There is to be an urgent review of clinical malpractice cases, after concerns that workforce pressures were not taken into account in a recent high profile case involving a paediatrician.
Health and social care secretary Jeremy Hunt announced today in the Commons that there would be a national review into the application of gross negligence manslaughter in healthcare.
“The only way we can reduce mistakes in the NHS is to learn from every single one”
The move follows the case of Dr Hadiza Bawa-Garba, who was struck off the medical register last month following a High Court ruling that related to a conviction for manslaughter in 2015.
The General Medical Council had appealed to the High Court to overturn the decision of one of its own tribunals that had previously allowed her to remain on the register despite the conviction.
Dr Bawa-Garba was convicted of the gross negligence manslaughter of six-year-old Jack Adcock, due to her failure to recognise and act on signs he had sepsis. Jack, who had learning disabilities and a heart condition, died at Leicester Royal Infirmary in February 2011.
But during her shift, Dr Bawa-Garba was working with a range of systemic issues including IT failures, delays in test results and widespread staff shortages.
“Nurses and midwives do an extremely challenging job in often very difficult circumstances and mistakes can happen”
As a result, the ruling has prompted concerns, especially among doctors who have claimed that factors such as short staffing and lack of support staff were not given significant weight in the case.
A 47-year-old agency nurse, Isabel Amaro, was also convicted of manslaughter on the grounds of gross negligence relating to the same incident. Her monitoring of Jack’s condition and record-keeping were criticised.
She was sentenced to a two-year suspended jail sentence and struck off by the Nursing and Midwifery Council in 2016. However, fellow nurse Theresa Taylor, then a 55-year-old ward sister, was cleared.
Speaking in the Commons, Mr Hunt said the review would look at how “we ensure there is clarity about where the line is drawn between gross negligence manslaughter and ordinary human error in medical practice so that doctors and other health professionals know where they stand with respect to criminal liability or professional misconduct”.
The health and social care secretary told MPs that the review would also look at issues around reflective learning to ensure openness and transparency was protected, so mistakes were learnt from.
“The only way we can reduce mistakes in the NHS is to learn from every single one, and the tragic case of Dr Bawa-Garba raises many important questions about how the health system supports staff to be open and transparent when things go wrong,” he said.
In addition, the review would consider lessons to be learnt by the General Medical Council and other regulators, he said. Mr Hunt added that the devolved countries of the UK would be involved and also the Professional Standards Authority, which oversees regulators including the NMC and the GMC.
Sir Norman Williams, former president of the Royal College of Surgeons, has been appointed to lead the national review and will produce a report by April this year.
Responding to Mr Hunt’s comments, the NMC said it welcomed the announcement of a review into application of gross negligence manslaughter in healthcare.
NMC chief executive and registrar Jackie Smith said: “We welcome this review and will work closely with Professor Sir Norman Williams and other regulators to explore the long-standing issues in this important and complex area.
“Nurses and midwives do an extremely challenging job in often very difficult circumstances and mistakes can happen,” noted Ms Smith.
“While charges of gross negligence manslaughter among healthcare professionals are very rare, there must be a public discussion about how the health and care sector can ensure an open and transparent culture in which individuals and organisations can learn from their mistakes,” she said.
She added: “We’ll continue to work with the GMC and others to look at how gross negligence manslaughter cases are handled within the health and care sector and to ensure that healthcare professionals have the right support in place to raise concerns.”