The only way to improve patient safety is to talk openly about everything that contributes to patient harm, says Rachel Clarke
It almost makes me flinch to imagine it. Anxious parents, consumed with fear, rush their limp and vomiting six-year-old to hospital. Yet mistakes are made, diagnoses are missed, and somehow—before the day is out—Jack Adcock suffers a cardiac arrest from which he never recovers.
As the mother of a six-year-old myself, Jack’s fate makes me want to sweep my children into my arms. Any child’s death is horrific, but none more so than an avoidable death—one that never should have happened.
For Jack’s grieving parents, the outpouring of concern among medics for Hadiza Bawa-Garba, the doctor who treated Jack that day, must feel like acid in an open wound. In 2015, Bawa-Garba was convicted of gross negligence manslaughter. A paediatric registrar at Leicester Royal Infirmary, she recognised neither the early signs of sepsis in the child, nor the importance of severely deranged blood gas results. Antibiotics were delayed and senior review not sought. Finally, when Jack arrested, she mistook him for another child with a DNACPR order in place, erroneously halting CPR for around a minute.
Framed like this, the facts of the case look incontrovertible. Justice, surely, demanded that someone was held to account for Jack’s death? Bawa-Garba, whose mistakes were undeniable, clearly appeared to fit the bill (as did Jack’s nurse, Isabel Amaro, also convicted of grossly negligent manslaughter). Yet over 800 doctors signed a letter this week appealing to the GMC not to permanently strike Bawa-Garba off the medical register, in spite of her criminal conviction. You can see why Nicola Adcock, Jack’s mother, told the Times newspaper she was, “disgusted that doctors are all sticking together.”
On social media, the case has provoked fire and brimstone. Other bereaved family members have accused doctors of self-interest, complacency and the belief they are “untouchable,” while some angry doctors have accused their Twitter critics of cowardice. High emotions, ramped up by the constraints of 280 characters, on both sides.
What, at root, is driving the outrage? From my experience as a doctor, I believe that most of us—patients, families, colleagues and me—tend to be prone to anger when we are scared. Right now, this case makes me terrified. We know that Bawa-Garba was working in an understaffed unit. We also know that the wider system in which she worked was profoundly unsafe—not least since the Trust’s own, internal inquiry into the tragedy instigated no less than 23 recommendations and 79 actions to minimise risks to future patients.
Significantly, the Trust’s investigation also concluded that no single root cause for the death could be identified. Yet the report was never heard in court. Prosecution lawyers successfully argued for its exclusion, enabling blame to centre on Bawa-Garba and Amaro alone.
I feel terrified because—like every junior doctor I know—I too have worked shifts so overstretched, so appallingly understaffed that, by the time they end, I can barely think straight, let alone deliver exemplary care. I’ve felt sick with dread and wept with exhaustion, tormented by fear that patients will slip through the net on my watch. And no-one, frankly, has given a damn. Not my seniors, not the managers, and certainly not the health secretary, in spite of his avowals that, for him, patient safety really is everything. Bawa-Garba could have been me—she could have been any frontline member of staff working in today’s underfunded, overstretched NHS.
Medics have been accused this week of cynically closing ranks. But can patient safety really be improved by loading blame on individuals while ignoring the systemic and human factors underpinning medical error? Should a doctor’s errors be criminalised in a working environment that routinely renders them punch-drunk with exhaustion?
For bereaved families seeking justice, there is a danger that the very complexity of medical error—the interplay of individual, systemic, and human factors—leaves no-one accountable. If “everyone” is a little bit guilty, then nobody—ultimately—carries the can. This feels like a failure of justice. But so too, perhaps, is deeming a professional’s actions “grossly negligent” if they were set up by extreme fatigue, stress, and overwork to fail.
I desperately want to be a good, safe doctor. I strive, I hope, to put patients first. My fear that Bawa-Garba has been the victim of a miscarriage of justice stems not from closing ranks, but the opposite. The only real way to improve patient safety is to talk openly, candidly, about everything that contributes to patient harm. Doctors’ errors, nurses’ errors, systems failings, rubbish IT, absent seniors, rota gaps, endemic understaffing, NHS underfunding. Patients, families, and frontline staff are all—rightly—frightened. Let’s talk to each other, about all of it, to help build a safer NHS.
Rachel Clarke is a specialty doctor in palliative medicine. Twitter @doctor_oxford
Competing interests: None declared.