Dr Bawa-Garba: lessons learned for professional regulation. Alan Clamp | Professional Standards Authority
Jack Adcock
18 February 2011 0930: Jack admitted to Leicester Royal Infirmary. 2121: Jack declared dead.
Investigation Internal investigation identified: Errors by Dr B-G Errors by nursing staff A series of system failings A total of 23 recommendations.
Expert views Interruption to resuscitation did not contribute to death. Enalapril was an aggravating factor. Jack should have been given antibiotics much earlier.
The criminal case July 2013: inquest referred the case to the CPS . December 2014: Dr B-G charged with manslaughter by gross negligence. November 2015: Dr B-G found guilty and received a two-year suspended sentence.
Regulation June 2017: Tribunal suspended Dr B-G for one year. January 2018: General Medical Council appealed the decision in the High Court – sanction changed to erasure. August 2018: Dr B-G appealed to the Court of Appeal and was reinstated to the register (suspension order in place; conditions added).
Response to the case [1] Many doctors argued that Dr B-G was unfairly punished for mistakes made while working in an overstretched and under-resourced NHS . “ We can’ t believe that she is allowed to practice again after a conviction like this” (Nicky Adcock).
Response to the case [2] “ I am sorry for my failure to recognise sepsis. I apologise for the pain I have caused the family. The pain will live with me for the rest of my life.” (Dr Bawa-Garba)
Themes Time Teamwork Culture Candour Law Workforce S ystems Mistakes Communicat ions
Where are we now? Court deference to panel decisions (and vice- versa )? Different outcomes for different professions? The importance of context in regulatory decisions? Was this a case of gross negligence manslaughter?
Review of GNM (June 2019) Origins in the case of Dr B-G. ‘ Personal and system accountability must be balanced with learning and prevention of harm’ We need ‘ better and fairer’ regulation. It is time for regulatory reform.
Jack Adcock
S peaker Contact Information Alan Clamp, Chief Executive, Professional S tandards Authority. alan.clamp@ professionalst andards.org.uk www.professionalst andards.org.uk
Thank Y ou
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