Bawa-Garba Granted 2-Year Conditional Registration to Return to Medical Practice 

Becky McCall

April 09, 2019

MANCHESTER - A 24-month period of conditional registration with review towards the end is the sanction imposed on paediatric registrar, Hadiza Bawa-Garba, for her return to medical practice, concluded today's hearing at the Medical Practitioners Tribunal Service (MPTS) in Manchester.

The conditions will come into effect on July 29th this year, the day after her current General Medical Council (GMC) suspension from the register expires. In their statement, the Tribunal wrote that it was "satisfied that a period of conditional registration would be an appropriate and proportionate sanction in this case which would adequately address Dr Bawa-Garba's extended absence from clinical practice whilst at the same time protecting the public and maintaining confidence in the profession."

Prior to today's decision, she told the Tribunal that if the opportunity arose, she would like to return to duties in February 2020, following her current period of maternity leave.  

As part of the lengthy conditions, the Tribunal determined that Dr Bawa-Garba "must be closely supervised by a clinical supervisor" for 3 months from the start of a training programme (which she will need to apply for), following which, the supervision level will reduce. If she fails to obtain a place on a training programme, then she will require supervision "for a period of 6 months, from the commencement of any other post".

The GMC released a statement following the decision, noting that both the GMC and Dr Bawa-Garba's legal representatives agreed her fitness to practise remains impaired due to the length of time she has been out of practice. "It is important the doctor's return to practice is safely managed. The Tribunal agreed, making a finding of impairment, and they have imposed conditions on Dr Bawa-Garba's registration for 2 years in order to allow her to return safely to practice."

In a statement, the Doctors' Association UK (DAUK) expressed its sadness at the death of Jack Adcock, but welcomed the verdict and noted that: "it is our duty as doctors to do all we can to prevent the same tragedy from occurring again. We strongly feel that scapegoating an individual doctor or clinician for human errors made whilst working under enormous pressure, does not serve this purpose."

Dr Jenny Vaughan, law and policy officer at the Doctors' Association UK commented on the perils of a culture of criminalisation: "Dr Bawa-Garba was working in appalling conditions that day in an NHS hospital…There is a culture of blame in the NHS at the moment which, if left unchecked, will mean patient safety is not what it should be as staff will be too scared to admit their mistakes. It's right that Dr Bawa-Garba is going to be restored to the medical register as the hospital too was at fault and should have provided better care."

Impaired to Practise Medicine by Reason of Her Conviction

Yesterday the MPTS hearing made a technical determination that Dr Bawa-Garba remained impaired to practise medicine, by reason of her conviction. In a statement released after day one of the hearing, the MPTS noted that: "it was satisfied that Dr Bawa-Garba has fully remediated in so far as she is capable whilst not in clinical practice." The Tribunal noted her evidence of continuing professional development (CPD) and the evidence of the CPD she intends to undertake in the near future and that "the risk of Dr Bawa-Garba putting another patient at an unwarranted risk of harm is low".

However, given the two periods of suspended registration, during which time she has been unable to have face-to-face contact with patients, it was decided that her fitness to practise was impaired because of her extended absence from medical practice.

Six-year old Jack Adcock who had Down's Syndrome (trisomy 21), and a surgical history of a repaired atrioventricular canal defect (also known as AV septal defect) died approximately 9 hours after being admitted in February 2011 with vomiting, diarrhoea, and shallow breathing. He was given antibiotics for pneumonia, and later developed septic shock and consequent organ failure. At 7.45pm his heart failed. The resuscitation attempt was stopped by Bawa-Garba after she mistook Jack for another patient who had a 'do not resuscitate' (DNR) order. Mistakes by Bawa-Garba included failure to recognise signs of sepsis, improper review of a chest X-ray, and a delay in obtaining blood test results and acting on these results.

At yesterday's hearing, Michael Hayton, who provided legal representation for Dr Bawa-Garba conceded that: "there were a series of failures where she performed at a level below that expected of a doctor at her level of experience. Those failings stand in isolation to what went before and subsequent to the event [Jack's death]."

Dr Bawa-Garba, speaking via video link during the hearing, apologised again to the parents, Nicola and Victor Adcock. After Jack's death she said she had contacted his mother to apologise for her role in patient A's death, as well as apologising publicly in front of court in London. "I apologise again for not recognising sepsis, it will be with me for rest of my life" she said yesterday.   

Reflecting on the events of the day, she highlighted that: "I've reflected at different points on how my care could have been better. I've tried to look at areas to improve and have worked on that."

Speaking as a witness for Bawa-Garba at the hearing was Dr Jonathan Cusack, consultant neonatologist at Leicester Royal Infirmary (LRI) and her former supervisor. He knew Dr Bawa-Garba from 2008, when she started as a registrar in the neonatal unit. "She was new and inexperienced as expected, but conscientious and hard working, well liked, with good communication skills," he said, adding that she returned to work with him in 2014. "[At this point] she had changed. She was more subdued, and reflective. The patient A event had deeply affected her."   

Prior to her conviction she passed the exam for consultancy work. "As her educational supervisor we'd discuss learning and reflection – she was keen to discuss errors in [patient] management." Dr Cusack explained that Dr Bawa-Garba had followed CPD to maintain confidence. "She had insight into when help was needed, and worked at a high level. She did online courses. We checked with other staff that she was coping and found that she coped with stress very well."  

If she gains a place on a registrar training scheme she will return at level ST4. At the time of her conviction she was ST8, the final training year prior to becoming an NHS consultant. "She will step back at least 2 years, with ongoing monitoring and annual assessments," said Dr Cusack.  

In their sanction statement today, the MPTS wrote: "There is evidence that Dr Bawa-Garba has the support not just of Dr Cusack and others at the Trust, but also the Postgraduate Dean for the East Midlands Deanery, and the Head of School, East Midlands School of Paediatrics."

There are various conditions attached to her return to work including that she must give the GMC a copy of her Personal Development Plan (PDP), she must have an approved responsible officer and educational supervisor.   

Towards the end of the 24-month conditional registration period, the MPTS states that the onus will be on Bawa-Garba to demonstrate that she has made a successful return to clinical practice and that her skills and knowledge are up to date.

Case History

The case against Dr Bawa-Garba began in 2011 when Jack Adcock died while under the paediatric registrar's care at Leicester Royal Infirmary. In criminal proceedings, Dr Bawa-Garba was convicted of manslaughter on the grounds of gross negligence and she received a 2-year suspended sentence. She was denied the opportunity to appeal against her conviction. Nurse, Isabel Amaro, one of the attendant nurses that day, was also charged with gross negligence manslaughter and was struck off.

Following this conviction, in June 2017, Dr Bawa-Garba's registration as a medical practitioner was suspended for 12 months, subject to review, after a decision by the MPTS. However, in January 2018, the GMC stepped in to overturn this decision and as a result the High Court ordered that Dr Bawa-Garba be struck off the medical register. The GMC maintained that the MPTS had overlooked the findings of a court of law and failed to take into account public confidence in the healthcare system.

This time Dr Bawa-Garba was granted the right to appeal and in August 2018 the Court of Appeal quashed the High Court's decision and ruled in the doctor's favour, requiring that her name be reinstated on the medical register. The court also ruled that the original decision by the MPTS of a 2-year suspension from the register should stand, and as part of that decision the tribunal ordered a review hearing prior to any return to unrestricted practice.

Reporting on Dr Bawa-Garba's appeal, Medscape News UK noted that in passing judgement, Sir Terence Etherton, Master of the Rolls, said the court accepted that  "no concerns have ever been raised about the clinical competency of Dr Bawa-Garba, other than in relation to Jack's death", and that "the risk of her clinical practice suddenly and without explanation falling below the standards expected on any given day is no higher than for any other reasonably competent doctor".

The Events Leading to Jack's Death

Jack Adcock was on enalapril, an angiotensin converting enzyme (ACE) inhibitor, to relieve hypertension.

On February 18, 2011, Jack's GP referred him to Leicester Royal Infirmary where he was admitted to the Children's Assessment Unit at around 10 am, after the boy presented with dehydration caused by vomiting and diarrhoea, and shallow breathing.

After initial treatment for what was believed to be acute gastroenteritis and dehydration, he was given antibiotics for pneumonia observed on X-ray. Subsequently he developed septic shock and consequent organ failure. At 7.45pm his heart failed. An attempt to resuscitate him was stalled after a misunderstanding when he was mistaken for another child who had a do not resuscitate (DNR) order in place, and Jack died at 9.20 pm. Dr Bawa-Garba was the most senior junior doctor on duty that day and she was accompanied by two nurses. Together, they treated Jack for the following 8-9 hours in the unit.

Documents detailing the legal proceedings in the case of the GMC against Dr Bawa-Garba articulate a range of failings upon which the prosecution case rested, including a lethargic and unresponsive patient, raised body temperature but cold hands and feet, poor perfusion of the skin, an acidotic blood test reading indicative of shock, and a significantly raised blood lactate reading. In addition, they state that there was an improper review of a chest X-ray that would have confirmed pneumonia much earlier, and a delay in obtaining blood test results and acting on these results, which had indicated both infection and organ failure from septic shock. Signs of shock were said by the GMC to have been present on admission, and Jack's risk of death from this on admission was said to be in the range of 4-20.8%. According to the GMC, Dr Bawa-Garba did not raise appropriate concerns with Dr Stephen O'Riordan the senior consultant when he arrived on  the ward at 4.30pm. ( Judgement of General Medical Council v Bawa-Garba [2018] EWHC 76 (Admin) (25 January 2018) ). Cause of death was streptococcal sepsis combined with Down's syndrome and the repaired hole in the heart.

In Dr Bawa-Garba's defence, the following points were included: by approximately midday, Jack was showing clinical signs of improvement on the second blood gas results and he was sitting up and laughing during the X-ray; the hospital's computer system that day delayed receipt of blood test results from the laboratory despite best efforts to obtain them (received at 4.45pm); Dr Bawa-Garba was without the assistance of a senior house officer, and there were agency nurses in attendance due to a shortage of permanent staff. She alerted the consultant to the rise in CRP at the 4.30pm handover; and an agency nurse failed to properly observe and communicate Jack's deterioration to Dr Bawa-Garba and turned off the oxygen saturation monitoring equipment without seeking her approval.  Dr Bawa-Garba prescribed antibiotics for Jack at 3pm, as soon as she saw the X-ray, but the nurses failed to administer them until an hour later; the decision to transfer Jack to another ward was not hers; she bore no responsibility for the administration of enalapril; and the mistaken belief that Jack was 'DNR' was made towards the end of her 12/13 hour double shift, without break, and was quickly corrected. ( Judgement of General Medical Council v Bawa-Garba [2018] EWHC 76 (Admin) (25 January 2018) ). An hour after receiving the ACE inhibitor, Jack had a cardiac arrest and died. 

Personal Culpability Versus Systemic Failures in the NHS

The week of Jack Adcock's death, Dr Bawa-Garba had returned from a 14-month maternity leave to be faced with a short-staffed Children's Assessment Unit. Dr Bawa-Garba's supervisor was unavailable because he was teaching in a nearby city, and her registrar's colleagues were also away on educational leave. 

In a commentary article reprinted with permission from The Health Care Blog following the High Court decision to strike Dr Bawa-Garba off the medical register, radiologist Dr Saurabh Jha, who practised in the UK previously and is now based at the University of Pennsylvania, Philadelphia, US, remarked: "Triple booked, Dr Bawa-Garba was making critical decisions and also doing the scut work and teaching and supervising her team. To borrow an aviation analogy, she was flying the plane and serving food to the passengers."

An uprising of solidarity among medical professionals emerged following Dr Bawa-Garba's erasure from the medical register. It struck a chord with other medics who felt it was unfair to place the weight of the blame on a single doctor's head. Around 11,000 people signed a petition against the GMC's action in the case and over £366,000 was crowd-funded to support Dr Bawa-Garba's appeal; #IamHadiza was born.

The Bawa-Garba case entered new territory at this point; it was no longer about one doctor but about setting what was widely considered to be an unfair precedent that could undermine efforts to support transparency in practice, whilst failing to recognise the wider systemic problems in the health service that underpinned the events surrounding Jack's death. 

Doctors argued that Dr Bawa-Garba was ultimately punished for being too honest about failings through her reflective practice notes. These are notes that doctors are encouraged to write as a pedagogic exercise. According to Jha, she wrote about her own remorse but did not mention system failures. Perhaps unsurprisingly, a poll by the website, GPOnline, following the Bawa-Garba case found that 70% of 'GPs believe it is unsafe to record reflective notes in writing'.

Following the Court of Appeal's decision to reinstate the earlier 12-month suspension, Medscape News UK reported that the GMC, which had experienced intense criticism from the medical profession in the aftermath of the case, said it had highlighted issues "that have gone unaddressed for far too long". Charlie Massey is the GMC Chief Executive. At the time he was reported as saying: "Doctors have rightly challenged us to speak out more forcefully to support those practising in pressured environments, and that is what we are increasing our efforts to do."

Furthermore, the GMC had commissioned an independent review into gross negligence manslaughter issues.

Editor's Note: This article was updated after publication to include updated information from the MPTS hearing. 

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