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System pressures 'must be considered in patient death cases'

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The pressures under which clinicians are working must be taken into account when they are put on trial over the death of a patient, an independent inquiry has warned.

The review was carried out in response to backlash from the medical profession over the treatment of trainee doctor, Hadiza Bawa-Garba, who was found guilty in 2015 of gross negligence manslaughter over the death of a six-year-old Jack Adcock from sepsis.

Following the conviction, professional regulator the General Medical Council fought to have her struck off the register by successfully appealing a ruling by a tribunal that she should just be suspended.

The case sparked debate because some believed Dr Bawa-Garba – who had an unblemished six-year record before the event – was being unduly punished for mistakes she made while working in an under-resourced service.

Agency nurse Isabel Amaro was also found guilty of manslaughter on the grounds of gross negligence and struck off the nursing register for her care of Jack.

In his foreword to the report published today, Leslie Hamilton, who chaired the review, said doctors had lost confidence in the GMC and in the operation of a fair and just culture in medicine.

“In the minds of many doctors, the fear begins when things go wrong in the workplace and with the belief that the ‘system’ is structured to apportion individual blame rather than to learn from events and prevent future harm,” Mr Hamilton said.

“It continues through coronial inquests, criminal investigation and the regulatory process which, some doctors feel, does not sufficiently recognise the realities of medical practice,” he added.

Mr Hamilton said healthcare services had “woken” to the need for just and fair treatment of staff, but the application of these principles was “patchy, at best”.

A key recommendation from the inquiry is that when a healthcare professional is being investigated for gross negligence manslaughter or culpable homicide, authorities should “scrutinise the systems” within the department in which they were working. 

Nursing and Midwifery Council

Andrea Sutcliffe

Source: NMC

Andrea Sutcliffe

Furthermore, if the accused is a trainee, their education and training environment should also be scrutinised.

Andrea Sutcliffe, chief executive and registrar at the Nursing and Midwifery Council, said the review provided “essential lessons” for not just the GMC but professional regulation more widely, including the NMC.

The NMC is currently overhauling its fitness to practise procedures, with a big part of this being around taking greater account of the context in which mistakes happen.

“Creating a just culture – one which encourages openness and learning – is at the heart of our new approach to fitness to practise, as is working with employers to ensure better local investigations and referrals,” said Ms Sutcliffe. 

“That way we will all understand better what happened and what we have to do to make sure it doesn’t happen again,” she added.

“We continue to work closely with the GMC and other regulators on these important, shared issues,” said Ms Sutcliffe.

The recommendations of the review have been welcomed by the Royal College of Nursing.

An RCN spokeswoman said: “Healthcare needs to be viewed as a safety-critical industry, with a focus on learning lessons from mistakes and preventing errors in the future rather than apportioning blame.

“Taking the approach we witnessed in the Dr Bawa-Garba case risks creating an environment in which clinical staff feel afraid to come forward for fear of censure,” she added.

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