Dr Bawa-Garba would travel from her home in Leicester up to Nottingham. But the fluid he was losing from having diarrhoea had not been documented by his nurse. She says: I walk in and say, ‘He’s not for resuscitation,’ because I thought it was the child with the ‘do not resuscitate’ order.”. Get up to date with the latest news and stories about the person Steven O Riordan at The Irish Times. During phone calls home, she could hear the hungry baby crying. Dr Siobhain O'Riordan is a Course Co-Director on the coaching and coaching psychology programmes and a trainer at the Centre. On the fifth day of the trial, Dr Stephen O’Riordan, the consultant who was meant to be on duty the day Jack died, took the stand. Cusack, who was asked by trainees and the hospital trust to lead a debriefing for staff affected by Jack’s death, said that trainee doctors working in Leicester were concerned and angry about the conclusions of the trust’s investigation and the subsequent legal process. “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. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. “I’m a very private person, but I had my face in the newspaper.”. When a junior doctor was convicted of manslaughter and, How I'm feeling after my MS ‘body reboot', It all made sense when we found out we were autistic. The court heard that Stephen O’Riordan, duty consultant paediatrician that day, had written them down at evening handover but chose not to review … Jenny Vaughan, a neurologist who runs Manslaughter and Healthcare (www.manslaughterandhealthcare.org.uk), an online resource that follows prosecutions of healthcare staff in the criminal courts, has been watching Bawa-Garba’s case. I didn’t want my dad to see me being taken away in handcuffs. Though it criticised aspects of Bawa-Garba’s involvement, it also found fault with “many aspects of the care that child JA received, and many of these were system failings.”, Andrew Furlong, medical director at University Hospitals of Leicester NHS Trust, which runs Leicester Royal Infirmary, told The BMJ that the trust had “implemented a number of improvements to our systems and processes which have reduced the risk of such events occurring again.”, He added, “This was a tragic event, and in 2015 a jury reached its decision having had all the evidence presented to it.”. Instead, Dr O’Riordan insisted on seeing Jack’s parents without her. It had been higher than it should have been since the SHMI was introduced in 2010. “The reason the doctors are doing what they’re doing, they’re scared for themselves. In the morning Jack was taken to the GP by his mother, Nicola, and referred directly to Leicester Royal Infirmary’s children’s assessment unit (CAU). “I’ve seen people behaving very defensively for understandable reasons, and trainers across the country are worried it’s having an impact because it’s such a high profile case.”. What went wrong?’”. The three pleaded not guilty to the charge of manslaughter by gross negligence at the start of what was to be a four-week trial. “I had two very young children - my oldest is severely autistic and goes to a special needs school. In his evidence to the practitioners tribunal Cusack said that although a trainee might not realise the full significance of this abnormal blood gas result, a consultant should. Routledge, Jan 31, 2014 - Business & Economics - 288 pages. Meanwhile, Nicola Adcock was waiting outside the room. Because of this, she says, she left it off his drug chart. One doctor said she would pray before she went into work because she was worried something bad would happen. “After I realised that we were actually resuscitating Jack, I just couldn’t understand why he had crashed. The media were carefully managed, Dr Hsu says. Trainee doctor Hadiza Bawa-Garba arrived at work expecting to be on the general paediatrics ward - the ward she’d been on all week. Dr Bawa-Garba was given a two-year suspended sentence. “I've been in the UK for more than half my life,” she says. It’s a description Mr Furlong rejects. “Jack was really lethargic, very sleepy. What was at stake was whether she fell below the standard of a reasonably competent junior doctor. The next day was spent exploring all the points in detail. This we believe would have a detrimental effect on the overall quality and safety of healthcare.”. Dr Jonathan Cusack was the head of the unit, so she didn’t think much of it. “I remember sitting there and listening to their account of my actions and I felt like a criminal,” says Dr Bawa-Garba. He said: At no time was this patient highlighted to me as urgent, unwell, septic or that I needed to see him.”. Charlie Massey, chief executive of the GMC, says that after receiving legal advice the GMC applied to the High Court to overturn the decision made by its own tribunal. Dr Bawa-Garba had already started to write down her reflections. “And that's important, because the vast majority of referrals that come to us from employers, do result in investigations, whereas it’s a minority of complaints that are made to us by the public,” he says. But when medical staff gathered to discuss the day’s work, they were told someone was needed to cover the CAU – the doctor supposed to be doing it was on a course. Dr Bawa-Garba had enjoyed an unblemished career before Jack’s death and was well-regarded by her colleagues. But some local GPs were frustrated and thought there was a resistance to change and a reluctance to talk openly about the problems. He also had a cough. Dr Bawa-Garba passed her bleep on to another doctor and went home, her head spinning with thoughts about what would happen to her family if she were to be convicted of manslaughter and sent to prison. There she would see lots of children with sepsis, some of whom would get better then get worse – like Jack, she says. But he just started sobbing on that morning because I wouldn’t let him come to court with me.”. “They were concerned about the abruptness of the presentation, they would like it softened, as it were, maybe made user-friendly,” he says. In 2017, the General Medical Council’s tribunal service suspended Dr Bawa-Garba for a year. “Every week we receive reports from our constituent GPs informing us of incidents of distressing medical and nursing care that patients are being exposed to at Leicester Royal Infirmary,” the letter said. Clare was born on November 20 1931, in Rathgar, Dublin, Ireland. The role of the enalapril, the drug given to regulate Jack Adcock’s blood pressure, has also generated debate. The prosecution relied on the fact she ignored “obvious clinical findings and symptoms”; did not review Jack’s X-ray and give antibiotics early enough; failed to obtain the morning blood test results early enough and act on the abnormalities they showed; and failed to make proper clinical notes. It raised over £360,000 in about a month with contributions from around 180 countries. However, she didn’t agree with all Dr O’Riordan said and didn’t sign the form. But Dr Bawa-Garba says she didn’t want him to have the enalapril, because he was dehydrated and it might have made his blood pressure drop too much. Everyone on the ward was crying, she says, including Dr Bawa-Garba, who was sobbing. The GMC acting in such a punitive way and focusing on retribution was only going to serve to make this situation worse, he added. 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. Not all failings were heard, he says. The hospital’s own investigation, which flagged up all the contributory factors and failings that had led to Jack’s death, wasn’t put before the jury, he says. She was told to list everything that she could have done differently, she says. But Dr Bawa-Garba says she wishes she had given him antibiotics sooner. Those tests would have indicated that Jack may have had kidney failure and that he needed antibiotics. Afterwards, she went to the nurses’ station and sobbed. “That kind of response, to me, said that he was responding to the bolus,” she says. “They were worried that people will lose faith in the health services,” he says. Mr Furlong says that improvements have been made and that the review has now been repeated, with results due for publication in September. During the afternoon handover, Dr Bawa-Garba told Dr O’Riordan about Jack – his diarrhoea and vomiting, heart condition, and enalapril medication. The decision has certainly been unpopular among the medical profession. She assumed it was the same boy. In October 2014 they sent a letter sent to former Health Secretary Jeremy Hunt and Simon Stevens, chief executive of NHS England, warning of “broken systems serving patients and carers in our area”. Because Jack’s death was unexpected, the hospital conducted an investigation to identify what had gone wrong with the little boy’s care. The following day, she was back at work at the assessment unit. The story began in an overstretched hospital in February 2011 when she was 34. Teams of doctors and nurses were tasked with going through the records of patients who had either unexpectedly died in hospital or died within 30 days of leaving between 1 April 2012 and 31 March 2013. One of the less experienced doctors in the unit had been unable to do Jack’s next blood tests. This was the last time Dr Bawa-Garba treated Jack, who was also being cared for by an agency nurse. He met representatives from the local Clinical Commissioning Groups, the hospital and NHS England to devise and agree a plan. Grant said that although he did not want to comment on the specific details of the case, the Royal College of Paediatrics and Child Health’s training standards required clinical supervision to ensure patients’ safety. The University Hospitals of Leicester NHS Trust was not the worst, neither was it the best, he adds. The negligence had to be gross or severe, he said - what they did or didn’t do had to be truly, exceptionally bad. “We have to help them understand what happened, to be open about what happened, to apologise for what happened,” he says. “I underestimated the severity of his illness,” Dr Bawa-Garba said. Junior doctors did try to raise their concerns that trainees were being used to plug rota gaps, often at the last minute. They said consultant cover had been patchy and that factional infighting between consultants had caused problems for trainee doctors - it wasn’t something they could speak out about, they had had to keep their head down. 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