I SHOULD BE SAFE TO
SPEAK AND FAIL
Tinaye
Mapako, 3rd
Year Medical
Student
It is not about how clever and
competent we are but how tired,
stressed and honest we are. Funding
gaps; rota gaps; Jeremy Hunt;
Mangers; targets and contracts circle
over us and our patient’s. Dr Bawa-
Garba is a ST6 Paediatric trainee and
she was looking after a young boy who
died under her watch. She made
mistakes and has been struck off
following a Manslaughter prosecution.
Criminal courts, internal trust
investigations, the GMC and FTP
Boards all came to different
conclusions. Different arbiters of blame
and complicity themselves failing to
make genuine recommendations for
improvement. We are told about
honesty, reflection, human factors and
team work yet for Dr Bawa-Garba none
of that mattered when full weight of
regulation fell upon her and therefore,
perhaps on all of us. Somewhere
something has gone very wrong. Six-
year-old Jake Adcock died, our first
thoughts, our genuine gut emotions
should be to that little boy. There is
rarely a singular causal event in the
death of a patient. A multiplicity of
factors is always involved. On days like
the one where young Mr Adcock died
Murphy’s law applied. Dr Bawa-Garba
was new to the ward and had just come
back from maternity leave. She was left
with the jobs of three doctors with an IT
system continually failing and senior
and junior staff weren’t available at
crucial moments.
The paediatricians previously
impeccable record became fatally
blemished. She should have noticed a
high lactate a key marker of sepsis, she
should’ve highlighted Jack’s case in her
handover to the consultant.
Serious mistakes were made. Could
you have behaved like her? Made
decisions like she did that day. Could
we…. Will we all be Dr Bawa-Garba?
Dr Bawa-Garba reflected as we are told
to do. Medicine learns from mistakes
we analyse the failure of systems and
behaviours finding what we can change
and improve. The Hospital itself found
errors beyond anyone’s control. Dr
Bawa-Garba found herself pressured to
take all of the blame from her
supervising consultant. The Fitness to
practise committee the MTSP decided a
two-year suspension was appropriate
but following a criminal conviction the
GMC sought to get the paediatrician
struck of and they succeeded. The
GMC chose to go for blame. A judge in
an earlier hearing said ‘…manslaughter,
does not, in my assessment,
automatically mean that suspension is
necessary or appropriate”. A respected
group of doctors also noted that cases
which involve black and minority ethic
doctors often receive harsher treatment.
What I can’t do is determine the legal
rationales but even as recently as 2015
two clinical expert witnesses believed
her to still be a “safe doctor”.
There are question I can’t answer.
Should she have not practised if she
thought staffing levels endangered
patients? Will taking Junior doctors to
court for mistakes and using their
reflection as “evidence” help patients?
Why speak up and act as scrupulously
as possible if blame and retribution are
the aim of our regulator instead of
rehabilitation and improving patient
safety. The question when should a
doctor be struck off is the last question
we answer. The first question is how do
we make it safe for all the Jake
Adcock’s in the future - if the answer is
get rid of Dr Bawa-Garba’s medical
license then we can answer our final
question - if it isn’t we must ask a
different question. How can we support
doctors who make mistakes?
So how do we speak up. Do we go in
when there isn’t staff? Wouldn’t that
make patient safety worse? Should we
risk reflecting, if our own words form
chains around our neck. It isn’t in the
interest of the public or patients for a
“safe doctor” in unsafe systems to be
strung up. I worry about medical
institutions incriminating those who are
honest and competent who get it wrong.
I worry that the term “putting the
profession in disrepute” only heightens
the public’s expectation of the NHS’s
ability at a time of active financial and
organisational strain.
The GMC put up a flowchart telling
doctors how to respond to unsafe
conditions; released a statement
encouraging reflections and pushed a
tool to report understaffing. Critics said
they were unsure more paperwork
would solve those problems and even
so if the law remains the same you’ll still
be blamed anyway. It should be safe to
speak and safe to fail if it is to be safe
for patients.