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On 18th February 2011 Jack Adcock was admitted to Leicester Royal Infirmary with a history of severe gastro enteritis. He had previously had an AVSD repair, doing well, on enalapril. He had a temperature of 37.7 degrees centigrade, dehydration and shock. A Blood gas showed a Ph, 7.0, base deficit, -14, lactate 11 mmols. He was prescribed a fluid bolus and maintenance fluids.  Blood tests including CRP were undertaken and a chest x –ray ordered. There was a delay of two and a half hours in review of chest x-ray during which time Jack showed some recovery, playing with the radiographer, drinking juice from his beaker, improvement in blood gas, to ph 7.24.  Jack was moved off the Children’s Assessment Unit (CAU) to the wards, where an unprescribed dose of enalapril was administered.  Approximately one hour later he suffered a collapse from which he was very sadly unable to be resuscitated.

The registrar that day was Dr Hadiza Bawa-Garba, a high flying doctor, with an unblemished record who had done considerable work for charitable causes just returned from 13 months maternity leave. Her last general paediatric post, ST4 commenced four years earlier in a DGH, outside Leicester.  She had received no Trust induction. When she came to work that day she found that the registrar covering CAU was on training, away from the wards. Dr Bawa-Garba was requested to cover CAU as well as her own ward duties.  Working under her were a foundation doctor and SHO.  Both had only rotated to paediatrics that month. The consultant covering CAU was teaching outside the city

Provision of care was dogged by the break down in IT facilities for the whole hospital, meaning that the team were constantly phoning to try to get results. Even when back on line, the flag system for abnormal results was down. The nursing staff were hard pressed, with staffing and equipment shortages logged. Jack was looked after by an agency nurse with a certificate in adult nursing.

It is not clear what debrief for the staff involved was undertaken after the tragic events of that day, but Dr Bawa-Garba met with her consultant in the hospital canteen, where she felt under pressure to fill in areas of a trainee encounter form. She continued to work without problem and indeed with plaudits.  A serious untoward incident inquiry was undertaken following the patient’s death, which was completed on 24th August 2012. A 14-person investigation team concluded that a single root cause for the death was unable to be identified. Numerous parts of the clinical process were identified as needing change. The report highlighted 23 recommendations and 79 actions that were undertaken by Leicester Royal Infirmary as a result of the organisational learning.

 At the beginning of 2012 Dr Bawa-Garba was arrested and questioned two weeks after her next baby was born. She was detained by police for 7 hours away from her baby who was fully breast fed, refusing bottles and at risk of hypoglycaemia.  Dr Bawa-Garba was in no state to face sustained police questioning and sign documents.

 On 17th December 2014 Dr Bawa-Garba was charged with manslaughter on the grounds of gross negligence and found guilty on 4th November 2015, after 25 hours deliberation, on a majority verdict of 10 to 2. On 8th December 2016 she was denied leave to appeal. On 13th June 2017 she was suspended for a year by the Medical Practitioners Tribunal service. The GMC applied to over turn the MPTS suspension and instead to erase Dr Bawa-Garba from the medical register.  Health Education England (HEE) withdrew Dr Bawa-Garba’s training number.

On 7th December 2017, considering the arguments surrounding the GMC case for erasure, the judge asked to know what was different about 18th February 2011, the day of the tragic events surrounding Jack’s death Jack’s admission.   This may pre-suppose that all works smoothly on other days although we do not know the level of incidents, recorded or unrecorded error, near miss, death or disability from care on other days. 

What we do know is as follows:

On this day: The team were relatively new due to the February change over and Dr Bawa-Garba had not received Trust induction.

On this day: The registrar covering CAU did not attend. Dr Bawa-Garba was doing their job.

On this day: The consultant covering CAU was in Warwick.  Dr Bawa Garba was doing their job.

On this day: Due to hospital IT failure the Senior House Officer was delegated to phone for results from noon until 4pm. For this period Dr Bawa-Garba was doing their job.

Therefore on this day Dr Bawa-Garba did the work or three doctors including her own duties all day and in the afternoon the work of four doctors.

On this day: Neither Dr Bawa-Garba (due to crash bleep) nor the consultant (due to rosta) were able to attend morning handover, familiarise themselves with departmental patient load and plan the day’s work.

On this day: Dr Bawa-Garba, a trainee paediatrician, who had not undergone Trust induction, was looking after six wards, spanning  4 floors, undertaking paediatric input to surgical wards 10 and 11, giving advice to midwives and taking GP calls.

On this day: Even when the computer system was back on line, the results alerting system did not flag up abnormal results.

On this day: A patient who had shown a degree of clinical and metabolic recovery due to Dr Bawa-Garba’s entirely appropriate treatment of oxygen, fluids and antibiotics was given a dangerous blood pressure lowering medication (enalapril) which may have  precipitated an arrest.

So what did Dr Bawa-Garba personally miss?   Her initial treatment was felt to be good. She was not informed of Jack’s further diarrhoeal fluid losses by the nursing team. In terms of laboratory results she missed raised creatinine which arguably may have not affected the ongoing treatment in and of itself.  She was unaware of the time of the chest x-ray, that she had correctly ordered, upload to the system, but as she had been personally undertaking procedures such as lumbar puncture and covering six ward areas, this must be understandable. No–one is all seeing. She correctly prescribed antibiotics as soon as she reviewed the x-ray.

Dr Bawa-Garba has inexplicably been held responsible for

-The fact that more senior staff did not apparently realise the implications of a blood gas result. Seniors supervise juniors, not vice versa.

-The fact that the nursing staff were not adequately supervised and supported to do their job.  This is the role of nursing management.

-The fact unprescribed medication (enalapril) was given, not checked with the medical team.  Dr Bawa-Garba could not take measures to counteract the effect of this medication, before patient deterioration into an arrest situation, as she was not informed enalapril had given.

-The fact that she did not personally apologise. Dr Bawa-Garba would have needed to obey all Trust and Medical Protection Society directives and the advice of her legal team with respect to communication with the patient’s tragically bereaved family.

Dr Bawa-Garba did mistakenly stop resuscitative efforts, confusing Jack with another patient, although this was not seen as contributory to the final tragic outcome.  There had been  confusing movement of patients of which Dr Bawa-Garba was not informed, so that when she was crash bleeped 13 hours after attending one arrest situation,  having had no time for food, drink or a break, she raced to the area and wrongly assumed that she was going to the same patient.   There were a minimum of 7 professionals in the cubicle, including Jack’s named professionals and equally senior, less exhausted paediatric and intensive care doctors leading or assisting the resuscitation. No–one queried Dr Bawa-Garba or double checked the name but rather they stopped resuscitative efforts on her word.

After these events, Nurse Amaro, an agency nursed trained in adult medicine, who had worked for 17 years with feedback attesting to a high level of performance, who was helping out CAU in a crisis, was struck off for 5 years.  In her statement to the nursing and midwifery council she said nursing was her life and she had always wanted to be a nurse, because she wanted to help people. Some staff from the Trust who were working on the day have left voluntarily, with some moving abroad.  Public statements from the Trust medical director say that improvements have been put in place to prevent similar tragedies. Dr Bawa-Garba awaits the decision of the Court of Appeal.

Signed:

Dr Lyvia Dabydeen, Consultant Paediatric Neurologist 

Dr Hilary Klonin, Consultant Paediatric Intensivist

Dr Nigel Speight, Consultant Paediatrician

Dr Sethu Wariyar, Consultant Paediatrician

Dr Sanjay Gupta, Consultant Paediatrician

Dr Sanjiv Nichani, Consultant Paediatric Intensivist

 References:

 1.       https://www.mpts-uk.org/static/documents/content/Dr_Hadiza_BAWA-GARBA_13_June_2017.pdf

2.       https://www.nmc.org.uk/globalassets/sitedocuments/ftpoutcomes/2016/august/reasons-amaro-cccsh-36269-20160804.pdf

3.       Bawa-Garba v R, Court of Appeal - Criminal Division, December 08, 2016, [2016] EWCA Crim 1841 https://court-appeal.vlex.co.uk/vid/201505475b1-654950101

4.       Back to blame: the Bawa-Garba case and the patient safety agenda BMJ 2017; 359 (Published 29 November 2017) doi: https://doi.org/10.1136/bmj.j5534 

5.       http://www.dailymail.co.uk/news/article-5146713/Doctors-rally-against-efforts-strike-Bawa-Garba.html

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