What is the Bawa-Garba case?
Jack Adcock, a six-year- old boy, was admitted to the Children’s Assessment Unit at Leicester Royal Infirmary on Friday 18th February 2011. He was assessed by resident doctor Hadiza Bawa-Garba, a paediatric registrar in her 6th year of training, and under Dr Bawa-Garba’s observation, Jack Adcock suffered a cardiac arrest at 8pm the same day and died at 9:21pm in part due to a series of failings in his treatment.
Why is the Bawa-Garba case an important topic for prospective medical students, current medical students, doctors and healthcare professionals in the UK?
Dr Bawa-Garba was found guilty of manslaughter on the grounds of gross negligence on 4th November 2015 by High Court. Along with her, Ms Amaro (an agency nurse) was also convicted of the same offense and Ms Taylor (the ward sister) acquitted. This case has brought national discussions on medical ethics, legal considerations and the continuous pressures faced by healthcare professionals that could risk patient safety and jeopardise public trust. The case has also exposed the ultimate consequences of the NHS staffing crisis, the role of electronic medical records and communication failures within the healthcare system.
Background on Dr Bawa-Garba and Jack Adcock
February 2011 – Dr Bawa-Garba is a junior doctor employed in the Children’s Assessment Unit at Leicester Royal Infirmary, at her 6th year of speciality training. She has recently returned to practice as a registrar at the hospital following 14 months of maternity leave and was the most senior junior doctor on duty.
Jack had been diagnosed from birth with Downs Syndrome (Trisomy 21) and he had a surgery as he was born with a ‘hole in the heart’ thus he required long term medication called enalapril. He had been referred by his GP the same day as Jack presented with dehydration caused by vomiting and diarrhoea, shallow breathings and slightly blue lips. When admitted to the hospital (at about 10:15 am), he was unresponsive and limp, showed clinical signs of septic shock like slow capillary refill time, breathlessness, cyanosis and lethargy. However, despite obvious evidence of both infection and organ failure, it has been argued that Dr Bawa Garba failed to make the right judgement for his initial diagnosis of acute gastro-enteritis and dehydration.
Timeline of Jack Adcock's treatments
When Jack was admitted, Dr Bawa-Garba ordered a chest X-ray that showed an infection. The X-ray results were available from 12:30pm but due to a lack of system to notify Dr Bawa-Garba that the X-ray was ready to be analysed, she did not view the results until 3pm. Dr Bawa-Garba subsequently prescribed antibiotics for pneumonia, which were administered at 4pm. This has questioned whether Jack Adcock’s condition would have improved if he was given appropriate medication for the right diagnosis much earlier. Furthermore, due to failings in the hospital computer system, Dr Bawa-Garba was unable to obtain the results from the blood tests she ordered on her initial examination at 10:45am. The blood test revealed high levels of C-Reactive Protein (CRP), which highlights the presence of inflammation in the body.
It has been argued that the failure to review this critical blood tests is not due to Dr Bawa-Garba’s incompetency as a doctor in the CAU but due to the hospital computer system prolonging blood testing results, and the alert system designed to flag up abnormal results on computer screen being out of action. During the trial, the prosecution highlighted Dr Bawa-Garba’s ‘failure to make proper clinical notes recording times of treatments and assessments. Dr Bawa-Garba stopped a medication (enalapril) for Jack’s heart condition, but she did not document this in his notes. This led to Jack’s mother administrating the medication to Jack at 7 pm, unaware that he is not to follow the usual course of treatment for his heart condition. It has been established that these actions could have contributed towards his death but did not directly cause it. The prosecutors stated Jack’s death was due to incorrect diagnosis and “serious neglect” by staffs as nurses did not notify Dr Bawa-Garba that Jack was deteriorating and thus the doctor was falsely reassured that her treatment was improving the patient’s condition. This was evident when Dr Bawa-Garba did not raise any concerns about the patient to Dr Stephen O’Riordan at 4:30pm and then to another consultant at 6:30pm and stated, ‘Jack had much improved and was bouncing about’. However, Nurse Amaro had failed to properly observe the patient and to communicate Jack’s deterioration to Dr Bawa-Garba. The nurse further turned off the oxygen saturation monitoring equipment without telling Dr Bawa-Garba and the nurse failed to mention Jack’s high temperature or the extensive changing of his nappies and did not record them regularly.
Unfortunately, Jack Adcock suffered a cardiac arrest at 8pm. Dr Bawa-Garba arrived at a scene of resuscitation on the patient, on ward 28. In the morning, Dr Bawa-Garba was on the same ward for a terminally ill patient who had a DNAR order. Without asking anybody for the name of the patient now, she assumed it was the same boy, unaware that Jack was moved to ward 28, she declared that Jack was not for resuscitation. The mistake was identified by another junior doctor and the resuscitation re-continued. At 21:21 the decision was made to stop resuscitation, and Jack was declared to have died of sepsis.
What went wrong that day?
1. Dr Bawa-Garba had been working a double shift that day (12/13 hours) straight without any breaks and she was covering for another doctor voluntarily. When asked about her mistake on the DNAR order: “Is it symptomatic of your behaviour that day that you rushed to a decision without checking?” She said: “It’s not that. It’s a reflection of how long I had been working without a break.”
2. There was a staff shortage issue where two of the three CAU nurses were from an agency and not allowed to perform many nursing procedures, meaning Dr Bawa-Garba was under sustained pressure; along with carrying the bleep where she responded to urgent medical cases in the A&E unit.
3. There was a lack of computer system to alert Dr Bawa-Garba that the X-ray results were ready to be examined or that the blood test was ready to be reviewed. Technical delays led to hindering the treatment of Jack’s condition.
4. Both Dr Bawa-Garba and Nurse Amaro failed to record treatments and Jack’s conditions throughout the day, which led to miscommunications and wrongly administrating medications.
5. The prosecutor stated that Dr Bawa-Garba failed to seek assistance from senior consultants. However, the hospital was heavily understaffed and the consultant (Dr Stephen O’Riordan) who was supposed to be on charge that day was not at the hospital until 4pm and the handover happened at 4:30pm. Moreover, there was a miscommunication during the handover, where Dr Bawa-Garba assumed Dr O’Riordan would go see Jack because he asked for further tests, but he did not visit Jack.
Conclusion
The Bawa-Garba case has highlighted the importance of reflections, better recognition of sepsis, maintaining public confidence in the profession and supporting doctors and healthcare professionals after medical failures. Moreover, the case encourages discussions about the degree of appropriate punishment for doctors regarding actions below the minimum standard of delivering patient care, the importance of a speaking-up culture in healthcare and the prominent existence of the blame culture in the NHS. As of July 2021, The Medical Practitioners Tribunal Service ruled that Dr Bawa-Garba is now fit to practise without restrictions.
Written by Tasfiha
Moderated by Adelene
References
https://www.facebook.com/bbcnews (2015). The inside story of a six-year-old boy’s death. And the trainee doctor who took the blame. - BBC News. [online] BBC News. Available at: https://www.bbc.co.uk/news/resources/idt-sh/the_struck_off_doctor .
Premela (2021). Bawa-Garba Case. [online] The Medic Portal. Available at: https://www.themedicportal.com/application-guide/medical-school-interview/nhs-hot-topics/bawa-garba-case/ .
Dr Hadiza Bawa-Garba: Struck-off doctor can return to work. (2019). BBC News. [online] 9 Apr. Available at: https://www.bbc.co.uk/news/uk-england-leicestershire-47859826 .
Laddie, J. and Hannett, S. (2018). HadizaBAWA-GARBAAppellant-and - THE GENERAL MEDICAL COUNCIL Respondent -and- THE BRITISH MEDICAL ASSOCIATION (1) THE PROFESSIONAL STANDARDS AUTHORITY FOR HEALTH AND SOCIAL CARE (2) THE BRITISH ASSOCIATION OF PHYSICIANS OF INDIAN ORIGIN (3) Interveners Approved Judgment. [online] Available at: https://www.judiciary.uk/wp-content/uploads/2018/08/bawa-garba-v-gmc-final-judgment.pdf .
New measures to protect doctors after Bawa-Garba case. (2018). BBC News. [online] 10 Jun. Available at: https://www.bbc.co.uk/news/health-44413443 .Jack Adcock: Doctor struck off over six-year-old’s death. (2018). BBC News. [online] 25 Jan. Available at: https://www.bbc.co.uk/news/uk-england-leicestershire-42816913.
Tran, M. (2015). Leicester doctor convicted over death of six-year-old boy. [online] the Guardian. Available at: https://www.theguardian.com/uk-news/2015/nov/04/leicester-doctor-convicted-over-death-of-six-year-old-boy .
