Overwork and the risk of negligence cases make safer specialisms preferable to acute medicine
I was once responsible for a patient’s death. Or that’s how it could have been seen. It was years ago, in a gap year job, but the experience was so searing I can relive it with terrible clarity.
I was working as a nursing auxiliary on a hospital ward. At 9pm all the nurses were gathered in the sister’s office, two doors and 30 metres away, handing over to the night team. A physio was with an elderly asthma patient when she threw open the curtains around the bed and shouted: “Resus! Nurse, get the resus trolley!”
She meant me. I was the only person in a nurse’s uniform in sight or earshot. I ran. The heart resuscitation team was bleeped. I dragged the trolley, which was new on the ward that month, to the bed. I unwound the electric cable, seized the plug, looked around for a socket. And looked. And looked.
This was an old ward in a crumbling outbuilding and there was nothing logical about its power points. As the newest and most junior person on the team, no one had thought it necessary to show me where they were. While I hunted, with rising panic, ducking between beds, the old lady’s heart began to fail. The heart team arrived, a nurse grabbed the plug from me, the old lady died.
Was this my fault, or the system’s? If I had been faster that woman may have lived. Is someone who tries their best when they don’t have adequate backup the guilty party, or is the system around them also responsible, for not providing the support they need?
Any sane person would think the latter, but thanks to the punitive decisions of the GMC and the High Court in pursuing the striking-off of Dr Hadiza Bawa-Garba after an error which led to a child’s death, every doctor and nurse in the country now fears that they may lose their jobs, futures and reputations for a single serious mistake.
The doctor was under extreme pressure, covering for an absent registrar while overseeing six wards on four floors, on a relentlessly demanding twelve-hour shift. It was her first day back after maternity leave and she had had no induction training. The nursing rota was understaffed and the IT system was down for hours, meaning blood test results were critically delayed. Her consultant wasn’t present. All the evidence given testified to her being a committed, above-average doctor, and yet she has been thrown out of the profession.
The chilling lesson of the Bawa-Garba debacle is that context, character, remorsefulness and a good record will be no defence.
The unintended consequences of this hardline decision by the GMC are going to damage the NHS, not protect it. Doctors across the country are aghast, feeling, as an editorial in the BMJ said, that “there but for the grace of God go I”. Furious senior doctors are reporting themselves to the GMC for long-ago errors, to make that point. Newer doctors are now afraid to admit to theirs in case it backfires on them. And the devastating practical effects are now unfolding, unseen.
“I’m practising defensive medicine now,” one doctor told me. “We all are. I’m not taking risks. If someone turns up with a non-specific lump, I might before have used my judgment, said wait and see. Now I’m sending them for scans, second opinions, follow-ups, blood tests. Lots of that will be unnecessary, the NHS is already overloaded, and I’m adding to that. But I feel now I’ve got no protection, I’ve got to watch my own back.”
His fears are widely shared, an A&E consultant tells me. It’s going to cut the numbers willing to work in areas of acute medicine that are already routinely understaffed, like paediatrics or emergency medicine. If doctors know, as they do, that those are the jobs where they must take what are now career-threatening high-risk decisions, while covering rota gaps, fewer people will apply. “They’ll retreat to safer options — dermatology, genito-urinary clinics, specialisms like that.”
He warns that it’s going to mean a rise in staff going off sick in high-pressure disciplines, as people assess the new pressures of being conscientious. Instead of putting the patients first, many doctors will choose caution. “If you’re feeling a bit off, why would you risk putting yourself in the firing line? It’s going to be a lot safer to stay at home.”
There is particular fury at the GMC’s attempt to cover its back by issuing guidelines telling doctors that if they are in understaffed, unsafe environments they must create a paper trail flagging that up. As one enraged doctor pointed out to me, hospitals already know exactly when their rotas are missing staff. And as a fine column in the BMJ by the consultant in geriatrics David Oliver points out, now we are ordering overworked doctors to spend more of the time they don’t have in documenting that they haven’t got it. It serves literally no purpose, since if nothing goes badly wrong on their shifts nobody cares that they were overloaded, and if something does go wrong, that record won’t protect them.
The NHS is clearly alarmed by what has been set in train here, with many hospitals declaring they stand by their staff and the health secretary Jeremy Hunt setting up an inquiry into the implications of the Bawa-Garba case. But warm words mean nothing laid against the cold legal danger doctors are now in. They need safer staffing levels and an absolute assurance that when they make mistakes their institutions will share responsibility too. Until they get that, the health service is going to be weakened by this cruel and foolish pursuit.
Laura Donelly in the Telegraph 6th February reports: Hunt orders review of Medical Malpractice and Doctors Outcry over manslaughter case:
Dr Hadiza Bawa-Garba was struck off the medical register after she was found guilty of mistakes in the care of a six-year-old boy who died of sepsis.
The case has been met with a backlash among medics, with thousands sending letters of support for the doctor, saying the decision ignored NHS failings and staff shortages which contributed to the death.
Dr Bawa-Garba was originally suspended from the medical register for 12 months last June by a tribunal, but has now been removed from the medical register following a High Court appeal by regulator the General Medical Council (GMC).
The GMC said the the original decision was “not sufficient to protect the public”.
Mr Hunt had already expressed unease about the situation, saying he was “totally perplexed” by the actions of the watchdog.
In particular, he raised concerns that doctors would no longer be open about errors, and be honest in their self-appraisals.
In a statement to the Commons, the Health and Social Care said clarity was needed about drawing the line between gross negligence and ordinary errors.
Speaking in the House of Commons today, Mr Hunt said Sir Norman Williams, former president of the Royal College of Surgeons, will lead a national “rapid review” of the application of such laws.
He said Sir Norman will review how “we ensure there is clarity about where the line is drawn between gross negligence manslaughter and ordinary human error in medical practice so that doctors and other health professionals know where they stand with respect to criminal liability or professional misconduct”.
Mr Hunt said the review will also look at the role of reflective learning, to ensure doctors are able to open and transparent and learn from mistakes.
The review, which is due to report by April, will also consider lessons to be learned by the GMC and other regulators.
Charlie Massey, chief executive of the General Medical Council said: “We welcome the announcement today from the Secretary of State to conduct a rapid review into whether gross negligence manslaughter laws are fit for purpose in healthcare in England. The issues around GNM within healthcare have been present for a number of years, and we have been engaged in constructive discussions with medical leaders on this issue.”
He said the watcdog was committed to examining the issues, and to ensure fair treatment of doctors working in situations where the risk of death is a constant and in the context of systemic pressure.”
“Doctors are working in extremely challenging conditions, and we recognise that any doctor can make a mistake, particularly when working under pressure. We know that we cannot immediately resolve all of the profession’s concerns, but we are determined to do everything possible to bring positive improvements out of this issue,” he said.
The GMC is carrying out its own review, and would endure the findings from the new review feed into it.
Dr Bawa-Garba was struck off over the death of Jack Adcock, aged 6, at Leicester Royal Infirmary in 2011.
The child, from Glen Parva, Leicestershire, was admitted to the hospital in February 2011, his sepsis went undiagnosed and led to him suffering a cardiac arrest. The courts heard Dr Bawa-Garba, a paediatrician, committed a “catalogue” of errors, including missing signs of his infection and mistakenly thinking Jack was under a do-not-resuscitate order.
But they also heard the doctor was working amid widespread staff shortages, with IT failures and delays in test results
At the time of the ruling, Jack’s mother, Nicola, said: “We are absolutely elated with the decision. It’s what we wanted.
“I know we’ll never get Jack back but we have got justice for our little boy.”
The Medical Protection Society, which represented Dr Bawa-Garba, said at the time: “A conviction should not automatically mean that a doctor who has fully remediated and demonstrated insight into their clinical failings is erased.”
An online appeal set up by concerned doctors has raised more than £320,000 to help pay the legal costs of Dr Bawa-Garba.
Agency nurse Isabel Amaro was also convicted of manslaughter on the grounds of gross negligence relating to the same incident and struck off by the Nursing and Midwifery Council.