Dr KK Aggarwal
Recipient of Padma Shri
A single clinical error can do away with all the good that we do as doctors.
The case of Dr Hadiza Bawa-Garba, a trainee pediatrician in the NHS-UK, convicted for homicide for the death of a child from sepsis, and hounded by the General Medical Council (GMC), is every junior doctors fear today.
Jack, a 6-year-old boy with Down syndrome was referred by a GP for nausea, vomiting, and diarrhea on February 18, 2011. At 10:30 am Jack was assessed by Dr Bawa-Garba, a trainee pediatrician in the NHS-UK, who made a presumptive diagnosis of fluid depletion from gastroenteritis and gave IV fluid bolus and started maintenance fluids. The patient had a past history of repaired atrioventricular canal defect and was on enalapril.
The doctors ordered a chest x-ray, which was done at 12.30 pm. Blood count, renal function, and inflammatory markers were also done. Blood gases showed that Jack was acidotic with a pH of 7 and a lactate of 11. The metabolic profile confirmed her working diagnosis of shock from gastroenteritis; but, judging from the tests she ordered, pneumonia was in her differential. Repeat blood gas showed pH of 7.24, heading towards a normal pH of 7.4.
Dr Bawa-Garba looked at the chest x-ray only at 3 pm, which showed pneumonia. She prescribed antibiotics, which were given at 4 pm. At 4:30 pm, she met Dr ORiordan, her boss, in the hospital corridor. She showed him Jacks blood gas results and explained her plan of action. Her boss did not see Jack.
In the ward, Jack received enalapril. Dr Bawa-Garba had not prescribed enalapril, and she clearly stated in her treatment plan that enalapril must be stopped. Nor was enalapril given by the nursing staff. But, she did not make it clear to the mother not to give it, who subsequently gave it to the child that day at 7pm (Wikipedia). He suffered a cardiac arrest one hour after receiving enalapril. CPR was interrupted because Dr Bawa-Garba mistakenly believed that there was a DNR order for Jack, but was then continued with. Jack died from streptococcal sepsis at 9.20pm.
Dr Bawa-Garba, and the two nurses who were caring for Jack, were charged with manslaughter. The doctor was not only clueless, but also grossly negligent.
Clinical errors or mistakes by the doctor cited were delay in getting chest x-ray, delay in reading the x-ray, which would have helped reaching a diagnosis of sepsis much earlier and delay in prescribing the antibiotics for the same.
Unwittingly, the court was exposing system failures, but Dr Bawa-Garba was being held responsible for each failed component. Expert doctors opined that had Jack received antibiotics within 30 minutes, rather than 6 hours, his chances of survival would have increased dramatically.
Dr Bawa-Garba was found guilty of manslaughter by gross negligence for the preventable death from sepsis; the jury returned the verdict 10:2 and was sentenced to two years in prison, suspended for two years. General Medical Council (GMC) appealed against that decision and called for Bawa-Garba’s “erasure from the medical register”.
The case made by the GMC was allowed in the High Court of Justice and on the 28th January 2018, the Court ruled that the doctor’s name be erased from the Medical Register, ostensibly to protect public confidence in the profession.
The case of Dr Hadiza Bawa-Garba and the Court action taken by the GMC against Dr Bawa-Garba and the subsequent erasure of her name from the Medical Register has created controversy, and has raised several areas of concern for doctors working not only in UK, but all over the world. One being that Dr Bawa-Garba has been unduly punished for system failings, especially the understaffing. It has also generated fear among junior doctors. A reflective note written by Dr Bawa-Garba on e-portfolio was allegedly used in evidence against her.
More than 8,000 doctors have signed a petition in her support, a crowd funding campaign has raised over £260,000 for an appeal against the decision.
Dr Bawa-Garba was held responsible for a sequence of failings.
- She did not recognize the early features of sepsis in the child and as such appropriate antibiotic treatment was delayed.
- She appeared not to recognize the implications of seriously deranged blood gas results and failed to fully communicate the implications to her consultant.
- When the child suffered a cardiac arrest there was a further problem as the patient was wrongly identified as another child for whom a DNACPR order applied.
Inquiry revealed that multiple errors and failings contributed to the mishap. No one cause could be found that led to the death of the patient.
- Dr Bawa-Garba had only recently returned to work following maternity leave
- She was covering the work of another registrar, with her supervising consultant teaching on a different site, and the two junior colleagues, for whom she had supervisory responsibility, had no pediatric experience.
- She was expected to review unwell patients and perform procedures on six wards over four floors, field the GP calls and struggle without a functioning IT system.
- The patient was shifted to a bed previously occupied by a patient with a DNR order; that change had been made without her knowledge. She was blamed for failing to recognize this.
Implications of this judgment for us
Such a case has now happened in the UK. We face this situation every day in India. And an event such as this is waiting to happen in our country.
Resident doctors can be called the backbone of the hospital. They work long shifts. At times, they may have to continue shift, which may extend to as long as 36 hours, to cover for their colleague without break, putting the needs of the patients first rather than their own. Such an overworked and exhausted doctor is liable to make mistakes.
In Martin F. D’Souza vs Mohd. Ishfaq SCI: 3541 of 2002, dated 17.02.2009, the Supreme Court of India had observed that “The higher the acuteness in an emergency and the higher the complication, the more are the chances of error of judgment...” Errors can be made in an emergency even by experts and may not amount to negligence.
The judgment in the case of Dr Bawa-Garba may impact decisions in cases of medical negligence in India too and error of judgment may no longer be a defense.
We have been fighting against criminal prosecution of doctors, but such judgments may weaken our stand on this issue.
What this judgment also implies that if you are overworked, ask for help. And, if there is staff shortage or you do not have adequate staff to share the volume of work, report it to your superior.
But even with the prevalent staff shortages, inadequate or poor infrastructure, can residents/doctors really refuse to work to save themselves from such a possible criminal conviction? And also from possible employer retribution?
Like a batsman in cricket, a single error can ruin your career.
With the rising trend of litigation and violence against the medical profession, clinical medicine may well become defensive medicine.
What can be done