Doctor struck off for gross negligence manslaughter permitted to return to work

She was later struck off following an appeal by the GMC in which it was argued that the initial one-year suspension was not sufficient. In a further appeal held on Tuesday, it has now been decided that Dr Bawa-Garba can return to work following maternity leave, in February 2020.

The case attracted significant controversy, with many medics fiercely supportive of Dr Bawa-Garba, arguing that she had been made a “scapegoat” in a flawed NHS system. The limitations of an overstretched NHS were laid bare in the various investigations into Jack’s death and a number of systematic failures were identified which contributed to the catastrophic outcome.

Factual background

In 2011, Jack, who had Down syndrome and suffered from a heart condition, presented to Leicester Royal Infirmary’s Children’s Assessment Unit (CAU) with diarrhoea and vomiting.

Although Jack had initially been admitted under the care of Dr Stephen O’Riordan, the consultant who was supposed to be in charge that day, Mr O’Riordan had double-booked himself with teaching commitments in Warwick. As a result, he had not arrived at work. Dr Bawa-Garba had recently returned to work from maternity leave and had been working on the general paediatrics ward. On the day in question, however, she volunteered to cover in the CAU, also being allocated the emergency “bleep”.

Dr Bawa-Garba assessed Jack and made a working diagnosis of gastroenteritis. An x-ray was also requested and his medications reviewed. As part of her assessment, bloods were taken but unfortunately, despite these being fast tracked, the computer system went down which affected the whole hospital. This caused not only a delay, but meant that the usual “alert” system for abnormal results was not functional.

A bolus of fluid was provided and as time progressed, initially Jack appeared to have improved. Dr Bawa-Garba was reassured. The chest x-ray performed earlier that day demonstrated a likely chest infection and antibiotics were prescribed. This was the last time Dr Bawa-Garba physically saw Jack before his death.

Unfortunately, Jack’s improvement was short lived.  Jack’s condition worsened significantly at around 7pm that evening, resulting in an emergency call being put out. At this stage, Dr Bawa-Garba had worked for over 12 hours without a break.

In what would prove to be the most significant and tragic mistake of her career, when receiving the emergency call Dr Bawa-Garba confused Jack with another child she had been treating, a child with a “do not resuscitate” order in place. As a result of this confusion, Dr Bawa-Garba issued an order to stop resuscitation, unaware that the child requiring her attention was actually Jack Adcock.

Tragically, at 21.21 hours, Jack died of sepsis.

Investigations, hearings and appeals

A number of detailed internal investigations took place after the events, in addition to a Police investigation and an Inquest. Following the internal investigation, six root causes were identified in relation to Jack’s death, 23 recommendations for improvement made and 79 actions to minimise the risk of another child dying in such unacceptable circumstances.

In 2015, in a decision which caused shock waves in the medical profession, a Jury convicted Dr Bawa-Garba of gross negligence manslaughter. She received a two-year prison sentence, which was suspended for two years. Following the verdict, a review of manslaughter by gross negligence laws was commenced by Jeremy Hunt, over fears that punitive sanctions could prevent staff raising the alarm about preventable medical errors.

In 2017, the Medical Practitioners Tribunal Service suspended Dr Bawa-Garba from the medical register for a year. However, the General Medical Council appealed against this decision, arguing that the sanction was “not sufficient.” In January 2018 she was struck off at the High Court.

Following an appeal on Tuesday 9 April 2019, legal fees for which were largely funded by support from the medical profession, the MPTS has now ruled that Dr Bawa-Garba can return to work, as it is now satisfied that she has “reflected appropriately” on her actions. Tribunal Chairwoman Claire Sharp stated that she was satisfied that Dr Bawa-Garba’s risk to patients was low.

Dr Bawa-Garba will practice under close supervision for a period of two years, and at a lower grade to her previous level of seniority within the hospital. It was held that the tribunal was satisfied that “the imposition of these conditions on Dr Bawa-Garba’s registration will be sufficient to allow her safe and successful return to practice and to also adequately protect the public.”

Jenny Vaughan, Law and Policy Officer for the Doctors’ Association UK, which helped support the appeal, said it was “right” that Dr Bawa-Garba would be allowed to return to work. She said: “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.”

Jack’s parents had opposed Dr Bawa-Garba being allowed to practise again. Mrs Adcock commented that Dr Bawa-Garba’s apology was “eight years too late”.

Dr Bawa-Garba, now a mother-of-four, has apologised for her part in Jack’s death and told the Tribunal that the case “will live with me for the rest of my life.”

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