Doctor Hadiza Bawa-Garba, Behind Six year Olds Death Hung Out To Dry
Damning new evidence suggests junior paediatrician caring for boy, six, when he died of sepsis was hung out to dry and others are equally to blame. So was she a scapegoat? The handwriting on the form analysing the events that led to the death of six-year-old Jack Adcock looks like it has been hurriedly scribbled, but damning phrases leap from the page nonetheless.
Dr Hadiza Bawa-Garba, the junior paediatrician caring for the little boy when he died of sepsis, had, wrote Dr Stephen O’Riordan, the senior consultant in charge, compromised a child in her care and demonstrated a failure to monitor Jack’s medical needs.
After reeling off a string of her mistakes, O’Riordan rounds up his report with the words LACK OF CLEAR COMMUNICATION written confidently in capitals and underlined boldly for effect.
His apparent unwavering certainty as to what had happened that day contrasts starkly with the tentative scrawl of Bawa-Garba that follows on from his words. Part faltering refutation of some of the criticism levelled against her by O’Riordan, part candid admission she could have done more to prevent Jack’s death, Bawa-Garba, 41 — a married mother-of-two with a previously exemplary medical record — wrote the system had failed the young boy and she had ‘learnt a lot’ from the tragedy.
Neither Bawa-Garba nor O’Riordan could have anticipated the lasting ramifications of this four-page document on the day they wrote it; ramifications which — seven years on — threaten to tear the medical profession apart.
A subsequent inquiry at Leicester Royal Infirmary revealed that myriad systemic failures — from IT issues to chronic understaffing — contributed to Jack’s death. But it was Bawa-Garba, along with nurse Isabel Amaro — also on duty that day — who shouldered the blame.
After both were arrested and charged with manslaughter through gross negligence, this form was appended to the prosecution’s evidence, and some doctors argue its inclusion helped secure Bawa-Garba’s unprecedented conviction and two-year suspended prison sentence at Nottingham Crown Court in 2015.
Although the Medical Practitioners Tribunal Service (MPTS) — whose job is to decide whether a doctor is fit to practise — later ruled that she could resume her career after a year’s suspension, the General Medical Council (GMC) appealed the MPTS decision at London’s High Court, resulting in Bawa-Garba being struck off the medical register last month.
Yet this paperwork is not a witness statement or, indeed, any sort of legal document whatsoever. It is a training encounter form designed purely to help junior doctors improve their performance — and, most doctors strongly assert, should never have been used in the case at all.
After all, O’Riordan — who faced no responsibility over Jack’s death and moved to Ireland, where he continues to work as a doctor — could just as easily have been implicated. He showed this form to Bawa-Garba just a week after the tragedy, at a time when she would presumably have felt intimidated and vulnerable.
Also, far from being compiled in quiet and confidential contemplation, the report was presented to her in Leicester Royal Infirmary’s canteen. Little wonder, perhaps, that Bawa-Garba refused to write her name in the space where her signature was requested.
‘Hadiza felt uncomfortable being presented with a list of things she’d done wrong and asked to sign the form agreeing to them without being given any time to think about it,’ said Dr Jonathan Cusack, a neonatologist at the infirmary who became Bawa-Garba’s supervisor as part of her retraining following Jack’s death, in an interview with the Mail.
He added pointedly: ‘Dr O’Riordan makes no reference to any of his own efforts on the form. Normally, a training form like this would be filled in together, but it was Hadiza’s idea to add her recollections to it. She was devastated by what had happened and felt it important to be honest and reflect on what occurred.’
No one, least of all Bawa-Garba, denies she made serious mistakes in her treatment of Jack, who had Down’s syndrome and a known heart condition, and died of cardiac arrest caused by sepsis 11 hours after being admitted with vomiting and diarrhoea.
Having diagnosed him with gastroenteritis, she failed to act on abnormal blood tests that would have revealed Jack was suffering from sepsis — a condition which can be fatal if left untreated — and took hours to assess an X-ray that revealed he needed antibiotics.
Yet whether her errors were criminal is another matter entirely. So, too, is the question of whether her words on this training form, written with no lawyer present, should have ended up attached to the back of O’Riordan’s witness statement after criminal proceedings started.
‘Prosecution barristers cross-examined Hadiza in court knowing what she’d written to help her reflection, which is fundamentally wrong,’ believes Dr Cusack.
Senior medical figures across the country claim not only that Bawa-Garba has been made a scapegoat for wider failures in a beleaguered NHS, but that exploiting the training reflection system and criminalising medical error this way will lead to a climate of cover-up where doctors are too terrified to admit to mistakes, let alone learn from them.
Meanwhile, bitter in-fighting is mounting within the medical profession, with more than 8,000 doctors so furious that the GMC fought to expel Bawa-Garba that they have signed a petition stating that the handling of the case will only ‘lessen our chances of preventing a similar death’.
Health Secretary Jeremy Hunt last week ordered an urgent review into manslaughter by gross negligence rulings in the NHS, while Leicestershire Police have suggested they will discuss with the CPS the possibility of prosecuting University Hospitals of Leicester NHS Trust, in charge of Leicester Royal Infirmary, for corporate manslaughter in the Adcock case.
A crowdfunding appeal has also raised £347,000 in legal funds for Bawa-Garba — something she has said she is ‘humbled’ by.
She has now employed a new legal team and this week launched an appeal against the High Court’s decision to strike her from the medical register. She also plans to appeal against her criminal conviction.
‘Dr Bawa-Garba was effectively signing a confession form in the hospital canteen that day,’ says Dr David Nicholl, a consultant neurologist at City Hospital in Birmingham who set up the doctors’ petition to appeal her erasure from the medical register.
‘That her words were taken in such an inappropriate manner, from a man she was supposed to trust who had a vested interest in maintaining a certain narrative of events, beggars belief. I can’t see how this is a safe conviction.’
Yet the GMC successfully argued that public trust in the medical profession would have been ruined if Bawa-Garba — who moved to Britain from Nigeria in 1994 and qualified as a doctor in 2003 — was allowed to continue to practise.
But should she really have been convicted of manslaughter in the first place? Considering her conviction within its wider context, it is hard not to harbour doubts.
When Jack was admitted to the hospital’s Children’s Assessment Unit at 10am on February 18, 2011, Bawa-Garba was newly returned from maternity leave. She had only recently been transferred to the hospital, where short-staffing meant she had received no induction to familiarise herself with her environment. She was also doing the work of two doctors as another registrar was on leave.
Due to a roster mix-up, consultant paediatrician O’Riordan, who was supposed to be on duty all day, was instead lecturing at the university in Warwick and also absent until 4.30 pm.
‘Hadiza was responsible for patients in at least five ward areas spanning four floors that day, in addition to dealing with constant calls from GPs and community midwives,’ says Dr Lyvia Dabydeen, who is now a consultant paediatric neurologist at King’s College Hospital NHS Foundation Trust but worked with Bawa-Garba between 2011 and 2014.
‘Even fully staffed, this would have been a busy day,’ she says. ‘Like any new mother, Hadiza was apprehensive about coming back from maternity leave, but looking forward to starting her new post. She had last worked in general paediatrics, dealing with acutely unwell children, several years previously.’
Yet the professional devotion of Bawa-Garba was never in doubt.
‘Parents always commented to me on her caring manner, and she was calm, safe, capable and hard working,’ says Dabydeen.
She adds that Bawa-Garba had been passionate about medicine since the age of 13: ‘She set up and funded a charity to provide education and health care for disabled children in Nigeria, and, in Britain, used her position to raise HIV and organ donation awareness.’
Hardly the conventional profile of a convicted killer, then. It should be noted, too, that on the day Jack died, Bawa-Garba had successfully made dozens of critical decisions involving other patients with life-threatening illnesses.
And, while she failed to spot that Jack’s blood tests showed raised levels of urea and creatinine, which suggested he had kidney problems caused by sepsis, and took so long to check his X-ray that it was mid-afternoon by the time he was prescribed antibiotics, other mitigating factors suggest she wasn’t solely to blame.
A hospital IT failure meant Bawa-Garba had been forced to write down some 20 complicated blood sample readings by hand, instead of reading them on a computer screen, leading to what Dr Cusack describes as a ‘cognitive error’ borne of understandable brain fatigue. O’Riordan, meanwhile, had also written down Jack’s abnormal blood tests and chose not to review the boy, yet was not criticised for his decision.
Another mistake that contributed to Jack’s death was purely the fault of hospital procedure.
Shortly before he died, Jack had been given his regular supply of Enalapril, a drug that lowers blood pressure, but actually reverses the body’s natural defence to sepsis and should never have been taken in his condition.
The drug was given without the knowledge of Bawa-Garba, who knew it would be unwise, because hospital culture (which contravened national guidelines) allowed drugs to be taken on site without the hospital doctor’s approval.
A complex picture, then, but one that had become clear by the time the hospital’s serious untoward incident inquiry was concluded in August 2012 — by which stage Bawa-Garba, initially suspended for three months, had been allowed to return in a supervised role.
In addition to IT failure and staff shortages, the inquiry revealed deficiencies in handover, accessibility of the data at the bedside and the absence of a mechanism for an automatic consultant review.
It concluded there was no root cause responsible — instead recommending some 23 changes be made at the hospital to remedy the multiple systemic failures.
Initially, the CPS claimed that precisely because there were so many different failings, there were no grounds to charge an individual doctor. Yet at the inquest into Jack’s death in July 2013, experts debated the criteria for manslaughter and decided there were sufficient grounds to prosecute.
Perhaps understandably, Jack’s parents, Nicola, 43, who works for a retail chain, and Victor, 52, who works for a water company, sought justice for their son.
But if anyone was to be responsible, shouldn’t it be the consultant in charge, rather than the junior left to flounder out of her depth?
‘When Dr O’Riordan, the duty consultant, arrived at 4.30pm, Hadiza showed him the test results,’ says Dr Dabydeen. ‘In the NHS, the consultant carries ultimate responsibility for patient care.’
But, she adds, ‘two of the most junior members of staff — who did their very best in impossible circumstances — took the full force of the blame for the tragic outcome.’
She says that when Bawa-Garba — already ‘absolutely distraught’ at Jack’s death and willing to admit to her mistakes — was arrested by police in 2014, her younger child was just two weeks old. ‘She was questioned for seven hours at a time when she wasn’t in a fit state to sign important documents,’ says Dabydeen. ‘She felt frightened and isolated.’
Once she and nurse Amaro were charged, the well-documented hospital failings were all but discounted by the justice system.
Dr Cusack, who gave evidence at Bawa-Garba’s trial at Nottingham Crown Court in November 2015, claims expert witnesses were stopped by prosecution barristers from discussing the improvements University Hospitals of Leicester NHS Trust made after Jack’s death that would have highlighted how many other factors were to blame.
‘Their job is to find one person responsible, but in health care multiple factors are nearly always involved,’ says Cusack. ‘Of course, doctors need to be held accountable for their actions, but I don’t think manslaughter charges are appropriate here.
‘Causing wilful and deliberate harm is different from making genuine mistakes, and it would be difficult for a lay jury who don’t understand what it is like to work in medicine to understand the key issue of whether Hadiza’s mistakes were criminal.’
Once branded a killer, Bawa-Garba, whose elder son is autistic and whose husband works in aviation in Dubai, struggled to cope. ‘Her address was published in the local press and, living alone with two young children, she feared for her safety,’ says Dabydeen.
‘As a Muslim woman with a headscarf, she was subject to vile racist abuse. She’d had her career taken away from her and was facing financial hardship.
One organisation that did show support was the MPTS, which ruled last June that given the wider failings involved, Bawa-Garba’s erasure would be disproportionate and that she should be suspended for 12 months instead.
The GMC appealed the MPTS decision, in a move that has angered doctors.
‘The GMC has allowed doctors on the sex offenders register and with other criminal convictions to continue to practise,’ says Dr David Nicholl. ‘That they took this action against a doctor whose practice was otherwise exemplary is unbelievable.
‘What happened to Jack Adcock is an absolute tragedy, but the GMC has turned it into a disaster.’
Charlie Massey, chief executive of the GMC, told the Mail their decision to appeal ‘was not taken lightly’, adding that while there are ‘a small proportion of doctors on the medical register with convictions’, some of which predate the GMC’s right to appeal MPTS decisions, ‘for serious convictions such as serious sexual offences, we will now always call for the doctor to be struck off the register’.
Andrew Furlong, medical director at Leicester’s Hospitals said: ‘Following Jack’s death, we carried out a full investigation and implemented improvements to our systems which have reduced the risk of such events occurring again.’
The Medical Protection Society — who defended Bawa-Garba during her trial — told the Mail that the training encounter form ‘did not include any admission of liability, or guilt pertaining to gross negligent manslaughter’ and that ‘this form was not referred to by either the CPS or the defence in the hearing, and was therefore not considered by the trial jury’.
But, that, Cusack counters, is missing the point: ‘While the form wasn’t shown to the jury, it was shown to prosecution barristers and would have influenced their cross-examination, which would have, in turn, influenced the jury.’
Meanwhile, Nicola and Victor Adcock have said they are ‘elated’ that Bawa-Garba has been struck off. ‘What it means is that, in future, the actions of this doctor cannot put another family through the nightmare we have endured since our son’s death,’ says Nicola.
Yet while their grief must be respected, the wider issue should not be neglected: a dedicated paediatrician who made mistakes has been branded a criminal, and both doctors and patients might well end up the worse off for it.
By Antonia Hoyle | Daily Mail
