Unsafe Hospital Major Contributory Factor In Doctor's Manslaughter Conviction

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...