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?
Dr Bawa-Garba had just returned from maternity leave and was the on-call pediatric registrar at Leicester Royal Infirmary on Friday February 18th, 2011. Instead of having a registrar each covering wards, the emergency department and the Children’s Assessment Unit, Dr Bawa-Garba had to cover all three positions alone on that day. Adding to her woes, the IT system at the hospital was down and she had to chase up pathology results manually. During that shift, she not only took referrals from GPs, ED, midwives and surgeons, attend to emergencies in the ward, she also had to supervise her intern and a junior trainee. Her supervising consultant was teaching in a nearby city.
At 10.30 am, 6 year old Jack was referred in by his GP with vomiting and diarrhoea. He had a history of repaired AV defect and was on enalapril. Assessed to be dehydrated, intravenous fluids were prescribed but a CXR and bloods including blood gases were ordered. The gases showed that Jack was acidotic but following iv fluids, a repeat blood gases showed that he had improved.
The Xrays were performed at 12.30pm but it wasn’t till 3pm when Dr Bawa-Garba saw the films. It showed that Jack had pneumonia and antibiotics were prescribed. At 4.30 pm, she met her consultant in the corridor and showed him the gas results. She discussed the plan with him. He did not see Jack and no alarm bells were raised.
In the ward, she specifically stated in her plan that enalapril should be omitted but it was still given. Within an hour of enalapril, Jack had a cardiac arrest. After vigorous attempts at resuscitation, interrupted for a minute by Dr. Bawa-Garba’s mistaking Jack for another child who was not for resuscitation, Jack was pronounced dead.
After Jack’s death, she was encouraged by her consultant to record her failings in her electronic portfolio. She was asked to “reflect” on the case. In a cruel twist, her reflections was later used against her in court!
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
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.
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.