We must all be committed to protecting patients from harm in a system that promotes both learning and accountability for staff, writes James Titcombe

When adverse events occur in healthcare, the consequences can be catastrophic for patients and their families. In the aftermath of such events there are multiple needs, expectations and demands. Patients and their families need support and an open, honest explanation as to what happened and why.

Often overlooked, however, is the impact on healthcare workers involved in an incident. The healthcare organisation in which they work has a duty to ensure staff are appropriately supported, that the underlying factors that contributed to what happened are understood and that action is taken to prevent similar circumstances occurring again. There is also a legitimate and important need to address accountability.

Very rarely do such events have a single or “root” cause. Done properly, incident analysis usually reveals a combination of multiple factors. Systems, processes, equipment, resources, organisational culture and normal human fallibility are often interlinked factors in the chain of causation.

People working in healthcare generally set out each day to do the very best for their patients, but they work in complex and often challenging circumstances where the functioning of wider systems, processes and the support around them play a crucial role in the overall quality and safety of care they are able to provide. In this context, the issue of accountability can become fraught with difficulty. This has been brought sharply into focus in recent weeks by the case of Hadiza Bawa-Garba.

Systems, processes, equipment, resources, organisational culture and normal human fallibility are often interlinked factors in the chain of causation

At the centre of this case is the tragic avoidable death of a six year old boy, Jack Adcock. Jack died of sepsis, a complication of infection, which had been missed during earlier assessments after Jack was taken to hospital by his concerned mother. Dr Bawa-Garba was the doctor in charge of Jack’s care.

A court later heard that “any competent junior doctor” would have made a correct diagnosis after an inquiry identified 21 clinical mistakes made during Jack’s care. Dr Bawa-Garba was subsequently convicted of manslaughter.

However, the Medical Practitioners Tribunal Service reviewed Bawa-Garba’s case, taking into account a number of mitigating circumstances (including staffing shortages in the unit, IT failures and the fact that Dr Bawa-Garba was on her first day back after a period of maternity leave) and decided to impose a sanction of 12 months’ suspension.

Earlier this month, the General Medical Council succeeded in overturning that decision in court, meaning that Dr Bawa-Garba was stuck off the medical register, effectively ending her career as a doctor.

Strong response

These events have triggered a strong response amongst the medical profession both here in the UK and internationally. A crowdfunding campaign was established to fund a legal team to look into appealing the decision (quickly raising over £350k) and the hashtag #IamHadiza has trended on twitter, used by other doctors in a show of solidarity.

Dr Bawa-Garba’s failures over Jack’s death have been described by the GMC as “not simply honest errors” but “truly exceptionally bad”

The response from the medical profession is fuelled by a sincere sentiment that other doctors working in the same circumstances as Dr Bawa-Garba could have made the same mistakes and that real learning from the case can only be served by understanding and addressing the system within which Dr Bawa-Gawa was working that day and not by individual blame.

As these events have unfolded, it’s hard not to reflect on the impact all this must be having on Jack’s family. Having lost their beautiful little boy, they have had to go through the agonising process of investigations, inquest hearings and court proceedings, forced to relive the circumstances of what happened time and time again.

No one else has the perspective or understanding they have and no one else can fully comprehend the depth of their loss and grief.

Dr Bawa-Garba’s failures over Jack’s death have been described by the GMC as “not simply honest errors” but “truly exceptionally bad”. Imagine how it would feel as Jack’s mother or father to read “This campaign wouldn’t have been possible without these selfless, courageous doctors who’ve been beside the brilliant Hadiza from the off…” which was recently tweeted from the @TeamHadiza account?

Urgent review

In a welcome move, Jeremy Hunt has announced an urgent review of manslaughter by gross negligence rulings in the NHS to be carried out by Sir Norman Williams  which will report in May.

Leaders must also commit to support healthcare professionals, giving them space to undertake self-reflection and learning

In the meantime, the repercussions of this case will continue. However, one fact is already clear: trust in the current systems for learning from patient safety incidents in the NHS is broken and that if we want to create a safer NHS for patients and staff, things must change.

The expert advisory group established to help set up the new Healthcare Safety Investigation Branch described the importance of a system wide “just culture”:

“…a shared set of values in which healthcare professionals trust the process of safety investigation; and are assured that any actions, omissions or decisions that reflect the conduct of a reasonable person under the same circumstances will not be subject to inappropriate or punitive sanctions.”

This shared set of values and the trusted processes that complement them, must encompass every part of the system. It must start with healthcare leaders being open and honest about their own mistakes and sharing the learning from them.

Leaders must also commit to support healthcare professionals, giving them space to undertake self-reflection and learning. All parts of the system involved with the investigation of adverse events must have the trusted expertise to distinguish between normal human error, risky behaviour and true recklessness.

Achieving this must now be an urgent priority for everyone involved in healthcare, but it won’t be easy. If we are going to build a consensus around the changes we want to see, we need to do so with utmost compassion, sensitivity and humility. A good starting point would be to recognise that talk of sides or “teams” is deeply divisive. We must all be on the same side, committed to protecting patients from harm in a system that promotes both learning and accountability for staff.