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Confidence intervals

Still practising

Chris Preece

Thursday, 15 February 2018

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AdobeStock_8009771_stethosope.jpgThere is a 10-year-old boy inside me that will never tire of watching stuff getting blasted into space. The recent launch of the Space X Falcon Heavy was no exception. A remote controlled re-usable rocket firing a Tesla Roadster to Mars – it was enough to make you giddy. Certainly, the press seemed to agree – coverage of the car drifting merrily through space, or of the balletic simultaneous landing of the two booster rockets, was everywhere. Reports tended not to linger so much on the fate of the core rocket (it crashed), or the fact that the Roadster’s trajectory was slightly off, and it will now be travelling to the asteroid belt instead.

Who cares, there’s a car in space – and besides, everyone makes mistakes, right? In fact, Space X are pretty open about their errors. They’ve even released a video of all their crashes, set to the theme of Monty Python’s Flying Circus, and explaining just what went wrong in every case. Of course, it’s easier to talk about those mistakes when the victim is a billion-dollar rocket, rather than a human being.

Which leads us sadly, and inevitably, to the Dr Bawa-Garba case, and the tragic death of Jack Adcock. The case has been widely reported and debated, but for those who have somehow escaped it to date, I shall recap the story as it was reported originally.

Jack Adcock was a six-year-old boy with Down’s Syndrome and a history of AVSD repair. He was admitted to Leicester Royal Infirmary with a history of diarrhoea and vomiting on 18th February 2011. The registrar covering the Children’s Assessment Unit that day was Dr Bawa-Garba, recently returned to work after 14 months of maternity leave. Over the course of Jack’s illness, she made a number of mistakes, including not properly reviewing his chest x-ray, failing to act on blood gas reports, failure to make proper clinical notes and mistaking (briefly) Jack for another child who had a Do Not Resuscitate order. It would seem, fundamentally, that she had not appreciated quite how sick he was until it was too late.

Jack Adcock died from sepsis caused by a Group A Streptococcal infection.

As a result of her errors, Dr Bawa-Garba was convicted of manslaughter by gross negligence in November 2015. She was subsequently suspended from practice for one year by the Medical Practitioners Tribunal in 2017, only for this to be overturned by the GMC itself this January, who took the case to the High Court and successfully petitioned for Dr Bawa-Garba to be struck off the medical register for good. The reason for seeking, and granting, this erasure, was the belief that it was necessary to maintain public confidence in the profession.

Given the facts presented as they are above, that position seems reasonable. Let’s start adding some more facts to the story though, and see how long that confidence is preserved.

As noted Dr Bawa-Garba was freshly back from maternity leave. She had had no induction to speak of, and the two junior doctors working beneath her had only just been rotated into a paediatric post. IT facilities across the hospital that day had fallen over, and so they had to phone through for results opportunistically, and even then, the usual flags to indicate a result is abnormal were absent. To make life for Dr Bawa-Garba more complicated, the registrar who was supposed to be covering the CAU (where Jack was admitted) was away, and she was drafted in to cover this in addition to her normal duties. Meanwhile her consultant was also off, giving a teaching in a different city. She was doing the work of three doctors (including her senior). It has been reported that Leicester Royal Infirmary identified 23 specific recommendations and 79 actions that needed to be taken as a result of learning from this sad case. The more you look at the case, the clearer it becomes that this was not so much a single individual making mistakes, but rather a failing of the entire system. A system that continues to face many of the same pressures now as it did then.

How confident do you feel now?

The fallout from the case has been substantial. There has been some confusion as to whether Dr Bawa-Garba’s record of her own reflections on her mistakes were used against her in court. (The quick version seems to be that whilst they weren’t used directly, they were seen by the expert witnesses.) Whatever the truth of the matter, it has led to widespread concerns within the medical community, with doctors now reluctant to document and discuss their errors.

Similarly, the treatment of a doctor whose mistakes resulted, at least in part, from being asked to cover for absent colleagues, has led to calls for doctors not to agree to cover for absent colleagues. The GMC has responded by insisting all doctors must provide cover in such situations, and seemingly laying the responsibility for reporting these shortages at their feet – whilst singularly failing to reassure that such concerns would be considered as mitigation should something go wrong again.

How confident do you feel now?

Still, the argument goes, at least the Adcock family finally has some closure after the tragic loss of their son. This, sadly, doesn’t appear to be the case either. On the 9th February The Sun ran a story reporting that Jack’s mother, Nicola Adcock, was being accused on social media of being “a racist” after campaigning for Dr Bawa-Garba to lose her job. She went on to criticise doctors who had contributed to a crowd-funding campaign to support Dr Bawa-Garba – “all these doctors jumping on the bandwagon to clear her are just doing it to protect themselves”. Comments beneath the story included those suggesting she be forced to return to Nigeria, and demands that the paper name and shame all those who contributed to the fund.

This, apparently, is what public confidence looks like, according to the GMC. An individual held responsible for massive ongoing system failures, a profession no longer willing to reflect on mistakes or cover for emergencies, and a public more fearful and angry than ever before.

Perhaps it’s deliberate. An attempt to make a mess so rancid that even Jeremy Hunt had to step in and demand an urgent review into whether the manslaughter laws are fit for purpose. Otherwise, the GMC has failed the public on a significantly larger scale than Dr Bawa-Garba. Space-X’s approach to mistakes has people paying them vast sums to take them to space one day. The GMC’s risks making people scared to seek life-saving treatment for free. Perhaps it’s time they changed their approach to errors, lest they fall foul of it themselves.

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Chris Preece

Chris has worked as a GP Partner in North Yorkshire since 2004, and still relishes the peculiar challenge of never quite knowing what the next person through the door is going to present with. He was the chair of his local Practice Based Commissioning Group, and when this evolved into a CCG he joined the Governing Body, ultimately leaving in April 2015. He continues to work with the CCG in an advisory capacity. When not being consumed by all things medical, Chris occupies himself by writing, gaming, and indulging the whims of his children. He has previously written and performed in a number of pantomimes and occupied the fourth plinth in Trafalgar Square. Tragically, his patients no longer tell him he looks too young to be a doctor.
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