Should the NHS get rid of the *BLEEP*ing pager?

From the Oxford Handbook for the Foundation Programme (2nd edition) by Hurley, Dawson, Saunders & Eccles

In some sort of weirdly morbid onomatopoeia, the pagers which junior doctors carried all across the country are called “bleeps”. My Dad did his first house job in the UK in 1968 and they were introduced shortly afterwards. Up until that point, they had some weird light system which given my Dad has been telling the same 5 stories for about 50 years, you’d think I’d remember how it worked..

My bleep number as an F1 (Foundation Year 1 – first-year doctor) was 7144. If a nurse wanted to get in contact with me, they had to dial a prefix (let’s say 77), then the bleep number (7144), then the extension they were phoning from (let’s say 26723). So they’d dial 77 7144 26723. My bleep would bleep and the number “26723” would appear on my bleep. I would then find a phone, ring 26723 and they’d answer the phone.

There are significant advantages to this system. In the ten (I think) hospitals I’ve worked at over 9 years in the NHS, the system was roughly the same in each hospital. It worked throughout the hospital grounds (with one key exception). It’s been around so long, even the oldest, most technophobic staff understood how it work.

The actual bleeps themselves were fairly bulletproof. Whilst perhaps not as robust as the Nokia 3210 (it’s pronounced “thirty-two, ten” for you youngsters), you could certainly drop it without worry it was going to break. They rarely need batteries changing and the AA batteries they run off were readily available from switchboard.

It ain’t broke so, why fix it?

There are a whole bunch of issues with a bleep. By way of example:

  1. You bleep somebody and they don’t bleep back – how long do you wait?
  2. You get a bleep and phone back but get an engaged tone. Do you wait for the person to bleep you again or do you wait and then phone back on the same number?
  3. You answer a bleep but nobody is picking up. How long do you wait before hanging up?
  4. You bleep somebody but then the person that rings back isn’t the person you bleeped. You then have to go and find the person they’re ringing to speak to. Do you wait until that conversation is over or do you go and bleep from another phone? How long does the conversation have to go on for before you bleep from another phone?
  5. You get two bleeps in a row. The second bleep wipes the number of the first bleep. You don’t know how to bring the first number back because there are three buttons on the bleep with icons you don’t understand.
  6. You are seeing to a sick patient and get a bleep. There is nobody nearby. Do you leave the sick patient to answer, go and find somebody else to answer, or ignore it and hope they’ll bleep back.

Taking 30 minutes, sat in front of a phone, trying to contact somebody is a waste of everybody’s time. It has happened so many times in every doctor’s career.

Everybody’s got mobiles now, don’t they?

I spend a lot of time in theatres. Theatres are often in the basement of a hospital. As such, reception can often be very poor. Historically, hospitals restricted access to Wi-Fi (though this is largely changing); thus even Wi-Fi calling couldn’t get you through to people. Where Wi-Fi is available, this is useful for calling people but you can’t send anonymous patient data via messages.

Out-of-hours (OOH), it’s patently not feasible to have every doctor on internal medicine give their mobile phone out to every medical ward, especially if you’re covering multiple wards where you don’t normally work. And I wouldn’t be comfortable with my mobile being accessible to that many folks anyway.

What are the alternatives?

In terms of inter-doctor communication whilst on-call, now I’m on anaesthetics or ICU, I work in relatively small teams of doctors. For instance, when I worked at a tertiary children’s centre, there was me on-site and a consultant anaesthetist at home. Us having each other’s phone numbers worked well and we could actually text each other patient data as long as it didn’t use any specifics.

Hospital-at-night (now more accurately hospital-out-of-hours (OOH)) coordinators are wonderful things for bigger teams, particularly for the more junior junior doctors. They are nurse practitioners who triage OOH calls into job lists for doctors on-call.

Instead of an on-call junior having to stop to answer their bleep every time anybody needs them for something regardless of how urgent, they can work through their list overnight. It also means that sicker patients get triaged to more senior doctors by the nurses. Even in a world with mobiles which nurses could ring, it would clearly be frustrating if you got phoned every time you were needed.

Whilst I was an F1 in 2010-11, the hospital piloted Blackberries with an app which sent you your list of jobs. You ticked them off as you went along on the app and this let the OOH coordinator how busy you were. I assume it was more efficient; it was certainly less stressful.

Glorious! Let’s just switch it all online!

Woah, there. I’ve worked in hospitals where bleeping is online, ones where the nursing observations are online, ones with prescribing online, ones with notes online and currently work on an ICU where everything (with some minor if important exceptions) is computerised. Blood results and investigations are the only things which have been online in every hospital I’ve worked at.

A new system always come with problems. At one of the hospitals I worked at, the problem was there was a dead zone for bleeps. Unfortunately, it was on ICU where I, as the 2nd on-call for anaesthetics and ICU, covered crash Caesarean sections and paediatric arrests. If either went out, switchboard would have to ring ICU to ensure I wasn’t there.

They introduced a slightly bizarre system where the crash team carried mobile phones which said “cardiac arrest” when there was an arrest call (I think they’d set it as the ringtone). Being modern-ish mobile phones, the batteries didn’t last very long and even though there were (eventually) chargers and battery replacements, if you were busy and forgot your phone only had 30% charge, when you later went to put your head down for an hour, you might not realise it had run out before you woke up.

(They also introduced a replacement to the bleep system which relied on Google Hangouts. Unfortunately, Hangouts is due to be retired at the end of the year so, that’ll be fun for them. I thankfully don’t work there any more.)

All the systems I mention have had teething problems. The biggest issue is not user-friendliness (though that can be an issue, particularly for short-term or supply posts). It’s generally that the NHS usually has rubbish hardware. So even if you introduce your fancy new app, it doesn’t work.

So is Matt Hancock right?

To be honest, probably.

Whilst not an early adopter, I am quite happy trying new technology. The ICU system I mentioned earlier is the best NHS computer system I’ve used; indeed I and most of my colleagues agree that it is very likely to have saved lives. When I have to go back to ICUs that use paper, I just find the whole thing incredibly frustrating.

Computer systems are like any other system. There is an inevitable period of change. They need to be slowly but surely improved and updated. It will, frankly, probably be crap for at least the first 12 months.

But my question to folks who want to keep the bleep is this: would you be happy to return to paper blood results and films for X-rays? And if you’re not somebody who has to regularly bleep people, this probably isn’t the debate for you.

Like any government initiative, I await it with large and healthy doses of cynicism but this is a much more sensible challenge that Jeremy Hunt and Andrew Lansley who respectively took on junior doctors’ pay and the entire structure of the NHS.

Trying to get rid of bleeps seems a much more feasible and achievable goal, if for no other reason than a lot of trusts have made waves to do it. It just needs to be done right; that’s where I remain cynical of any government initiative.

PS: If you want to hear my fun opinion about fax machines, it can be found here.

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Leaving a political party

So this post isn’t a judgement about the newly formed Independent Group (TIG) and its 11 members (Tiggers) per se. Rather, just a comment on what it’s like being in a party.

I’m a pretty minor activist in the Liberal Democrats. I’m on the local branch executive (a subset of the local party which represents Sheffield) and I’m a candidate for a very much non-target seat.

In the 4 years since I became a Liberal Democrat, I’ve enjoyed being a part of the party. I have my frustrations and it is a lot of hard work. But when I look particularly at my branch and my constituency, I believe our candidates will make Sheffield and the country better places to be.

I cannot imagine being active in a party for years and decades and seeing that fall away. To feel so alienated that your party no longer feels like the one you joined. It was probably how many Lib Dems felt when the party entered coalition. And it is clearly how members feel about both government and opposition now.

Throughout a campaign, you bond over your shared beliefs and shared experiences. The challenge of living in a city which has letterboxes round the back and the front; meetings which go on longer than anybody intended; and the decision as to when to ask a (usually older) councillor to sum up their point because they’ve spent 5 of the 10 minutes of their Q&A rambling. Victory is sweeter and defeat easier to bear when they’re shared.

The MPs will have left with heavy hearts. Many in their local parties will have been enraged, old friendships broken, and cries of “traitor” will still be ringing in the ears.

Whatever your opinion of TIG – cynical opportunist carreerists or MPs willing to put their country first – the choices weren’t made lightly. For whatever they’ve gained, they’ll have certainly paid a hefty personal price.

What is going on?

So, 7 and then 8 Labour MPs and 3 Conservative MPs have formed the Independent Group, now being abbreviated to TIG (hopefully meaning we can refer to them as Tiggers soon).

The Home Secretary has stripped a teenager of her British citizenship for joining ISIS as a child, potentially breaking international law.

A Tigger did a racist on TV only to have the headlines fall squarely back on Labour when another MP claimed TIG may have been funded by Israel.

A former member of Militant who was booted out of Labour 34 years ago was readmitted then booted out again two days later for antisemitic tweets he’d made in the past (and stood by).

David Cameron has claimed the three ex-Tory Tiggers should have stayed to form a “modern, compassionate Conservative party”, presumably being unaware of events since his resignation and subsequent exile to his shed to write an increasingly irrelevant memoir.

A UKIP MEP suggested he’d stand for the Conservatives against Anna Soubry only to be told his application to be a member had been rejected (although his tweet sort of implied he was going to fight Soubry).

And there’s an amusing video of the Labour candidate for the North East mayoralty being unable to define Labour’s Brexit position (even though now it’s actually fairly clearly a customs union).

And Bernie Sanders is running for president again.

Anyway, I’m going to bed on the suggestion that apparently there are to be more defections tomorrow.

Some Muslims are angry a gay told their kids “hey, it’s OK to be gay”

Whilst posting this breaks my “try not to get distracted, you’re supposed to be revising” rule, I was intrigued by the story of Muslim parents protesting Andrew Moffat teaching No Outsiders, a book he wrote which, I think, is now used to teach the Equality Act 2010 (including LGBT rights, the ostensibly contentious issue) to kids.

Let’s be clear – the Muslim protestors are wrong albeit not representative of all Muslims. That said, a 2016 ICM poll found that 52% of UK Muslims thought homosexuality should be illegal (I couldn’t find a comparison with the general population) and that 47% thought gays were unacceptable as teachers (14% for the general population). Perhaps then, they’re representative of quite a lot of Muslims.

LGBT rights and Islam is a strange intersection for progressives with Islamophobia itself something of a nebulous term. Attacks on Islam aren’t per se racist but often anti-Muslim bigotry is inextricably mixed with racism. The EDL thinly veil their racism with claims they simply oppose Islam. Clearly shouting “raghead” at a woman wearing hijab is both anti-Muslim bigotry and racist.

But how about claiming it’s wrong to wear hijab? One could argue it’s Islamophobic; but what do you say to the woman who’s escaped Saudi Arabia to the UK who only wore it on pain of a beating? To her, it’s a symbol of oppression being proudly worn by British citizens.

Subsequently claiming Islam is an awful, medieval religion maybe insensitive and even unhelpful but it is certainly not racist, particularly if it comes from an ex Muslim. And it’s clear that a gay teacher telling children it’s OK to be gay (some of whom know or will conclude they are gay themselves) should be defended.

There are a couple of things to conclude from this. Firstly, LGBT rights trump rights to religious expression. Being religious is a choice, no different to holding political beliefs. Being LGBT is not something you can change though even if it were is not something you should have to.

Secondly, I strongly suspect that were this a predominantly white Christian group à la the Westboro Baptists, progressive protestors would have been out in force, defending Mr Moffat. Muslims don’t get free passes for being bigots. It does sometimes feel that progressives are concerned with protesting against brown groups for fear of looking racist, forgetting there are plenty of gays and atheists who are brown too.

One can argue British Muslims don’t have a responsibility for every terrorist act committed by a Muslim extremist. It’s harder to argue that they don’t have responsibility for the homophobia so pervasive amongst their communities; we should all be holding them to account.

Dr Hadiza Bawa-Garba – Part 1: what does this case look like to medics?

Dr Hadiza Bawa-Garba, a paediatric specialty registrar, was struck off the specialist medical register a few days ago. Pulse, a GP magazine, provide a timeline for her case. In summary:

  • 18/2/11 – Jack Adcock, a 6 year-old boy, dies in Leicester Royal Infirmary of sepsis secondary to pneumonia whilst under the care of Dr Bawa-Garba.
  • 2/11/15 – Isabel Amaro, a Portuguese agency nurse involved in his care, is convicted of gross negligence manslaughter and is later struck off.
  • 4/11/15 – Dr Bawa-Garba is convicted of gross negligence manslaughter.
  • 29/11/16 – She applies to the Court of Appeal for “leave to appeal”; it refuses her application.
  • 13/6/17
    • She is suspended from the medical register for 12 months by the Medical Practitioners Tribunal Service (MPTS).
    • The MPTS reject an appeal from the General Medical Council (GMC) to strike her off the register.
  • 25/1/18 – She is struck off the medical register by the GMC following their appeal to the High Court.

Dr Bawa-Garba will no longer practise medicine in the UK.

Sources

I am neither a lawyer nor a paediatrician; my opinions are my own. Further, I do not have the transcript from the 2015 Crown Court trial – my sources for the original trial are the judgment from the 2016 Court of Appeal hearing. the Record of Determinations from the MPTS tribunal in February & June 2017 and the 2018 judgment from the High Court. I don’t have access to the coroner’s inquest.

54000 doctors is a website set up by Dr Chris Day, an Emergency Medicine trainee who fought a legal battle against Lewisham and Greenwich NHS Trust over whistleblowing. On it, is a letter concerning Dr Bawa-Garba’s case signed by four paediatricians and another doctor involved in the Child Death Review for a London Clinical Commissioning Group.

I have purposefully referred to this letter sparingly as I cannot easily verify the facts within it.

The story

Jack had a background of Down’s syndrome. He was on enalapril for a heart condition described as a “hole in the heart”. He also had a bowel abnormality. He was prone to chest infections. When well, he was a happy child who enjoyed playing with his sister.

10:15 am – Jack arrives at the Children’s Assessment Unit (CAU) from the GP having been off school the previous day. In the surgery his breathing was shallow and lips slightly blue.

10:30 am – Jack is admitted to CAU.

10:45-11am – Dr Bawa-Garba reviews him. He presents with a 12-hour history of diarrhoea and vomiting. He is lethargic and unresponsive and does not flinch when a cannula is inserted. His peripheries are cold and his temperature is raised.

Dr Bawa-Garba takes a blood gas. He is acidotic and has a high lactate.

A “blood gas” is a blood sample taken for analysis of partial pressures of specific gases, ie levels of carbon dioxide and oxygen. Machines for blood gas analysis are available in emergency departments, intensive care and, depending on the hospital, other areas.

The test also shows levels of blood acidity, lactate levels and bicarbonate levels. More modern machines can show levels of electrolytes and haemoglobin but these latter results are not as accurate as a lab sample. Staff can see the results within 2-3 minutes of the sample being run. This does not include time to obtain the sample and get it to the machine.

She diagnoses gastroenteritis with moderate dehydration and prescribes a fluid bolus.

11:30-11:45 am – Jack improves after being given fluids. Dr Bawa-Garba is cautious with fluid administration due to the Jack’s pre-existing heart condition.

12:01 pm – he has an X-ray during which he is “sitting up and laughing” and reacts to having his finger pricked

12:12 pm – on a second blood gas, results are better.

12:30 pm – the X-ray result is available but at this point not seen by Dr Bawa-Garba.

12:00-3:00 pm – Dr Bawa-Garba sees other children including performing a lumbar puncture on a baby. Nurse Amaro stops monitoring Jack’s oxygen saturations, records a high temperature at 2:40 pm and Jack’s nappies require frequent changing (presumably from diarrhoea). Nurse Amaro does not inform Dr Bawa-Garba.

3:00 pm – Dr Bawa-Garba reviews the X-ray and prescribes antibiotics.

4:00 pm – Nurse Amaro administers the prescribed antibiotics.

4:15 pm – Dr Bawa-Garba reviews blood tests ordered at 10:45 am. The results were not back until 4:15 pm due to a failure in the hospital’s electronic computer system. She was unable to obtain them “despite her best endeavours”.

4:30 pm – Dr Bawa-Garba flags a rising CRP (a blood test) with the paediatric consultant, Dr Stephen O’Riordan alongside the patient history, pneumonia diagnosis and treatment. She spoke to him again at 6:30 pm but does not raise concerns. There is no specific mention that she tells him about the high lactate and acidosis.

7:00 pm – Jack is transferred from CAU to Ward 28 “out of Dr Bawa-Garba’s care”. Jack’s mother administers his enalapril though this had deliberately not been prescribed. (It is unclear when she did this.) The plan to omit enalapril is not documented.

7:45 pm – Jack’s heart “fail[s]”. (I have no idea what this means!)

8:00 pm – A crash call is put out. On arrival, Dr Bawa-Garba stops resuscitation as she mistakes Jack’s mother for a different patient’s mother. The other patient has a “Do Not Resuscitate” order. With 30 seconds to 2 minutes, another doctor identifies the mistake and resuscitation is restarted.

Despite resuscitation, Jack dies at 9:20 pm.

The context

Dr Bawa-Garba was a Specialty Trainee Year 6 (ST6) in paediatrics. It takes 8 years of specialty training to become a paediatric consultant. This was her first shift in an acute setting after 14 months of maternity leave. She was asked to cover the CAU, Emergency Department (ED) and the ward.

(54000 doctors claim that there should have been a second registrar – a doctor of Dr Bawa-Garba’s level – to cover CAU, effectively leaving her doing two people’s jobs. They also claim the covering consultant was away teaching. I’ve not been able to verify these facts from the two legal sources to which I refer.)

The computer system was down for some hours. Nurse Amaro was an agency nurse who primarily worked in adult medicine. Dr Bawa-Garba worked a 12-13 hours shift without a break by the time of Jack’s cardiac arrest.

How bad is this?

So…I qualify the following comments by repeating that I was not at the trial, I was not in the hospital looking after Jack nor have I reviewed the notes. I’m not a paediatrician though I do look occasionally look after sick kids (probably more so as I’m soon moving to a paediatric anaesthesia rotation).

Initial management

Most of the initial management seems pretty decent. The diagnosis of gastroenteritis (infection of the stomach and bowel, occasionally referred to as “food poisoning”) is not unreasonable and is a condition not treated with antibiotics (indeed they can make it worse). The primary symptoms are diarrhoea and vomiting. This can lead to shortness of breath.

Dr Bawa-Garba gives Jack a fluid bolus and by the time the X-ray happens at 12:01, he’s laughing. That’s a massive improvement from the description of him being limp and unresponsive to pain initially. The second blood gas being better is also reassuring.

This is nonetheless difficult to judge. Should she have informed her consultant that there was a floppy, acidotic child with a background of previous cardiac surgery presenting with a high lactate? Possibly…but then he was getting better after she’d initiated treatment. It’s not unreasonable to initiate your treatment, see what the result is and then call the boss. Especially, if you know your senior is highly likely to institute the same plan as you.

X-ray

There is a 2½ hour delay between the X-ray being available at 12:30 pm and her review at 3:00 pm. It is impossible to say what happened in this time. Doing a lumbar puncture in a baby is no small feat. It’s entirely possible she had spent 2½ hours treating a baby with meningitis.

It also appears nobody informed her the X-ray was being done but in fairness to the nursing staff, it’s not that unreasonable – it’s the doctor’s job to chase up investigations she orders. If the diagnosis is gastroenteritis and the X-ray is not expected to be positive, it’s still understandable that Dr Bawa-Garba prioritises other sick patients over Jack and does not tell the nursing staff to let her know when it’s been done.

Dr Bawa-Garba admits she should have reviewed the X-ray earlier. It is unclear why she believes this.

Consultant discussion

This is where it gets a bit trickier. If Dr Bawa-Garba didn’t mention the blood gas results to the consultant, that’s pretty bad. Then again, at 4:30, Dr Bawa-Garba may have been unaware that Jack’s oxygen saturations were not being monitored and she was not aware of the high frequency of diarrhoea. The continuing high temperature would probably have made little difference to treatment.

(NB: 54000 doctors suggest that she did tell Dr Riordan but he thought the results unremarkable as Dr Bawa-Garba didn’t “stress” their importance. There are some numbers in the 54000 doctors letter. If any of this is true, Dr Riordan’s practice is questionable at best and at worst, gross negligence manslaughter.)

(Presumed) Cardiac Arrest

It is not specifically noted from the judgments where Jack had a cardiac arrest at 8pm. The MPTS record notes a crash call was put out at 8:00 pm so one must assume ward 28.

As an aside, some time ago, Do Not Resuscitate (DNR) orders were switched to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) – one can resuscitate somebody with fluid but this is not what a DNR is intended for.

At this point, the trial notes that Jack was beyond the “point of no return” which, from what I’ve read, is a reasonable assumption. In adult medicine, it is certainly rare for somebody to survive a cardiac arrest secondary to septic shock.

How bad was Dr Bawa-Garba’s failure to correctly identify the DNR order? To be honest, given the situation Jack was in, the 30 second to 2 minute delay will have made little difference. Even in a different situation, with otherwise good quality CPR, it would be very difficult to claim that stopping for 30 seconds to 2 minutes would be the key to surviving. I can imagine making the same mistake. I think every doctor can.

It’s worth noting Leicester Royal Infirmary is a tertiary centre for paediatrics. As such, there will likely be a number of children who have DNR orders in place ie it is probably not highly unusual. It is only human that after 12 hours with no break, she picks up the wrong set of notes (or is even handed the wrong set) and sees the DNR without checking the label properly. Yes – even in the case of a DNA-CPR order, I can imagine this happening.

Enalapril

Enalapril is an angiotensin-converting enzyme or ACE inhibitor used to lower blood pressure and treat heart failure. They are potent drugs. It is the only class of anti-hypertensive anaesthetists insist on stopping prior to surgery. From the outside, it seems odd that an ostensibly improving child suddenly went into cardiac arrest.

My best guess, and I emphasise guess, is that the enalapril may have been significant. Again, I was neither at trial nor in the hospital so I cannot say whether that’s a reasonable assumption. Without knowing the child’s blood pressures and heart rates in the intervening period between 12:00-8:00 pm. But enalapril has an onset of action of 1 hour and peak effect between 4-6 hours – it seems Jack’s cardiac arrest was somewhere between 1-2 hours after its administration.

If the nurses were asked about the drug and the mother was told she could give it despite it not being prescribed, that would be shocking. Enalapril has a long duration of action (it’s usually taken once daily); a couple of hours without the drug would have been highly unlikely to have killed Jack. The Court of Appeal notes that the deliberate nature of Dr Bawa-Garba’s omission was not documented; whilst this is good practice, it is not essential. Doctors should expect that drugs which are not prescribed are not given as regular medications are otherwise routinely prescribed.

If they were in doubt, nursing staff should have checked with doctors if the omission was deliberate. If this was simply a mother understandably doing what she thought best for her son – giving him a life-saving medication – that is a tragedy.

Questions

The pressure Dr Bawa-Garba was under was immense. Without timely blood results, a junior doctor down, 14 months out of practice, an adult-trained agency nurse on a kids’ ward with anyway too few nurses and a patient who was when she last saw him getting better and who had presented with atypical symptoms of pneumonia (although all kids can get diarrhoea and vomiting when they have an infection), I find the absence of any investigation into the wider issues difficult to parse.

Indeed, I’m left with a number of questions. (I accept these may have been answered at trial and have simply not been included in the Court of Appeal judgment’s summary of the case.)

Specific to the case:

  • What observations were done between 12:12 pm when the second blood gas was done (meaning Dr Bawa-Garba must have seen the patient) and his cardiac arrest at 8:00 pm?
  • More specifically, what were the blood pressures and heart rates, key in assessing the level of shock? (Note, blood pressures are done less frequently in children than adults but this is still a basic and pertinent observation.) How frequently did Dr Bawa-Garba request observations be done?
  • If blood pressures and heart rates were being measured, how frequently? Was Jack triggering the hospital early warning score system such that Dr Bawa-Garba should have been contacted? If he was triggering, why wasn’t she contacted? If he did not trigger it, how can it be expected that Dr Bawa-Garba know Jack is getting sicker?
  • What was Dr Bawa-Garba doing between 12:00 pm-3:00 pm? What efforts have been made to discover this? Was she seeing patients sicker than Jack had initially appeared?
  • Did Jack’s mother discuss the enalapril administration with nursing staff? If so, did nursing staff advise her either to give or not give enalapril to Jack? What prevented them from discussing this with Jack?
  • What were the blood results? Would they have made much difference anyway? There is no mention of electrolyte abnormalities. Dr Bawa-Garba already knows he has an infection. The raised CRP is marker of infection but a single result is not a particularly useful marker of infection severity.

The wider organisational issues:

  • Why was she covering GP referrals, A&E referrals and another ward? What is the usual cover for this? What efforts were made to find cover given it was a Friday and so regular administrative staff were in?
  • Why didn’t the consultant on CAU step down to do the registrar shift or the regular ward consultant step down to cover so Dr Bawa-Garba could cover CAU?
  • Even if the computer system was down, why weren’t urgent blood results being phoned through to CAU?
  • How often was CAU understaffed with nurses?
  • How often were there too few juniors?
  • Were these concerns escalated to management?
  • If they were, what did managers do?

Doctors’ vs the public’s interpretation

The reason that so many doctors have come out in support of Dr Bawa-Garba is that this just looks like a normal day in the NHS. This post is not meant to conclusively prove Dr Bawa-Garba’s innocence or guilt. It hopefully gives you an insight into some of the thoughts doctors will have reading this case. Though I’ve attempted to be neutral in this post, I can’t help but feel a kinship with those tweeting #iamhadiza.

“Manslaughter by gross negligence occurs when the offender is in breach of a duty of care towards the victim, the breach causes the death of the victim and, having regard to the risk involved, the offender’s conduct was so bad as to amount to a criminal act or omission.”

p. 7, Manslaughter Guideline Consultation, The Sentencing Council, 4 July 2017

The definition on Wikipedia is of negligence such that “it showed such a disregard for the life and safety of others as to amount to a crime and deserve punishment”. (Though this is Wikipedia.)

I suspect many doctors will read this account and think “I’m simply lucky to have not gone to jail”. I will talk more about openess in Part 2 but take this quote:

“I never, ever want another family to go through what we’ve gone through”

Nicky Adcock, mother of Jack Adcock, Leicester Mercury, 25 January 2018

For entirely understandable reasons, Nicky Adcock may have inadvertently achieved the opposite. Indeed, I cannot even begin to blame her given the tragedy she has endured.

However, consider the case of Elaine Bromiley, a woman who died after a poorly managed anaesthetic emergency. Below is the story of her remarkable husband Martin Bromiley who, rather than suing the doctors, went about trying to find out why his wife died and how he could stop it in the future. Dr Bawa-Garba’s practice was, I think, significantly better than that of the doctors caring for Elaine Bromiley yet so many more lessons have been learned from that – and probably lives saved – than will be from the death of Jack Adcock.

In Part 2 (now available), I’ll try and explain some of legal aspects and why much of the interpretation of the case is wrong but its consequences for all healthcare professionals but particularly doctors-in-training (aka junior doctors) are profound.

Edit (30/1/18): the Crown Court does not publish judgments routinely – this post previously implied otherwise. I did not mention that there had been a coroner’s inquest where systemic failures should have been examined. I also mistakenly referred to Chris Day as an EM consultant – he is an EM trainee.