26 July 2018
Fear of Failing
By Lynda Goetz
Unless you are a doctor or are somehow personally involved, you will probably have no idea that this week Dr Hazid Bawa-Garba is appealing in the High Court against the General Medical Council’s (GMC) decision to strike her off the medical register – forever; a decision which was made against the advice of the Medical Practitioners’ Tribunal Service at the time.
Cast your mind back and you may well remember the case of Dr Bawa-Garba. She was the doctor who became the ‘fall guy’ for a multitude of failings at the Leicester Royal Infirmary back in 2011; failings which led to the death of a six-year old boy, Jack Adcock, from septicaemia. Dr Bawa-Garba had the misfortune to be the most senior doctor on duty at the time. She was a registrar, a fully qualified doctor (i.e. she had done her 5 or 6 years of initial medical training; she had completed her two foundation years, formerly known as junior house years) but she was still in training as a paediatrician (see BMA training pathways). Her consultant was not around at the time, nor was her fellow registrar, and her senior house officer was attempting to chase up test results from a failed IT system. There was a shortage of nursing staff. She herself had just returned from maternity leave and was facing her first ‘on-call’ night following that return. She was responsible for six wards spread over four floors. She was on a 13-hour shift. She made mistakes.
After a trial in 2015, Dr Bawa-Garba was convicted of gross negligence manslaughter (GNM) and received a 24-month suspended sentence. Following that conviction, The Medical Practitioners Tribunal Service decided to suspend Bawa-Garba for just 12 months, having taken into account the various mitigating factors which the court had declined to admit as evidence. However, the GMC, a regulatory body ‘that is widely viewed as alienated from the realities of clinical practice’, went to the High Court to have her struck off in the ‘public interest’.
A very moving article in today’s Telegraph by Dr Kimberlie Gard, who had worked with Dr Bawa-Garba, describes, amongst other things, the fear and anxiety which currently seem to hover over so many junior doctors. The situation faced that night in 2011 by Dr Bawa-Garba may have been particularly difficult and stressful and may well not be replicated in every hospital in the UK (although this may be a moot point). It is unarguably the case that many junior doctors could relate completely to Dr Gard’s description of her medical training as having transformed her from a ‘confident, capable young woman’ into a ‘perfectionist… filled with anxiety’. I have seen the same transformation in my own daughter who started her first F1 rotation earlier this week. Friends who are ahead of her (having not intercalated with a degree year) have spoken of ‘absolutely the worst year of my life’ and all are fearful of making a mistake and the consequences that might entail – both in terms of putting a patient’s life at risk and their own career in jeopardy.
Dr Bawa-Garba’s High Court appeal has been crowd-funded mainly by other doctors, all of whom consider that the current culture of blame is positively detrimental to long-term patient safety. As Dr Gard points out quite reasonably in her article, Jack Adcock’s death was not in fact caused by the doctor, the nurse, the hospital or indeed anyone else. It was caused by bacteria. An overstretched and understaffed system failed to save him, but no-one maliciously killed him. (Sepsis apparently has a 45% chance of causing death ‘even when hospitals are fully staffed with working equipment).
Dr Gard argues that the culture of blame which predominates encourages doctors to hide mistakes rather than learn from them. She also points out that medics do not need punishment to feel bad about any mistakes they make (let alone ones that prove fatal). She herself did not have the self-confidence to return to work after her own maternity leave in 2012, having already experienced severe anxiety and depression resulting from her experience of working in the NHS. She claimed she felt intimidated to ask for help and that ‘encouragement was scarce’. All those comments chime so clearly with comments made by my daughter’s contemporaries. Do the NHS and the GMC really want to make practising medicine in this country such a terrifying prospect; one where all those years of study and sacrifice can be removed by regulators at the stroke of a pen?
Nicky Adcock, the mother of Jack, appears to believe that striking Dr Bawa-Garba off the register was absolutely the right thing to do and she managed to whip the media and the tabloid press into a frenzy of biased reporting (headings such as ‘Downs Boy Death Doctor Seeks Return to Work’ from Sky News). She holds the view that allowing Bawa-Garba to return to work would be ‘a mockery of justice’. A mockery of justice is the fact that individual culpability is prosecutable, but that systemic failure is not; a mockery of justice is the fact that the doctor’s own confidential reflections (a routine learning tool) on the situation that night were used as evidence against her during the hearing process.
As fellow doctor and freelance journalist Ahmed Khan wrote in his article for the Independent in February, he worried that ‘I, or any of my colleagues, could have made the same mistakes’. He points out that the ‘verdict is shocking because these kinds of institutional failures are experienced by most British doctors’. Phil Whitaker, author and former doctor, makes a similar argument in his article for the New Statesman last November. So, if mistakes are to be punished by erasure from the register, why, apart from supreme altruism, are junior doctors going to continue to work under a system which holds them criminally responsible and punishes them for institutional and systemic failures? Combine all this with an increasing feeling of entitlement coupled with a growing lack of respect from the general public and it is not hard to see why serious disillusionment is rife amongst our junior doctors.
Let us hope for all our sakes that this week the vicious and vindictive pursuit of a caring and dedicated doctor will cease and that the courts will have the common sense to overturn the decision urged on them by the GMC. Perhaps too in its own review, set up following the backlash to its decision from the profession, the GMC will have the vision to tackle the existing system which instils fear above all else into the daily lives of so many doctors. (An excellent BMJ article by the broadcaster and President of HealthWatch, Nick Ross highlights the dangers of GNM as well as the fact that in most cases criminalising doctors does not make patients safer.) I personally would also like to wish Dr Kimberlie Gard every success in her bid to return to medicine following her time as a full-time mother (and part-time writer).