To err is human… actually, it’s now manslaughter!

February 2018, Dr Chee L Khoo

I am sure you have read about Dr Bawa-Garba who was “thrown under the bus” by the system for her treatment of a 6 year old child with Down’s syndrome who died of sepsis while being treated in hospital. . There have been many discussions in UK and internationally about the ramifications of the court and tribunal’s decisions  but what can GPs in Australia learn from this case?

She was initially charged with “negligence manslaughter” in 2014, convicted in 2016 and initially, suspended for 12 months by the medical practitioners tribunal. In February 2018, she was struck off the UK medical register for life!

The case has left the UK medical professions (and medical professions from across the world) rattled

Risk management

With the advent of potent antibiotics, it is easy to be complacent when we diagnosed and treat patients with pneumonia. In the 21st century, patients still die from pneumonia. Younger or older patients and patients with other co-morbid conditions are particularly susceptible. When they deteriorate, they do so rapidly. Jack ticked most of the boxes for susceptibility. He was seen at 10.30 am and was dead by 5.30 pm. Jack happened to be managed in hospital but he could easily be managed in general practice by one of us. We need to know whom we can send home and see in one week and whom we need to be worried and review  closely or send to hospital tonight. It is all about risk management. I am not suggesting that Dr Baba-Garba did not recognise the gravity of the sepsis in Jack. To the contrary, she did  but she was distracted big time which leads us to the next issue.

Mitigating factors?

Dr Baba-Garba was convicted of homicide. Sure, in retrospect, there were gaps in her management. Homicide? Seriously? Jack’s blood gases were deemed characteristic of sepsis. If they were so characteristic, why did her supervising consultant not instantly diagnose sepsis when he saw the blood gases? Or is it characteristic only in retrospect?

Dr Baba-Garba was running off her feet doing the job of 3 doctors. The IT systems were down. She had to manually chase up the results. It was some hours after the xrays were done before she got to see them causing a delay in commencing antibiotics which the expert witnesses opined that had Jack received antibiotics within 30 minutes, rather than 6 hours, his chances of survival would have increased dramatically.

What is obvious and a lesson for all of us to learn is that “I was too busy” is never accepted as an excuse for poor patient outcomes. Despite recognising the failures of the fund-strapped NHS, Dr Baba-Garba was held responsible for each one of those failings. If you work in an organisation, a centre or a system which is not conducive for you to practise safe medicine, beware. You could be another Dr Baba-Garba in the making. You are on your own if things go wrong.

Protecting the public?

The UK’s General Medical Council (GMC)’s purpose is to protect patients and guide doctors. Does throwing Dr Baba-Garba under the bus consistent with that purpose? Removing her from the register indefinitely will not ensure another Jack will not occur. Striking her off the register is just grandstanding to divert attention from the failings of the system. She was a scapegoat for the failings of the system in more ways than one.

Can this happen in Australia? You bet.