He was due his second dose of the day. A crowdfunding campaign also got under way to enable Dr Bawa-Garba get another legal opinion. The University Hospitals of Leicester NHS Trust was not the worst, neither was it the best, he adds. “Trainees felt that their colleague was being scapegoated and taking the blame for a series of system failings,” he said. “I made my own action plan about how I would be able to address those things that I wish I had done differently.”. “Since April 2020, the insulin pump training is now provided online,” said Dr Stephen O'Riordan, consultant endocrinologist at CUH. It didn’t look at paediatrics. Not all failings were heard, he says. But she says Dr O’Riordan told her that she had to get on with her clinical duties. At the Adcocks’ home in Glen Parva, a suburb of Leicester, Jack’s sister Ruby has moved into his old room. I suspect that many would have died anyway but in some cases my errors are likely to have contributed to poor outcomes and some patient deaths,” he says. What was at stake was whether she fell below the standard of a reasonably competent junior doctor. he asks. Written by a team of experts from around the world, each chapter in Coaching Psychology will help you to understand the key concepts, providing you with the essential theory, research and applications for practice. On 4 November 2015, the jury found Dr Bawa-Garba guilty. These included that fact she had learnt from her errors; had an unblemished record before and after Jack Adcock’s death; and the system failures at the Leicester Royal Infirmary. After an hour of being on fluids to rehydrate him, Jack seemed to be responding well. Dr O’Neill said whether or not enalapril played a role was beyond his expertise. Though there has been an outpouring of sympathy for the trainee paediatrician being pursued by the General Medical Council (GMC),1 there is also an increasing sense that the case will leave the patient safety agenda in tatters by closing down any discussion of medical errors for fear of litigation. Some doctors have expressed concern that its role in Jack’s cardiac arrest has been underplayed. One doctor said she would pray before she went into work because she was worried something bad would happen. Dr Bawa-Garba spent the next six weeks trying to plan for every scenario. The 41-year-old mother of three says the impact on her and her family has been huge. Nor did the hospital comment, when asked by The BMJ, on the appropriateness of how Bawa-Garba was asked to reflect on the incident by O’Riordan. Then she asked for a pen to write. At 16.30 hours Dr Bawa-Garba gave one, of two handovers, to the consultant on-call, Dr Stephen O’Riordan. “I remember going hysterical and just thinking, you know, ‘Please look after my little boy,’” says Mrs Adcock. But Mrs Adcock says the doctors are mistaken in their interpretation of what happened. “I’ve made clinical mistakes including delayed diagnosis and errors in treatment. He said, “The reflections in her e-portfolio show that at no point has she failed to admit her mistakes, which is critical if we are going to learn from tragic incidents and build a safety net to prevent them happening again.”, The Royal College of Paediatrics and Child Health would not comment on the case but highlighted a statement from its consultation document sent to the Sentencing Council for England and Wales, which is reviewing its guidelines on manslaughter, including gross negligence manslaughter.3 The college said that trainees were required to use their portfolios for personal reflection and subsequent learning. Copyright © 2020 BMJ Publishing Group Ltd     京ICP备15042040号-3, Back to blame: the Bawa-Garba case and the patient safety agenda, https://www.sentencingcouncil.org.uk/wp-content/uploads/Manslaughter_consultation_paper_Final-Web.pdf, Brighton and Sussex University Hospitals NHS Trust: Consultant in Stroke Medicine, Practice Plus Group: General Practitioner, Rush Hill & Weston Surgeries: Salaried GP, Herefordshire and Worcestershire Health and Care NHS Trust: Consultant Psychiatry, Women’s, children’s & adolescents’ health. “I sat in that small room and prayed,” she says. It was a mistake she regrets to this day. Stars featuring handwritten messages from Jack’s schoolmates, saying how much they will miss him and his cheeky laugh, adorn the navy blue walls of the replica bedroom. Dr Chris Day, a junior doctor and one of the people behind the crowdfunding, says he was overwhelmed by the response. But five months after Jack’s death, Dr O’Riordan left the Leicester Royal Infirmary and moved to Ireland. His practice focuses primarily on investment (both institutional and private equity) and on development (acting for developers and investors), with a particular emphasis on transactions requiring solutions to issues arising on structuring and financing. That December he was asked to see officials from NHS England. The following day, she was back at work at the assessment unit. The boy’s hands and feet were cold and had a blue-grey tinge. Dr Hadiza Bawa-Garba, the junior doctor who treated him (under the supervision of duty consultant Dr Stephen O' Riordan) and a nurse, Isabel Amaro, were subsequently found guilty of manslaughter on the grounds of gross negligence. “Everything was in place. She asked one of the doctors in her team to chase up the results for her patients, and took on some of that doctor’s tasks. Please note: your email address is provided to the journal, which may use this information for marketing purposes. Nine months after Dr Hsu submitted his report, it was posted on the Trust website. Join Facebook to connect with Steven Oriordan and others you may know. After Jack’s post-mortem examination, two days later, the family was told that he had died of a streptococcal infection and had developed sepsis and they could make plans for his funeral. Dr Liz O’Riordan has joined social enterprise Working with Cancer as an ambassador, and the author and blogger will help the organisation support patients on a practical and emotional level. During phone calls home, she could hear the hungry baby crying. The GPs went on to say that in their view the hospital was “potentially on a par with Mid Staffordshire Hospital”. I welcome the verdict because for me that’s an opportunity to do something that I’ve dedicated my life to doing, which is medicine. “I remember sitting there and listening to their account of my actions and I felt like a criminal,” says Dr Bawa-Garba. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. “We were told, ‘I’m really sorry but your son’s passed away,” says Mrs Adcock. Both her reflections and the training encounter form were uploaded to her e-portfolio, an online system used for learning purposes. It included issues with “do not resuscitate” orders, delayed antibiotics, failure to detect serious illness despite multiple clinical signs, unexpected deterioration, medication errors, and IT failures. In over half, there were “significant lessons to learn” – aspects of care that could be done better. Dr Bawa-Garba continued to describe where she should have done better. The judge told the jury they could only convict the health professionals in front of them if they were negligent and that their negligence significantly contributed to Jack’s death or its timing. Junior doctors did try to raise their concerns that trainees were being used to plug rota gaps, often at the last minute. But then they were asked to cancel their plans and meet the police at the coroner’s office to discuss an inquest. Dr O’Riordan declined Panorama’s invitation to comment on Dr Bawa-Gaba’s account of the meeting. “However, we would be concerned if the duty of candour and educational reflection was wrongly influenced by court cases and convictions of medical professionals for gross negligence manslaughter. Jack Adcock wasn’t himself when he returned from school. On his way up there, he had been sick again. This time, when Dr Bawa-Garba went to take blood from his finger, Jack resisted, pulling away. “I had two very young children - my oldest is severely autistic and goes to a special needs school. In 2017, the General Medical Council’s tribunal service suspended Dr Bawa-Garba for a year. Those tests would have indicated that Jack may have had kidney failure and that he needed antibiotics. Teams of doctors and nurses were tasked with going through the records of patients who had either unexpectedly died in hospital or died within 30 days of leaving between 1 April 2012 and 31 March 2013. . Dr Hsu says he’s been around long enough to know if reports don’t work out well for someone, people have ways of of ensuring that the report doesn’t really get anywhere. “I’m a very private person, but I had my face in the newspaper.”. She was led away in handcuffs to a cell while her team worked out her bail conditions. Dr Hsu asked to meet the medical directors of the Trust. She told the team to continue the resuscitation. Recognising her need for further training, the hospital took Dr Bawa-Gaba off the on-call rota and put her on to the paediatric intensive care unit under the supervision of a consultant. Her photograph and fingerprints were taken. The story began in an overstretched hospital in February 2011 when she was 34. Dr Bawa-Garba says no-one had flagged it was available. She had only recently returned to work after having her first baby. During the afternoon handover, Dr Bawa-Garba told Dr O’Riordan about Jack – his diarrhoea and vomiting, heart condition, and enalapril medication. Dr Jonathan Cusack was the head of the unit, so she didn’t think much of it. They had to consider the circumstances within which the defendants were working when considering if they were guilty. technical support for your product directly (links go to external sites): Thank you for your interest in spreading the word about The BMJ. Dr Bawa-Garba tried a number of extensions before managing to speak to someone. One of the less experienced doctors in the unit had been unable to do Jack’s next blood tests. It suggests that factors that let her down were her interpretation of biochemistry and venous blood gas results and her “lack of clear communication.”. Stephen had one sister: Unknown O'Brien (born O'Riordan). “He had no tubes, he had nothing,” she says. The GMC’s Charlie Massey says he understands these concerns. According to the UK Sepsis Trust, about 14,000 people die each year because it is not diagnosed or treated early enough. Jenny Vaughan, a neurologist who runs Manslaughter and Healthcare (www.manslaughterandhealthcare.org.uk), an online resource that follows prosecutions of healthcare staff in the criminal courts, has been watching Bawa-Garba’s case. At the meeting she was asked to reflect on the circumstances and to sign a trainee encounter form setting out what she should have done differently. But Dr Bawa-Garba says she didn’t want him to have the enalapril, because he was dehydrated and it might have made his blood pressure drop too much. In October 2014 they sent a letter sent to former Health Secretary Jeremy Hunt and Simon Stevens, chief executive of NHS England, warning of “broken systems serving patients and carers in our area”. “I don’t think I registered because I said, ‘Er, OK – but I need to finish my shift and I have teaching tomorrow.’ I was supposed to be teaching some medical students the next day. Dr Bawa-Garba would travel from her home in Leicester up to Nottingham. Aspects of the trial have caused consternation among the medical profession. A social media storm ensued, accompanied by the hashtag “#IamHadiza”, with doctors wearing T-shirts and badges in her support. “I can’t face it.”. But when medical staff gathered to discuss the day’s work, they were told someone was needed to cover the CAU – the doctor supposed to be doing it was on a course. After Jack’s death, Dr O’Riordan and Dr Bawa-Garba should have visited the parents together, expressed their deepest sympathy and promised an independent, open investigation to ascertain the full facts. “Doctors work in teams and the consultant is in charge of that team. In 2013, Leicester GPs had started to become concerned about the University Hospitals of Leicester Trust’s SHMI. My picture was there and the passenger sitting opposite me kept looking at the paper and looking at me and looking up,” she says. I didn’t want my dad to see me being taken away in handcuffs. She also carried the bleep – which alerts the doctor that a patient needs seeing urgently on the wards or in the Accident and Emergency unit, across four floors of the busy Leicester Royal Infirmary – and was required to respond to calls from midwives, other doctors or parents. Dr Bawa-Garba looked for Jack’s blood results from the lab. “We couldn’t speak to anyone – we weren’t really told anything.”. If they had done everything they could, the Adcocks say, they would have been devastated but could have said “Thank you,” and walked away. It was at this point that another failing in Jack’s care occurred. What she didn’t know was that Jack had subsequently been moved to the same ward as the boy who had crashed in the morning – ward 28. Grant said that although he did not want to comment on the specific details of the case, the Royal College of Paediatrics and Child Health’s training standards required clinical supervision to ensure patients’ safety. “I was probably slower than I used to be, because I was micromanaging and double-checking everything and second-guessing myself all the time,” she says. But they say they heard very little from the hospital. “I knew that I had to get a line in him quickly to get some bloods and also give him some fluids to rehydrate him,” says Dr Bawa-Garba. She returned to court in December for sentencing. “List for us, please, all of the mistakes,” Mr Thomas said. It's a full-time job. They were sent a copy of the Leicester Royal Infirmary investigation and invited to discuss it, but they didn’t want to. Clare was born on November 20 1931, in Rathgar, Dublin, Ireland. As the police were investigating Jack Adcock’s death, other failings in patient care across Leicestershire were emerging. “I was shocked and I was like, ‘Why is Jack crashing?’” she says. There was then a second post-mortem examination in case criminal proceedings were opened. Indeed, one official review concluded that BAME groups are also disproportionately prosecuted for gross negligence manslaughter - although it only looked at a small number of cases. Her consultant, (senior doctor) Dr Stephen O'Riordan, was teaching in another town that morning and Dr Bawa-Garba was doing the work of at least one other paediatric registrar, who was on leave. The decision has certainly been unpopular among the medical profession. “I think that we let Jack Adcock down - there’s no doubt about that in my mind,” says Andrew Furlong, medical director since 2016 of University Hospitals Leicester, which includes the Leicester Royal Infirmary. Most of the patients who died were emergency admissions who were not expected to do so.”. There are 20+ professionals named "Steven O'riordan", who use LinkedIn to exchange information, ideas, and opportunities. Irish News; Barry Roche; January 17, 2016, 20:33; A 51 … If you walked into a hospital and saw that doctor, would you be happy for her to treat your child?”. It not only pointed to errors made by Dr Bawa-Garba and nursing staff - including Dr Bawa-Garba’s failure to recognise the severity of Jack’s illness - it also found a series of “system failings”. “I said to her, ‘I'm really sorry about the outcome – I don't know how this happened,’” she says. “The best way to protect patients is by supporting doctors. The jury also heard from Dr Simon Nadel, a paediatric intensive care consultant in London, who thought enalapril had aggravated Jack Adcock’s condition, but wasn’t the cause of death. She then repeated the point, saying that there was “no evidence that the enalapril was incorrect or caused or contributed to his death”. “I had parents from my daughter’s school asking if I was OK because they were getting leaflets in their letterboxes saying that they should sign a petition to say that I should be struck off,” she says. In February 2012 – a year after Jack’s death, and just after Dr Bawa-Garba had given birth to her second child – she received a phone call from the police. Stephen O'Riordan Senior Automation Integration Architect (IT) at AbbVie Ireland. At the coroner’s inquest in August 2014, Dr O’Riordan’s barrister suggested that enalapril had been a significant factor. “My hope is that lessons learnt from this case will translate into better working conditions for junior doctors, better recognition of sepsis, and factors in place that will improve patient safety.”. “Nobody expected Jack would die.”. “That isn’t unique to this trust, nor was the difficulty in recruiting doctors and nurses, too few were coming out of training nationally, a fact which the NHS locally and nationally is still struggling with. Everyone on the ward was crying, she says, including Dr Bawa-Garba, who was sobbing. O’Riordan left the trust a few months after the incident to take up a post at Cork University Hospital in Ireland. After deliberating with the Trust, they asked Dr Ron Hsu, then a public health consultant and now associate professor at the University of Leicester, to investigate further. Genealogy profile for Stephen John O'Riordan Stephen John O'Riordan (1958 - 1993) - Genealogy Genealogy for Stephen John O'Riordan (1958 - 1993) family tree on Geni, with over 200 million profiles of ancestors and living relatives. The police then arrived – there was to be an investigation after the unexpected death of the child. When a junior doctor was convicted of manslaughter and, How I'm feeling after my MS ‘body reboot', It all made sense when we found out we were autistic. “In the Mid Staffs enquiry they found that there had been hundreds of avoidable deaths, the reviewers drew no such conclusion in this review,” he says. But she didn’t consider that Jack might have had a more serious condition. She is a Chartered Psychologist, International Society for Coaching Psychology Accredited Coaching Psychologist and Supervisor, and a CABA Chartered Certified Coach. Dr Bawa-Garba says she was then told by another doctor that the patient was not the same boy as earlier – but was Jack Adcock. Charlie Massey, chief executive of the GMC, says that after receiving legal advice the GMC applied to the High Court to overturn the decision made by its own tribunal. “It’s terribly tragic that a child has died, but there are no winners in a system which blames tragic outcomes on a trainee. A number of other aspects of the case have also given rise to controversy. However, not enough blood had been taken to get another lactate measurement. This was the most important cause of his death, he said. She says: I walk in and say, ‘He’s not for resuscitation,’ because I thought it was the child with the ‘do not resuscitate’ order.”. Dr Bawa-Garba was given a two-year suspended sentence. “I wish that I had been clearer in my communication with the consultant,” she said. The next day was spent exploring all the points in detail. The BMJ has seen a copy of the form. It raised over £360,000 in about a month with contributions from around 180 countries. He says that when there’s been a serious tragedy families are understandably angry. They need to look at the number of errors that doctor made on the day for the judge to say ‘truly exceptionally bad’,” she says. There was an article going in the paper on the Friday to say when his funeral was going to be,” Mrs Adcock says. After initially being denied one, in case she harmed herself, she was given a pen outside the cell. Facebook gives people the power to share and makes the world more open and connected. Dr Bawa-Garba had enjoyed an unblemished career before Jack’s death and was well-regarded by her colleagues. “It’s my way of coping,” says Mrs Adcock. It was the same for CAU ward sister Theresa Taylor. The hospital appointed Dr Ian Sturgess to consider improvements in the emergency sector. The BMJ has learnt that, five days after Jack’s death, Bawa-Garba was asked to meet Stephen O’Riordan, the duty consultant at the time of the incident, in the hospital canteen. “While we’re running up the stairs, all I was thinking is, ‘It’s the child with the do-not-resuscitate again – that someone is trying to resuscitate. She says she told him Jack’s lactate level was 11, and mentioned some of the other blood test results. He didn’t flinch when she put his cannula in. 0 Reviews. A summary version was produced for the press and the public. Far from ignoring problems, he says, the Trust went looking for them. And Dr Bawa-Garba volunteered to step in. The hospital had carried out its own investigation and Dr Bawa-Garba continued to work there. View Stephen O'Riordan’s profile on LinkedIn, the world's largest professional community. Jack had been admitted under the care of Dr Stephen O’Riordan, the consultant who was supposed to be in charge that day – but he hadn’t realised he was on call and had double-booked himself with teaching commitments in Warwick and hadn’t arrived at work. “The GMC’s actions here are purely punitive against a paediatrician who trusted the investigation process,” she said. At the meeting, Dr O’Riordan took notes, which he then transferred to what is called a training encounter form, she says. Mr Andrew Thomas QC, for the prosecution, told Dr Bawa-Garba that no-one was suggesting that she deliberately set out to harm Jack Adcock. The case attracted a lot of media attention. Using what she had learned from Jack Adcock’s death, Dr Bawa-Garba says, she helped carry out a sepsis study and formed a junior doctor weekly teaching programme where doctors would discuss “near misses” or incidents when patients had died so they could learn from them. Stephen has 3 jobs listed on their profile. They said that while her actions fell “far below the standards expected of a competent doctor”, they had taken into account other factors. If you are unable to import citations, please contact The cells below were a constant reminder of what might happen to her. The X-ray showed that Jack had a chest infection so she prescribed antibiotics. In 2013, Professor Don Berwick MD, president of the Institute for Healthcare Improvement in the US, was asked by the then prime minister, David Cameron, to advise about how to improve patient safety in the NHS following the Mid Staffs scandal. At the start of every shift, the nurses and doctors in charge routinely review staffing levels and move resources to where they are most needed,” he says. With access to full trial transcripts, witness statements and internal hospital inquiries, Panorama talks to Dr Bawa-Garba and to the parents of Jack Adcock in order to tell the story in detail. On Sunday, struggling to process what had happened, Dr Bawa-Garba phoned Mrs Adcock to say she was sorry for the family’s loss. They said doctors and nurses at the hospital had been raising concerns about staffing before Jack’s death. She was struck off the medical register in January this year. But we are also a regulator, and sometimes we have to make tough and unpopular decisions,” Charlie Massey says. “It took three months to get my little boy back, to be able to lay him to rest,” Mrs Adcock says. Mr Furlong says the Trust was the first to use this review method and now others are using similar techniques to look at what can be learned from patients who have died. She says Dr O’Riordan noted down what she said and ordered repeat blood tests. An overworked and under-supported doctor was thrown under the bus by the GMC.”. By this time, Jack had been moved to ward 28 under the care of a different team. The three pleaded not guilty to the charge of manslaughter by gross negligence at the start of what was to be a four-week trial. What went wrong?’”. “Every week we receive reports from our constituent GPs informing us of incidents of distressing medical and nursing care that patients are being exposed to at Leicester Royal Infirmary,” the letter said. I am sorry for not recognising sepsis and I am sorry for my role in what happened to Jack.”. The jurors were instructed to decide whether the three defendants were guilty of unlawfully killing Jack Adcock, basing this decision exclusively on the evidence put before them. The family are clear about who they blame for Jack’s death – Dr Bawa-Garba and one of the nurses who had treated him. . By this point, Jack was sitting up in the bed drinking juice. She then went to chase up Jack’s blood results, which still hadn’t come through – the doctor she had assigned to do it hadn’t managed to get them. In the morning Jack was taken to the GP by his mother, Nicola, and referred directly to Leicester Royal Infirmary’s children’s assessment unit (CAU). “When you have a case that has had an impact on you, you write down how you feel and what you would change,” she says. , 2014 - Business & Economics - 288 pages active educational Supervisor I have seen a copy of the that... Noted down what she said, ‘I haven’t done anything, why are the police then arrived – was. 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