The recent case of Dr Hadiza Bawa-Garba has created a fire storm across the globe's healthcare community.
Dr Bawa-Garba has been convicted of manslaughter and removed from the UK medical register for her role in the tragic death of a 6 year old boy, Jack Adcock. While it appears that her actions contributed to Jack's death, it is also clear that factors such as staff shortages, poor orientation to workplace, a lack of supervision, locum nursing staff and the administration of a non-prescribed medication have also played a major role. A review of the case is presented here
This case is awful on so many levels. One can only imagine the gut-wrenching grief of a family, not only devastated by the loss of their son, but by the disintegration of their faith in a system they thought was supposed to protect him.
I'm sure Hadiza Bawa-Garba feels the same.
Incredibly, despite all the system failures, and the multitude of clinicians involved (including those supposed to be supervising her practice), she is the only one to face official consequences.
The case ultimately boils down to three main issues :
- The contribution of system failures to the ultimate outcome versus individual responsibility
- The decision to ignore system failures and place blame solely on the individual
- The apparent injustice in the treatment of the individual
The last of these will be dealt with in due course by the courts as Hadiza launches her appeal.
The UK Health Minister, Mr Jeremy Hunt has signalled his intent to address the second.
But will healthcare ever address the first?
High risk industries create environments to reduce the impact of inevitable human error. Healthcare could not sit further from this paradigm, with understaffing, poor orientation processes, migratory staff and under-resourcing contributing to mistakes.
But our processes are letting us down too. Take procedural medicine for example. In many cases, our junior staff are denied the opportunity to learn properly, are then expected to perform these skills without supervision, and the inevitable errors occur.
Blaming a lack of funding is an all-to-easy out, a case made by no less an agency than the Organisation for Economic Co-operation and Development (OECD), which has called for investment in patient safety initiatives as their cost is dwarfed by the unfathomable costs of mistakes.
It's time for health to stop making excuses and start taking action.
But will it learn its lessons from this tragic case?