Doctors are expected to be perfect; to never make mistakes. If we're honest we all know that's impossible. With the best intentions, some errors will always occur. Doctors do their best to reflect upon their errors and learn from them. But when multiple errors coincide - systemic failings, equipment problems, staff shortages, human errors - then in this perfect storm situation serious harm can occur.
Such a perfect storm happened when Dr Hadiza Bawa-Garba, an experienced paediatric registrar, was left to do the work of several doctors with no consultant or junior doctor support whilst IT systems failed and multiple sick children arrived. In this context she made a series of errors that led to the tragic death of a six year old boy, Jack Adcock. Dr Bawa-Garba was given a 24 month suspended sentence for gross negligence manslaughter, as was nurse Isabel Amaro. Dr Bawa-Garba was suspended for 12 months by the Medical Practitioners Tribunal, but this was overturned in the High Court last week by the General Medical Council, who wanted her struck off the register.
Medics are outraged, and with good reason:
- Responsibility for safe provision in hospitals in being put onto front-line staff, who are effectively scapegoats for systemic failings caused by poor funding and poor management.
- Reflective statements, which the GMC says doctors must use to show reflection on their errors, were reportedly used to convict Dr Bawa-Garba and thus have her struck off.
- Rather than a culture of learning from incidents, as seen in the airline industry, the GMC are fostering a culture of blame.
Instead of learning from them, doctors will avoid admitting errors. Appraisals previously used to improved quality of care will become pointless, tick-box exercises. Instead of hospitals fixing systems failures and short staffing, scapegoats will be found. Medics will be forced to avoid 'high-risk' posts in order to protect their careers. Confidence will be lost in the GMC, making it unfit for the purpose of protecting patients.
Punishing doctors for human error and systems failures will harm patient safety.
The NHA Party applauds Dr David Nicholl (pictured above) who tore up his GMC certificate outside their headquarters yesterday; Dr Peter Wilmhurst who has referred himself to the GMC pointing out the many errors he has made during his career; Dr Chris Day who continues to campaign for whistleblowing safeguards for doctors after he was punished for speaking out over unsafe staffing levels. We join them in speaking out, in the hope that the GMC will end the culture of individual blame and scapegoating in medicine. Only by doing this can we prevent further tragedies.
- Bawa-Garba: timeline of a case that has rocked medicine
- Patient safety fears after GMC wins bid to strike off junior doctor
- Dr Bawa-Garba: Doctors threaten to boycott their appraisals over treatment of trainee paediatrician
- More than 7,500 doctors warn they will be too scared to admit mistakes after pediatrician is struck off