It is exceptionally rare for a doctor to be convicted in a criminal court for gross negligence manslaughter which is why the case of Dr Bawa-Garba, who received a suspended sentence in 2015 for her role in the death of a child in 2011, has received such widespread attention.

Opinions over whether or not Dr Bawa-Garba was treated justly became polarised between those who believe that the doctor's actions alone contributed to the tragedy, and those who believe that she was a victim of endemic systemic failures within the hospital where she worked. The case is back in the headlines because the GMC's decision to strike her off the register has been overturned and she is back in possession of her practising certificate.

Multiple failures led to errors

A detailed examination of her case was conducted by the BBC's Panorama programme earlier this month (August 2018). The programme revealed a catalogue of errors from the time Jack Adcock was admitted to the University Hospitals of Leicester NHS Trust with vomiting and diarrhoea, to the moment he died, some 12 hours later, from sepsis. But what is particularly notable is the context in which those errors were made: the doctor had just returned from maternity leave, was working in a unit she was unfamiliar with, senior members of staff were absent, including the consultant whose diary was double booked, and the hospital's IT system went down for a crucial period during the day. After the child's death, Dr Bawa-Garba logged her reflections, as doctors are encouraged to do as part of the continual learning process, and concluded that she could have done better (this was used in evidence against her in court).

Unacceptable care experienced by 25% of patients

But what Panorama also revealed was that the systemic failures uncovered by the review following Jack's death were not immediately addressed. In 2013 local GPs noted that the hospital's Summary Hospital-Level Mortality Indicator (SHMI) was much higher than it should have been. As a result a public health consultant was appointed to find out why. He and his team researched patients' notes to find out what sort of care they had received. The results made alarming reading: 25% of patients had received unacceptable care against a norm of 10%. The list of issues uncovered included incorrect interpretation of 'do not resuscitate' orders, delayed antibiotics, failure to detect serious illness, unexpected deterioration, medication errors and IT failures. The following year (2014) Leicestershire GPs expressed their concerns again and wrote to Jeremy Hunt and Simon Stevens describing Leicester as on a 'par with Mid-Staffs'.

The unsafe working conditions at the hospital were echoed by doctors working in other NHS hospitals throughout the UK as they came out in support of Dr Bawa-Garba, describing their own experiences of working in understaffed, poorly managed hospitals – as well as the deleterious effect that her case had had on the promotion of open and honest dialogue about mistakes.

Put individuals' errors in context

That Dr Bawa-Garba's honest reflections on what went wrong on that fateful day were used in evidence against her, added to doctors' fears that the admission of a mistake was tantamount to an admission of negligence or worse. In 2014 Jeremy Hunt was actively pushing for a more 'compassionate and transparent culture within the NHS' – the outcome of Dr.Bawa-Garba's case seemed to throw this into jeopardy. If hospitals are unsafe, and medical staff are working in conditions which are almost guaranteed to cause mistakes then this needs to be acknowledged in the context of doctors' reflections on what went wrong. When David Cameron, then prime minister, asked Professor Don Berwick, then president of the US Institute for Healthcare Improvement, to advise on improving patient safety, one of his recommendations included moving away from blaming an individual looking to learn from errors. If doctors are worried that their honest self-appraisals will be used as a stick to beat them with when the chief contributory culprit is the unsafe environment in which they are working, then they simply will not own up to mistakes, lessons won't be learnt, and people will continue to die unnecessarily.

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