After Bawa-Garba: the principle of shared responsibility

Detail from Bawa-Garba trial illustration [BBC website]

The case had been rekindled in the minds of many this week for two reasons. Firstly, Hadiza Bawa-Garba has been allowed back to work, and secondly, court transcripts have become available. Excerpts from these have been Tweeted to counter several ‘myths’ or received facts such as ‘it was her first day back from maternity leave’ and ‘there was no consultant available’. I’m not sure I ever believed them when I heard them, but they were surely doing the rounds. Jack’s parents have commented on several of these excerpts on Twitter, and detailed the family’s frustrations in an unpublished letter to the BMJ. It contains criticisms of the BBC Panorama programme ‘Doctors on trial’ which highlighted multiple systemic failures and was supportive of Dr Bawa-Garba [written summary of programme available here]. The power of the parents’ comments is clearly magnified by their connection to Jack, and it is impossible not to feel confused and depressed by this polarising debate.

As a doctor it is easy to look on regretfully, shake your head, mutter the cliché ‘there but for the grace of God…’ and move on, hoping that you will never be brought into court to defend yourself. But if the reaction to the Bawa-Garba case stops there, what good has come of it?

The most direct good that can come from such a tragedy is improvement in the delivery of acute care to children. Leicester Royal Infirmary learnt pretty quickly, as MD describes in Private Eye, making ‘…23 recommendations, including that the consultant on-call for emergencies should review all the new admissions in person (something that was already happening in units providing a decent standard of consultant-led care).’

But there must be other forms of good, applicable to the wider medical community. Every doctor who has followed the progress of the case and felt an emotional response must have come away with a personal point of reflection or lesson that translates to their area.

For me, it is trying to understand the concept of shared responsibility that a medical team has for a patient admitted under its care. This reflection derives from the behaviour, widely criticised and somehow off-limits to all forms of inquiry, of the consultant involved in Jack Adcock’s care. It appears that following Jack’s death, Dr Bawa-Garba was immediately isolated. Again, in the words of Private Eye’s MD: ‘…Dr _______ insisted on seeing Jack’s parents without her. Given the parents’ sudden change in attitude to Dr Bawa-Garba from thankful to extremely hostile, it seems likely that blame for Jack’s death was apportioned to her…’ It looks as though the consultant took no portion of the burden of blame. He stood apart from the chaos, supervisory but uninvolved. [The timeline of the case does not support an immediate crystallisation of blame in the minds of Jack’s parents, as it was not until the inquest that they heard, from an expert witness, that their son might still be alive if he had been treated better.]

Let’s consider the mini-hierarchy of a medical team. There is pyramid, based on experience, knowledge and certification. Each member of the team has a supervisory role over those below them. The consultant is responsible for the way the team functions overall. This is challenging in an environment that does not encourage continuity or team stability, but the line of responsibility still holds. If a patient is admitted under my care and dies unexpectedly, it I who will be asked to justify the decisions that were made if there is an inquest, even if I never met the patient. (This happens – see previous post, ‘A Final Act’.)

If Dr Bawa-Garba’s very junior Foundation Year colleague had done something wrong that day, such as failing to communicate a seriously abnormal blood gas result that she or he had been asked to process, would Dr Bawa-Garba have felt responsible? Would she have stepped forward and taken some of the flak? To make the question less emotive, let’s imagine a different scenario. Would I feel responsible if, as a general medical consultant on-call from home, ‘my’ registrar (who may be someone I barely know), fails utterly to consider or diagnose meningococcal sepsis in a 19-year old?

It depends on the culture. If it is one where shared responsibility is explicit… then yes, I would feel responsible, I would feel nervous. I would act accordingly.

In such a culture, I would be talking to the registrar, checking-in before I turned the light off, asking ‘Is everything OK, is there anyone you’re worried about?’ In that way, I would get a sense of what is happening, my radar would be attuned to risk, and to the strengths or relative weaknesses of the trainee, albeit senior (I was in this position aged 39) doctor who is running that part of the hospital in my name. This seemingly enlightened and ‘team friendly’ approach exists in many places, though as you get more senior there is a tendency to be less involved, or to trust the senior trainees to escalate when they feel the need to – ‘a picture of a consultant sitting in chair, waiting for [junior staff] to come and get them’ as said by the judge in Dr Bawa-Garba’s trial. Standing back, not involved. And not to blame. It is a balance. A fine one.

In Jack Adcock’s case, the consultant was close. He sat with Dr Bawa-Garba at hand-over. I still find it hard to understand why his radar did not alarm when he was told that Jack’s blood pH was 7.08 (evidence of a body under extreme, life-threatening stress). Not being a paediatrician, I have told myself that kids behave differently, they swing from gravely unwell to stable in a matter of hours. I cannot comment on another specialty. But in the field of adult medicine, I can’t imagine hearing that information at handover and not feeling a shiver of risk, of impending danger, impelling me go and see the patient myself, to satisfy myself that the medical management and escalation decision were appropriate. It is data that cannot be unseen, and it draws you into the sphere of shared responsibility.

The culture of shared responsibility presents a potential problem. It could encourage a tendency to cover-up mistakes. If every individual error is dissolved among the many, will anyone ever learn? Yes, if the culture is also just, and can discriminate between different grades of error [see previous post, ‘The place of blame’].

Imagine again the registrar who missed meningococcal sepsis, showing a serious lapse of judgement or an unacceptable gap in knowledge. What do I do? My initial instinct is to talk. I complete the morning ward round, take the registrar aside, and ask, ‘Tell me about your reasoning here.’ Assuming I am appalled, what next? I now need to speak to the parents of the teenager who may be brain damaged or may lose limbs due to diagnostic and therapeutic delay. Do I go in to explain that there has been an error, avoidable harm… do I perform the duty of candour? Probably not, at this early stage. I talk to the parents about the team, about my role, the registrar’s role (initial assessment, early decision–making, diagnostic uncertainty). I explain that things could possibly have been done better, but we need to look into that. Then, later, when more information is revealed, I may have to embark on a painful process of investigation, apology, candour and learning. Perhaps even remediation for the registrar, via their educational supervisor or deanery. And yes, there may be a formal complaint or worse. What I do not do is throw the registrar ‘under the bus’ (an accusation made by many of Dr Bawa-Garba’s consultant). That early interaction will have made it clear to the family that blame rarely settles in one narrow area. And the same goes for blame’s extreme corollary, criminality.

Such an approach can be criticised. Relatives (the true ‘second victims’) may balk at it. Someone must be to blame. I do not lie at the end of the spectrum that refuses to see blame in individuals. The NHS is capable of employing bad doctors, and most consultants will have worked with a few. In the case of Dr Bawa-Garba, I do see serious underperformance in the available evidence. In the Panorama report, 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.” But I also see departmental underperformance, again clearly described in the Panorama report. It is a picture of the NHS at its most disappointing.

As a consultant of 8 years standing, I am too far away from current conditions to comment accurately on how profoundly UK trainees have been affected. But as a consultant with ‘shared responsibility’ for the actions of those I supervise, the case of Hadiza Bawa-Garba lingers, a reminder that error will never be fully dissociated from blame, and as an ever-present motivation to ensure that the team functions well and that risk does not grow into threat, then into catastrophe, before being recognised.

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