The Royal College of Nursing and other professional bodies have warned of the negative implications of “continuing down the path” that occurred in the case of Dr Hadiza Bawa-Garba on safety culture.
Yesterday, the doctor, who was struck off in January this year over the death of a six-year-old boy, won her High Court appeal to practise medicine again.
“Healthcare should be viewed as a safety critical industry”
Dr Bawa-Garba was convicted of manslaughter by gross negligence in 2015 over the death of Jack Adcock, who died of sepsis at Leicester Royal Infirmary in 2011.
Her appeal was funded by other doctors who said the original ruling would discourage clinicians from being open when reviewing mistakes.
A nurse, Isabel Amaro, was also found guilty of manslaughter on the grounds of gross negligence, after her monitoring of Jack Adcock’s condition and record-keeping were criticised.
Ms Amaro, an agency nurse at the time of the incident, was sentenced to a three-year suspended jail sentence in November 2015 and subsequently struck off the nursing register.
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Responding to Monday’s legal decision, Donna Kinnair, the RCN’s director of nursing, policy and practice, said: “Healthcare should be viewed as a safety critical industry, with a focus on learning and preventing future mistakes.
“Continuing down the path we have witnessed in the Bawa-Garba case risks creating an environment in which individuals feel afraid to come forward, or even to work in pressurised, understaffed environments for fear of blame,” she said.
Dame Donna Kinnair
“Safe and effective care can only be achieved with an adequate number of staff with the right skills, in the right place at the right time,” said Dame Donna.
She added: “We urgently need a workforce plan for England that responds to patient need, and prioritises recruitment and retention.”
In November last year, former health secretary Jeremy Hunt announced plans for a new national workforce strategy designed to help secure the long-term supply of nurses and doctors for the NHS.
He suggested the plan – to be developed by Health Education England – would draw together all the current staffing initiatives, such as nursing associates and apprenticeships.
Meanwhile, his successor Matt Hancock has pledged to launch a consultation exercise across a range of issues facing the health service workforce.
Specifically, he said it would consider issues such as bullying and harassment in the workplace, diversity and how to establish more pathways for nurses and other clinicians into leadership roles.
“It is important to explore the wider issues that create the potential for patient harm, particularly understaffing”
Also commenting on the Bawa-Garba case, Professor Derek Bell, president of the Royal College of Physicians of Edinburgh, said: “Looking ahead, it is vital that lessons are learned from this case.
“It is important to explore the wider issues that create the potential for patient harm, particularly understaffing,” said Professor Bell.
“We must encourage an open and no-blame culture where the focus is on identifying and addressing risks and failures in systems of governance, and where all staff and patients are empowered to raise concerns over standards of care,” he said.
He added: “Only by doing so can we ensure that we learn from cases such as this and prevent similar tragedies from occurring.”
Professor Dame Jane Dacre, president of the Royal College of Physicians in London, said: “The judgment of the court of appeal is a welcome step towards the development of a just culture in healthcare, as opposed to a blame culture.”
She said: “On 18 February 2011, Jack Adcock was not the victim of a truly, exceptionally bad doctor, but of an overstretched system that saw a competent trainee covering the workload of several doctors.”
“There continues to be too much of a blame culture where individual health professionals are made scapegoats”
The charity Action against Medical Accidents said it was calling for all concerned with the case to “reflect deeply on how this affair has been handled”.
AvMA chief executive Peter Walsh said: “There is now an opportunity to move on and deal with some of the deep-seated issues that this controversy has highlighted.
“No-one should be under any illusion that the ruling itself changes the fact that we still have an NHS which too often leaves patients at risk and health professionals in near-impossible positions,” he said.
“There continues to be too much of a blame culture where individual health professionals are made scapegoats for systemic failures,” he said. “There still needs to be more openness and honesty when things go wrong, and accountability when appropriate.”
Mr Walsh added: “However, a lot of fear has been stirred up unnecessarily. A prosecution for gross negligence manslaughter, as happened to Dr Bawa-Garba, is incredibly rare.”