribunal which summarizes the thoughts of Mr. Denney – the counsel on behalf of the GMC.
“Mr. Denney submitted that your performance on 18 February 2011 was so poor that, regrettably, regardless of the remediation that you have undertaken, there remains a risk that there would be a further collapse of standards in the future with an inevitable risk to patient safety. He acknowledged, however, that you had done all you could to remediate the specific failings identified. He further submitted that, given the fact that you have been convicted of manslaughter and received a custodial sentence, a finding of impairment is also required in the public interest.”
To save face in the public eye, the GMC had to make sure she could never practice medicine again. The GMC wanted to stay internally consistent. The law was an ass so, for the sake of consistency, the GMC had to be an even bigger ass.
The GMC seemed uninterested in the truth. They seemed uninterested in the mitigating factors of Dr. Bawa-Garba, of system errors, of absent consultants, of triple workloads, of a clinical hiatus. They seemed uninterested in making sure that another Jack doesn’t die from sepsis.
If they truly cared about public interest, one wonders why they didn’t conclude that it wasn’t in public interest, and it was a waste of taxpayer’s money, depriving the public of a competent pediatrician? How did they not see that their actions might deprive pediatrics of even more doctors?
The GMC side stepped cognitive dissonance deftly – by convincing themselves that Dr. Bawa-Garba was a dangerous pediatrician, who would remain a threat to public safety. And they ignored all evidence which pointed in the opposite direction.
The GMC’s plans were thwarted by the Medical Practitioners Tribunal. An independent panel concluded that Dr. Bawa-Garba had indeed erred, and had made a grievous error. But, given her exemplary record before, and after Jack’s death (she worked for nearly four years after the incident, and only stopped working when convicted of manslaughter), given the testimonies of her seniors – who vouched that she was an excellent physician, she was in the top third of her class – the tribunal concluded that suspending her medical license for a year, until the end of her suspended sentence, was reasonable – removing her from the medical register was disproportionate.
The GMC wasn’t happy with mere suspension of Dr. Bawa-Garba’s medical license. They wanted her removed from their register. The GMC continued to pursue Dr. Bawa-Garba’s expulsion with extraordinary zeal. Finally, the high court sided with them, which opened the flood gates of the national angst of doctors in Britain.
The tribunal believed that Dr. Bawa-Garba was remediable. The GMC did not. How was the GMC able to reason away the compelling evidence attesting to her competence? How did the GMC convince itself that she was a perennial threat to the public? What goes on behind the scenes at the GMC? I ask these questions not rhetorically but with incredulity – is the prime regulatory body of doctors in Britain no longer fit to regulate? Who regulates the regulator?
If the GMC genuinely can’t see any mitigation in Dr. Bawa-Garba’s circumstances that fateful day, they are beyond redemption. My concern isn’t that the GMC is dishonest or corrupt – these can be remedied by the right leadership. My concern is that the GMC does not understand clinical medicine.
The GMC’s tenuous grip with reality is best expressed in Mr. Denney’s submission that “wholesale collapse of the standard of care provided by you (Dr. Bawa-Garba) came out of the blue and for no apparent reason. He submitted that it was therefore impossible to have any confidence that this would not happen again.”
And this is the crux of the problem. The GMC can’t see that when a physician with an unblemished track record fails to make a diagnosis then perhaps, just perhaps, there may be something tricky about the diagnosis. The GMC can’t see that to err is to be a doctor. The GMC is out of touch with clinical medicine in the NHS. It is not evil – it is profoundly ignorant and is playing a dangerous popularity contest in the public. This isn’t good for either doctors or patients. It is hard to see how paying annual dues to the GMC can be considered ethical.
Respondeat superior
Many have suggested that had Dr. Bawa-Garba been a white female doctor with a posh accent she would not have been found guilty of manslaughter. The press would have been kinder to her, and not labelled her as a “child killer.” I’m not one to patronize racial accusations easily. And even if there is structural racism, this case illustrates a problem far deeper than structural racism. Britain’s junior doctors need to understand the nature of the problem they face.
Junior doctors run the NHS, the extent to which is difficult to explain to people who haven’t worked in the NHS. As I mentioned before, Dr. Bawa-Garba was doing the job of both an apprentice and a consultant. This state of affairs is not without dividends. By relying so heavily on junior doctors, the NHS is able to employ fewer consultants. Consultants aren’t cheap – once you factor their salary and benefits, particularly the pensions. Thus, the NHS saves money but, and this is the crucial point, so does the taxpayer.
So, junior doctors are workhorses but when the shit hits the fan they can’t take advantage of a legal doctrine known as “respondeat superior” – which basically means that the employer assumes responsibility for their actions. This is a win-win situation for hospitals and lose-lose situation for junior doctors – not only must they make tough clinical decisions, but if they screw up, and unsupervised apprentices will screw up, they’ll be thrown under the bus.
How this situation became palatable baffles me to no end. But it gets worse. When a junior doctor complains about being unsupported, i.e. whistle blows, they lose their job, as Dr. Chris Day, an aspiring emergency physician, did. Thus, junior doctors must choose between the devil and the deep blue sea – risk jail if they work unsupported or risk unemployment if they complain about being unsupported.
To emphasize, the problem isn’t just that junior doctors work unsupervised – to a large extent, this is unavoidable. The problem is that junior doctors work unsupervised AND are fried for errors of judgment inevitably made because they are not supervised. It is extreme cowardice court marshalling the foot soldiers for making decisions their generals were too busy to make. Trainees should be remediated by their teachers, not prisons.
Moving forward
Dr. Bawa-Garba’s case has sent a chill down the junior doctors. Instilling a fear of prison for an error of judgment isn’t the best way to raise the morale of the foot soldiers. Dr. Segun Olusanya, a colleague of Dr. Bawa-Garba from medical school, recalls her as a fellow Nigerian student who hardly partied and spent her time reading. Dr. Olusanya is a registrar in intensive care medicine, and isn’t one to be easily scared by medical emergencies. He’s the sort of doctor you want sitting next to you if you’re planning to have a cardiac arrest on a long-haul flight. Dr. Olusanya hasn’t slept well since hearing about his old medical school friend. He is, for the first time in his life, frightened to work in the NHS.
It is important for junior doctors not to lose their moral capital on this issue. It’ll be tempting to politicize Dr. Bawa-Garba – but this isn’t about Jeremy Hunt, or austerity, or Brexit. This problem has existed for a long time, and has become more pernicious recently. The solution is clearly more funding but this is a long-term solution.
In the short term, junior doctors must, without compromise, be protected from manslaughter charges. This has to be built into the employment contract. The principle of respondeat superior must be installed. The hospital must assume complete responsibility for the actions of junior doctors, contractually. This’ll put more skin in the game for the trusts, who will apply downward pressures on consultants.
The British public can’t have it both ways. They can’t simultaneously enjoy the thrift of a healthcare system with a tab of only 9 % of the GDP, yet demand a structure needed to catch outliers. Such a structure costs. It’d have taken a village to save Jack. Jack died not because the village failed him, but because the village did not exist. As the Americans have discovered, if you want zero deaths from sepsis, you need a sepsis protocol – if you want antibiotics to be delivered in 30 minutes, you need chest x-rays to be performed and read in 30 minutes, which means more technologists, more radiologists, more x-ray machines. You need beds in intensive care units, which means you need more intensive care units, and trained physicians to run them. Infrastructure costs. To have a high index of suspicion for sepsis you need to invest in structure and people. If the British public insist on thrift, they must also accept the errors which come with thrift.
A competent doctor’s career was torn by a virulent entity which has a mortality as high as 80 %, and against which the NHS is neither any safer nor any wiser, though its life blood, the junior doctors, will have coagulated a bit. In prosecuting Dr. Bawa-Garba and the agency nurse who, sadly, was struck off the register, too, attention has been diverted from the shortcomings of the NHS. The General Medical Council has contributed to the grand public deception. The actions of the General Medical Council will outlive them.
Addendum
Though it is true that Dr. Bawa-Garba had been on maternity leave for 13 months, Friday 18th February, 2011 was not her first day back, but it was her first day taking general pediatric call in the children assessment unit at Leicester Royal Infirmary. Before her maternity leave, she had rotated through neonatal intensive care unit and community pediatrics. She had last done general pediatrics at a district general hospital some time back. In other words, the specific clinical gap was taking acute call in general pediatrics.
About the author
Saurabh Jha is a British-trained medic who worked in the NHS for four years. He can be reached on Twitter @RogueRad
Source:
The above article is reproduced from material with same title from The Health Care Blog. Note: Materials may be edited for content and length.
Yeah, you are right! "It is important for junior doctors not to lose their moral capital on this issue". They can also work as a practitioner under the senior doctor to understand and realize the situation better.
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