Hadiza Bawa Garba: Struck off for honest mistakes {2}

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. The case attracted a lot of media coverage. “I’m a very private person, but I had my face in the newspaper.” •Bawa Garba Dr Bawa-Garba had enjoyed an unblemished career before Jack’s death and was well-regarded by her colleagues. Born in Nigeria, she had wanted to be a doctor since she was about 13 years old, after recovering from malaria. At 16 she moved to the UK to study for her A-levels. After her first degree at Southampton University, she studied medicine at Leicester and set her sights on becoming a paediatrician. “I’ve been in the UK for more than half my life,” she says. “I love the NHS. I love the fact that people can get access to free medical health and that you can be part of that process.” But that all changed the day she covered for a colleague at the CAU. “The last picture I have of Jack is him sitting up drinking from a beaker, nothing prepared me to see him crash,” she says. “After I realised that we were actually resuscitating Jack, I just couldn’t understand why he had crashed. When the team wanted to stop, I didn’t want to stop – because in my mind I’m thinking he’s not meant to crash,” she says. Afterwards, she went to the nurses’ station and sobbed. “I just couldn’t control myself and I’m not usually a weepy person,” she says. “I just kept thinking, ‘How did that happen? Why did he crash? What went wrong?’” Dr Bawa-Garba recalls the moment that Mrs Adcock came up to her to thank her for her help. “I said to her, ‘I’m really sorry about the outcome – I don’t know how this happened,’” she says. Later that night, Dr Bawa-Garba called Dr O’Riordan – the consultant who had arrived in the afternoon, after double-booking himself that day – to tell him about Jack’s death. She went home at 23:00 – some 15 hours after she had started her 12-hour shift – and updated Jack’s notes with what had happened at the resuscitation. The following day, she was back at work at the assessment unit. She knew the hospital was meeting the Adcocks and asked if she could attend. But she says Dr O’Riordan told her that she had to get on with her clinical duties. The consultant then added to the notes that Dr Bawa-Garba had made. He wrote that Dr Bawa-Garba had “not stressed” to him that Jack’s lactate level was 11. On Sunday, struggling to process what had happened, Dr Bawa-Garba phoned Mrs Adcock to say she was sorry for the family’s loss. “I just wanted to reach out to see how mum was holding up because it must be devastating,” she says. The following day, she says, she was admonished by Dr O’Riordan for making that call and told not to have any more contact with the family because an investigation was to be launched. He then told her that they needed to discuss Jack’s death properly because he thought she hadn’t highlighted to him how ill Jack was, she says. He wanted to talk about how things could have been done differently to stop it happening again, she adds. Dr Bawa-Garba had already started to write down her reflections. “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. “I made my own action plan about how I would be able to address those things that I wish I had done differently.” On 25 February, a week after Jack’s death, Dr O’Riordan asked Dr Bawa-Garba to meet him in the hospital canteen, rather than the office he shared with other consultants. She was told to list everything that she could have done differently, she says. So she continued that personal reflective process with Dr O’Riordan in the canteen. “I was beating myself up about every single detail and obviously wishing that I had recognised sepsis, so we spoke about that and I was very open and explained everything,” she says.dr-bawa-garba “It contained what I felt I could’ve done better plus some of the things that Dr O’Riordan also felt that I could’ve done better.” Jack died from sepsis. Sepsis is when the immune system overreacts to an infection and attacks the body’s own organs and tissues. According to the UK Sepsis Trust, about 14,000 people die each year because it is not diagnosed or treated early enough. At the meeting, Dr O’Riordan took notes, which he then transferred to what is called a training encounter form, she says. This contained one section for Dr O’Riordan to write on and one for Dr Bawa-Garba to document her learning points and reflections. However, she didn’t agree with all Dr O’Riordan said and didn’t sign the form. Both her reflections and the training encounter form were uploaded to her e-portfolio, an online system used for learning purposes. As soon as the meeting finished, Dr Bawa-Garba says she was sent home by Dr O’Riordan. Dr O’Riordan declined Panorama’s invitation to comment on Dr Bawa-Gaba’s account of the meeting. 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. There she would see lots of children with sepsis, some of whom would get better then get worse – like Jack, she says. “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. 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. The hospital had carried out its own investigation and Dr Bawa-Garba continued to work there. But five months after Jack’s death, Dr O’Riordan left the Leicester Royal Infirmary and moved to Ireland. Because Jack’s death was unexpected, the hospital conducted an investigation to identify what had gone wrong with the little boy’s care. They produced a report in August 2011 and updated it six months later. 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 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. There were six root causes for Jack’s poor care, the report said, listing 23 recommendations for improvement and 79 actions to minimise the risk of another child dying in such unacceptable circumstances.

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