Review Ordered by Health Secretary Into Criminalising Medical Malpractice Cases

Wednesday 7th February 2018

The Home Secretary, Jeremy Hunt, has ordered a review urgently looking into how medical malpractice cases are handled after an outcry by doctors over the handling of the manslaughter case looking into the death of Jack Adcock.

The review will look into concerns into specific aspects of the case, and whether the effects of the case have created a culture where lessons cannot be learned for fear of individuals being criminalised. It will also look into the extent systemic failures in the health service contributed to the 6 year old’s death.

Hunt has stressed the need for clarity between ordinary mistakes that contribute to a catastrophic outcome and gross negligence.

The case in question concerns Dr Hadiza Bawa-Garba, a junior paediatrician who was due to rota gaps alone in charge of the Accident and Emergency and Children’s Assessment Unit of Leicester Royal Infirmary on 18th February 2011. Adcock was brought in, a child with Down syndrome and a known heart condition, who was vomiting and struggling to breathe.

During the course of his treatment, Bawa-Garba made a number of mistakes with his treatment, most importantly failing to diagnose a case of sepsis, which would directly cause the cardiac arrest that would claim his life that night.

Bawa-Garba, as well as a nurse, Isabel Amaro, would be convicted of manslaughter by gross negligence and would receive a two year suspended sentence. Amaro would be struck from the nursing register, and, after an initial 12 month suspension, Bawa-Garba would also be struck off the GMC register on the 25th January of this year.

Over 800 medics have signed a letter of support for Bawa-Garba since, with the argument that she has become a scapegoat for major systematic issues in the hospital, and being blamed for consequences of a culture of understaffed hospitals, what staff there is being dangerously overworked.

There is also the risk that the e-portfolio that Bawa-Garba used to reflect on her medical practice was used against her to some degree, causing people worried of ending up in a similar situation to be far more reticent to be open and reflective of their work, since it could end up working against them and, as in the case of Bawa-Garba, cost them their job, the ability to practice medicine and give them a serious crime on their criminal record, damaging their prospects to get employment elsewhere.

Whilst it is clear serious mistakes were made, to lay them completely at the feet of Bawa-Garba is completely at odds with attempts to learn from mistakes. Adcock’s death was caused by systematic failures on top of individual mistakes. The failure to diagnose the ultimately fatal sepsis could have been caused by a number of factors beyond individual culpability, including computer errors that delayed test results. Bawa-Garba was covering the workload of two other doctors.

The results of the inquiry will be interesting and possibly as far reaching to paediatric care as the Lamming inquiry into the death of Victoria Climbie was to child protection.