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OVER the past few years a concerning number of junior doctors have been committing suicide at a rate that is much higher than that of other professionals. These tragedies seem to be a manifestation of widespread distress among junior medical staff who report feeling under pressure and unsupported. They are desperate to do well and are terrified of failing.
On 6 June 2017, the New South Wales Health Minister, Brad Hazzard, convened the Junior Medical Officer Wellbeing and Support forum to consider how this crisis should be addressed, listening to young doctors vividly convey the extent to which they feel exposed, vulnerable and personally responsible for poor outcomes. Excess workload and expectation that they should “manage” were also identified as additional sources of stress.
The sentiment was that every junior doctor feels as if they are one (poor) decision away from disaster.
The summit identified the vital need for these inexperienced doctors to work (and learn) in a system where they felt safe and supported. It is important to remember that junior doctors are still learning. They need supervision and support.
This background explains why the recent permanent suspension from medical practice of a junior doctor in the UK has so horrified junior doctors. This case embodies their worst nightmare.
The case has been widely reported but it may be worth reiterating the main points as outlined in the published legal reports.
On 18 February 2011, Dr Bawa-Garba was on her first day as paediatic registrar at Leicester Royal Infirmary (a new hospital for her). She had only recently returned from maternity leave.
From the start she was required to cover the duties of an absent registrar and does not appear to have had a more junior doctor to assist her.
She was responsible for children in the Emergency Department and those in the acute Children’s Assessment Unit. She was also reported to have been required to take calls from GPs and to provide service to the main children’s ward upstairs.
There was no consultant paediatrician available until later in the day.
There was a shortage of regular nurses and this was covered by agency nurses (who were likely to be unfamiliar with the hospital and its procedures). The computer system was down, so test results were delayed and difficult to obtain.
It was on this day that 6-year-old Jack Adcock was admitted to the Children’s Assessment Unit. He had Down syndrome and suffered a heart condition (for which he was on medication). Jack arrived looking very unwell with diarrhoea, vomiting and difficulty breathing.
Dr Bawa-Garba diagnosed gastroenteritis, gave him intravenous fluids and ordered tests (including blood tests and an x-ray).
The blood tests suggested that Jack had a severe bacterial infection (rather than viral gastroenteritis). It seems that Dr Bawa-Garba did not appreciate their significance, but exactly when she saw the results, and her circumstances at the time, are not explained in the legal judgements.
Safety experts recognise that when overloaded with tasks we can all miss things, even important things that should stand out. In safe systems there are multiple checks that ensure that these lapses are brought to our attention. Nobody appears to have alerted Dr Bawa-Garba.
Dr Bawa-Garba didn’t review the x-ray immediately after it was taken (apparently she was not informed that it was available while she was busy attending to other children). When she did get to review the x-ray, she correctly diagnosed pneumonia and prescribed intravenous antibiotic. Unfortunately, this was not administered by the nursing staff for more than one hour after it was prescribed.
There were additional things that made the situation worse, actions over which Dr Bawa-Garba had no control. It seems that the oxygen saturation monitoring was discontinued without instruction, and routine vital signs (pulse rate, blood pressure and respiratory rate) were not recorded by the nursing staff.
Dr Bawa-Garba had appropriately decided to discontinue the enalapril that Jack was on for his heart (enalapril drops the blood pressure and would not be helpful where the blood pressure was already low). Recognising that it would not be appropriate, Dr Bawa-Garba did not prescribe it on the hospital drug chart. However, it seems that Jack was given his evening dose, using his own tablets that had been brought in from home. In hospital, it is normal practice for patients to only receive medicines that are prescribed on the hospital chart, otherwise there is great potential for confusion.
The consultant paediatrician arrived later in the afternoon, at which time it is recorded that Dr Bawa-Garba told him about all the new patients (including Jack). He did not choose to see Jack, and is not reported to have made any suggestion (or criticism) about Jack’s management.
Jack went on to suffer a cardiac arrest from which he could not be resuscitated.
As is usual in these cases, there was an investigation by the hospital. Numerous errors and deficiencies were identified at multiple levels. A full and frank apology to the family providing them with a full explanation of what went wrong, together with assurance that urgent changes would be made to avoid something similar ever happening again, would have been the expected outcome.
It is not recorded whether the family were given this sort of assurance but, whatever the case, a relentless process began that appeared to put the blame for the outcome squarely on to the junior doctor, Dr Bawa-Garba. This resulted in a conviction for manslaughter on the grounds of gross negligence with a 2-year suspended sentence.
It went on.
This conviction led to an enquiry about her fitness to practice, where a tribunal of the General Medical Council (GMC) decided to suspend Dr Bawa-Garba from medical practice for a year. The GMC appealed against the decision of its own tribunal, on the grounds that a 1-year suspension was too lenient in the circumstances, and they won.
On 25 January 2018, almost 7 years after that tragic day in 2011, Dr Bawa-Garba was struck off the medical register and is unable to practise as a doctor ever again.
The GMC in the UK identifies its responsibility of “maintaining public confidence in the profession”. It states that “[p]atients must be able to trust doctors with their lives and health, so doctors must make sure that their conduct justifies their patients’ trust in them and the public’s trust in the profession”. Documentation also clarifies the role of erasure (“striking off the register”), stating that it “may be appropriate even where the doctor does not present a risk to patient safety, but where this action is necessary to maintain public confidence in the profession”.
Presumably Dr Bawa-Garba has been removed in the expectation that this will enhance public confidence. I fear it won’t. Indeed, I believe it does the opposite by suggesting that the system is unwilling (or unable) to address the real causes of risk.
Addressing the numerous system deficiencies identified in the initial investigation (and there were many) is needed to ensure public confidence.
Could it happen here? I fervently hope not, and think not, but that is not the point. The fact that it has occurred somewhere makes it a reality in the mind of junior doctors everywhere.
These events will reinforce those feelings of vulnerability that are the cause of so much anxiety for junior doctors. Mental welfare has been profoundly set back.
NOTE: The facts presented are based on the record of events as documented in the published legal report. They have not been independently verified by the author.
Associate Professor Charlie Corke is a senior intensive care specialist at University Hospital Geelong, and is President of the College of Intensive Care Medicine of Australia and New Zealand.
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I very clearly recall being the unsupervised nights’ intern, having to make critical dilemma about reversing warfarin in a young adult Down’s syndrome patient, with a metallic valve, whom I’d never previously met. I had to make that decision without a CT brain, and luckily i was correct about the intracerebral bleed when the on call radiologist finally agreed to do the scan… Now, I’m a consultant and know that the responsibility for the management of patients admitted under my care, is shared by me and the institution where I work, not the junior medical staff working on my team.
An assumption seems to have been made that the child would have survived if it were not for the errors. What has not been mentioned yet here is that a severe CAP is sometimes fatal, even in young people who are previously healthy. This child with Down’s Syndrome and a heart condition may well have succumbed regardless. It’s somewhat ironic that in this last week, I have been involved with a Downs syndrome patient with respiratory failure and severe CAP (who did very well) and a previously healthy 16 year old boy (who presented late with severe sepsis and respiratory failure and could not be resuscitated after cardiac arrest). It’s tragic but even with best possible care, death is still sometimes not preventable. At our institution (a tertiary referral centre without ECMO), there are still about one (maybe two) of these cases per year.
Dr B-G has clearly suffered a gross injustice, when her senior colleague and the system/institution have escaped scott free. I do hope that she is receiving the support that she needs.
If the doctor concerned were a white, Anglo-Saxon male, it is inconceivable that such a punitive outcome would have occurred. it is decades since I worked in the NHS as a junior resident. There was plenty of racism then. It seems nothing has changed
I would like to think that Dr Bawa-Garba is getting good emotional support. Does anyone know?
And it would be helpful for her to know that this conversation, and others like it are happening as far away as Australia, and around the world I’m sure.
Does anyone know if there is a social media campaign already established – facebook and twitter? I would think this need to driven by who are close to this issue such as Doctors in Training, but with strong contributions also from seniors.
In 1950 I was in my first job after graduation, it was a country hospital with only two first year RMO’s on the staff. A young boy was admitted with tetanus and severe breathing problems. The sister with me when I first saw the boy was highly experienced and suggested that I should do an emergency tracheostomy. I had never used a (surgical) knife before not seen a trachy. She should have taken over, I could do nothing. The consultant was “on his way” but arrived far too late, the lad died. Apart from the breathing, he was very ill and may well have died anyway but it does demonstrate that new young doctors should have close supervision. KBO
I would like to point out that several cases very similar to this have already occurred in Australia.
If you look up Dr Doneman and the Elise Neville coroners case you will see what I mean.
This junior doctor was forced to work 24 hour shifts at Caloundra ED without senior onsite cover was certainly hung out to dry by both his employer and the medical board. A salient lesson for all of us. We can argue all we like about the need for clinical contact hours for training but it wont save us from prosecution when fatigued.
https://www.sunshinecoastdaily.com.au/news/scd-doctor-banned-in-wake-of-girls-death/325437
Let’s not forget the child’s mother baying for blood and the media frenzy whipped up by some sections of the press. This, together with Hadiza’s skin colour and religion, likely contributed to the GMC’s appalingly vindictive behaviour.
Other commentators here have pointed out some very troubling points that I’d like to highlight
1. Her own impromptu personal reflection (done in a cafeteria in front of a consultant) was held against her.
2. It is clearly a system fault that a new doctor was given no backup on her first day after a gap. The administrator who set up such a roster without appropriate safeguards should be held accountable as well
3. Despite the consultant not seeing their OWN patient that day who was just admitted, it was the junior staff held to account.
4. This is clearly a textbook swiss-cheese model of failure and laying all the blame at this young womans feet screams of scapegoat!
This story alone makes medical residency in UK untenable: impossible situation followed by no support from the management or the law. I have heard of a similar case recently in Australia. If this is the future, then you have to counsel any young hopeful against a medical career.
Hope it won’t happen here. GMC has a track record:
http://www.pulsetoday.co.uk/your-practice/practice-topics/legal/gmc-fails-in-case-against-surgeon-exonerated-of-manslaughter/20036298.article
http://www.pulsetoday.co.uk/your-practice/regulation/gmc-taken-to-employment-tribunal-for-alleged-racial-discrimination/20036242.article
Call it for what it is -scapegoating. The junior doctor had no other doctors to call to help, the nurses appeared to be unhelpful not recognizing how sick the child was, not following orders, not chasing up a busy doctor with results on a seriously ill child, the hospital management was greatly at fault for its staffing problems, and the consultant paediatrician who was “absent” should bear the ultimate responsibility-he was after all supposed to be supervising. For the NHS, criticizing or prosecuting its hospital management, nursing agency, or paediatrician is too difficult, the scapegoat was the one with least power to retaliate. Medical politics at its worst. Cut funding and staffing then blame the remaining staff for problems! If you are going to have a unit dealing with emergencies, staff it properly.
To clarify Dr Michele Meitzer’s points:
1) The error in resuscitation status was made because the room occupied by JA had previously been occupied by a child with a DNR order, and not because of JA’s diagnosis of Down’s. Dr BG, who is a trained disability therapist, has a severely disabled child of her own.
2) At trial, the court accepted that the brief interruption of the resuscitation procedure was not relevant to the outcome.
The essence of good medical practice is communication – sadly absent throughout this matter.
The decision of the court may be legally correct but is derived from a corruption of morals and accountability.
As Dickens wrote in ‘OIiver Twist’:
“If the law supposes that,” said Mr. Bumble, “the law is an ass – an idiot”.
How many of us can think of a case in our junior hospital years where we could have been “hung out to dry”, after a a mistake made through inexperience, tiredness, overwork or lack of senior support? We perhaps were chastised, certainly chastised ourselves and moved on but most importantly learned valuable lessons. Doctors are humans and humans make mistakes. We learn most from them, and try not to make the same mistake twice.
This young UK doctor has been incredibly harshly and unjustly treated and deserves the support of the medical community worldwide.
This story would be unbelievable except for the fact that those of us who have seen hospitals from the inside know that abuse of junior staff still occurs decades after the profession decided that it must cease. What is equally troubling is that there seems to have been ignorance of the fact that in complex systems like hospitals only very rarely is a single person responsible when something goes wrong. Blaming a single person is rarely the way to fix a problem and as others have said it will likely occur again. How such severe handling of the young doctor in this case could have even been contemplated is beyond understanding. It was certainly unjust. We need to ensure it cannot happen in Australia.
I went to medical school with Dr B-G and was a medical student on the ward where this occurred. Charlie you aren’t correct to say that it was a new hospital for her, it wasn’t but she had been away on maternity leave. However you have gone up in my estimate once more for choosing to write about this in Australian medical circles.
The consultant was not disciplined simply because he chose to leave the UK pretty smartly returning to his native Republic of Ireland outside the jurisdiction of the GMC. I am guessing he won’t be back. In British medical circles a great deal has been made of the GMC’s unwillingness to overtly state that the hospital’s system were also at fault. This is because the GMC is not political and not the coroner, it cannot go on record blaming the institution, it’s role is only the regulate individual doctors. The coroner may go to town, the GMC cannot. Practically the GMC has a certain history of dancing the government’s tune, ie you do what we like (not blame us and our hospitals) and head of the GMC often ends up with a peerage…
As for the health minister, well he publicy stated many times that he fully supported the doctor and with it got him support that previously had been lacking (unpopular man) but that wasn’t enough to stop the malevolence of the GMC.
Total travesty, The medical profession have done everything possible to defend her including given her the funds for a high court appeal with the best legal representation. When it comes to court there is going to be a media frenzy.
Of interest another doctor who refused to carry other doctors work when absent (exactly the opposite of Dr B-G) is also in the process of appealing a GMC decision to severely discipline him, making it a farce in the UK at present of whom exactly is supposed to do the work of an absent colleague, it appears that the GMC have made a total arse of itself (not for the first time) in literally prosecuting British doctors, for covering absence therefore exposing patients to risk, and for not covering for absence therefore exposing patients to risk.
Insert expletive at your discretion.
This is an awful tragedy all-around, with an outcome that is manifestly unjust and which will also endanger attempts to improve practice.
It also illustrates what commonly happens when an incident occurs – hospital administrators head for the hills and hang the coalface staff out to dry, both medicolegally and sometimes also with a strategic referral to bodies such as AHPRA / GMC, to further shift blame and create the illusion of a commitment to quality and safety.
Being overworked/understaffed etc is NOT an effective defence in negligence for the individual who is in the frame. The only way out is to refuse to work under such conditions, but this is virtually impossible.
Why was the consultant not disciplined? Failing to support one’s juniors is a fundamental failure.
Why was the hospital administrator who allowed the understaffing not disciplined?
Why was the line manager who allowed her to work without orientation and adequate resourcing not disciplined?
Why will the health minister responsible for the gross under-funding of the NHS never face effective sanction?
As it stands the two individuals with least power to change things for the better ( the registrar and the nurse ) have been the ones left carrying the medicolegal can
This is a travesty. One can only hope that it produces a proper inquiry and some redress, but I am old enough and cynical enough to know that it would be foolish to hold my breath
The word “scapegoat” comes to mind!
What responsibility has been taken by the administering health authority for its staffing (medical and nursing) and its supervisory processes?
This was a classical case of all the “holes in the Swiss cheese lining up” and so canceling a single person’s career and allowing the GMC to allege it restores confidence in the system is wrong, morally and ethically.
I would have thought the parents of the child, the GMC and the UK community would have made greater gains by holding the system accountable….. I hope they sleep well at night feeling that have “fixed’ things by crucifying the easiest target……
I was horrified to read this article.
Nearly 40 years ago I was an Australian Medical Graduate in my first UK job and my first task, right on starting, was to be the sole paediatric doctor over a long weekend, the other paediatric staff all being away. I had never previously done paediatrics, in fact I was in the UK for that experience. A baby, born at 32 weeks gestation, died. I was not supported well by the paediatrician in the next hospital. I have never forgotten that family or that experience. It took me over 20 years to realise that things could and should have been otherwise.
The only difference with Dr. Barba Garba’s case is that it never went to the courts or the GMC, and of course in my case that was all the difference, and I have had a long career subsequently. So it appears that the only thing that has changed in that time is not the supervision and support that was needed, but the legal and institutional punishments that come when misfortune arises.
This case is a wake up call for all doctors working in hospitals. Whilst nurses are very particular about their nurse patient ratio there is no such fall back for junior doctors and they are often expected to manage many patients and must learn to prioritise their work. Doctors tend to soldier on and try to do their best
Dr Barwa Garba clearly took on too much and paid a heavy price. The lesson for junior doctors is to insist on support from senior staff when you are feeling overwhelmed
it was also reported that Dr Bawa-Garba’s hand written, honest reflection on what went wrong and what she might have done better was used in evidence against her. This was apparently prompted by an impromptu interview with her consultant in the hospital cafeteria soon after the child’s death, when she was presumably in a very vulnerable and emotional state. If this is true it makes a mockery of attempts to encourage reflective practice (surely a good thing) by all doctors. Once can’t help wondering about the consultant’s own reflection on where he was when his junior colleague needed support (apparently out of town for most of the day) and why he did not review his patients when he got back.
In the judgment, one of the issues which you have not mentioned here, is that she mistakenly thought that the patient was designated “do not resuscitate”, based on the fact that he had Down’s Syndrome. Later, she realised that this was a mistake and changed his status.
If this were a factor in the patient’s death, then this is related to disability prejudice rather than work overload. I am not sure how long the ensuing delay the mistaken assumption caused in his treatment, and to what degree this contributed to his death. The judgment that I read did say however that it caused much distress to his parents. As the parent of a child with a disability, as well as a doctor, this is the part of the story that I find the most frightening.
What happened to removing “blame and shame” from medical misadventure. A very regressive step. Health bureaucracies look for someone to blame rather than their own system failures
I can remember being overwhelmed, as an intern, by situations in casualty back in 1983 BUT I had great back up and support both from RMO’s and registrars. Consultants were also very approachable. That was the Queen Elizabeth Hospital in Adelaide.
Where on earth were the internal systems of incident review, and even a coronial enquiry? This was a disaster waiting to happen! The lack of support for a doctor starting out at a new hospital AND after an extended break from medical work shames both the hospital involved AND the GMC for not recognising their part in this. I do hope a full appeal and review is to be held and the CORRECT heads rolled.
I am appalled by the progression of events moving inexorably against this Doctor. Totally inappropriate decisions with seemingly no way back after the initial jury decision. I feel dreadfully for her having been in similar totally overworked situations with no backup when I was younger. This is a gross miscarriage of justice , but I don’t know what else can be done to save her at this point. I have already emailed various entities in the UK over this several weeks ago and also donated to her legal costs.
The loss of income to her young family must be devastating and even though the legal decision may not be reversible, I hope there is a Fund set up to support her outside of the legal challenge.
I work and teach in accident forensics in the second-largest academic safety science team in the world, and this story is all too familiar across all industries. The actions taken in this instance seem to arise from the agnotology associated with “safety” and “risk’, as well as an ignorance of safety science. The medical profession is not immune from this phenomenon, and should perhaps look at the newer thinking in examining complex socio-technical systems, such as the work of Professor Erik Hollnagel’s work using his functional resonance assessment method (FRAM). Blaming the worker, and excusing the system, does nothing to fix the latent failures you describe. With this approach, there is a high probability it will happen again.
Please Note there is also the Victorian Doctors Health Program available for both Doctors and Medical Students with any health issues they wish to discuss either over the phone or face to face with another Doctor. The Phone number is 9280 8712. Dr Tim Dewhurst Medical Director, VDHP.