Should we blame a single person for the failings of an entire system? Is it morally acceptable to forgive avoidable mistakes made by a doctor which resulted in the death of a child? An ethical dilemma which has sparked the attention of many medical professionals was the case of Dr Hadiza Bawa-Garba, who was claimed to be responsible for the death of 6-year-old Jack Adcock.
At 10.30 AM on the 18th of February 2011, Jack Adcock, who had underlying heart conditions and down syndrome, was admitted into Leicester Royal Infirmary due to diarrhoea, vomiting, and difficulty breathing. Dr Hadiza Bawa-Garba, the junior doctor responsible for Jack’s care was in year 6 of her post-graduate training (ST6) and had recently returned from maternity leave. (1) The senior consultant in charge, Dr Stephen O’Riordan, was away on a teaching day and had not arrived at the hospital until 4:30 PM. Due to staffing shortages, Bawa-Garba was the only doctor designated to cover the entire Children’s Assessment Unit (CAU), essentially being asked to perform the role of two doctors in addition to her own.
At 10.45 AM, Dr Bawa-Garba had ordered blood tests, however, the results were delayed until 4.15 PM because of IT failures. These blood tests contained information which showed vital markers of illness. Jack’s blood tests showed high CRP levels. CRP (C-Reactive Protein) is a marker for inflammation which is usually a result of infection. Bawa-Garba also ordered a chest radiograph at 12.00 PM, which she received at 3.00 PM. It showed signs of pneumonia, which resulted in Bawa-Garba prescribing antibiotics which were administered at 4.00 PM. During a handover meeting, Bawa-Garba informed the consultant of the abnormal laboratory results from the blood tests, however, had not asked the consultant to personally review Jack’s condition.
Bawa-Garba had successfully omitted enalapril on Jack’s drug charts, however, failed to mention this to his mother. This resulted in Jack’s usual dose of enalapril being given to him at 7.00 PM by his mother, which resulted in his death.
An hour later, at 8.00 PM, Jack had a cardiac arrest. Dr Bawa Garba had mistaken Jack for another patient who had a DNR (Do Not Resuscitate) order signed. She briefly paused CPR (Cardiopulmonary Resuscitation) for 2 minutes before realising her mistake, however, this was not deemed contributory to Jack’s death. At 9.20 PM, Jack died from streptococcal sepsis – the fatal dose of enalapril had caused a significant blood pressure drop which prevented his body from resisting the infection.
Jack’s death resulted in Bawa-Garba and the two nurses responsible for Jack’s death charged with manslaughter on the grounds of gross negligence. She was charged with a 2 year jail sentence and was ultimately struck off the medical register. Medical professionals throughout the UK were angered by this decision, and over £200, 000 was raised by doctors to fund an independent legal team to challenge the prosecution of Bawa-Garba.
Many factors had contributed towards Jack Adcock’s death, including the IT failings and lack of staff, not only Bawa-Garba’s negligence. It is unfair to blame a single individual for the failings of an entire system. In addition to this, medicine is a profession where the stakes are high – small tiny errors can eventually lead to such drastic consequences, such as the death of a child. Mistakes by individuals are inevitable – doctors are only human. By prosecuting Bawa-Garba, it creates a fear within the medical community that mistakes are not tolerated and that they will all result in severe consequences. There shouldn’t be a “blame culture” within the NHS, rather an environment which allows learning from mistakes to prevent them from happening again in the future.