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Not called- not informed. Cant help - sorry - they say.
http://www.bailii.org/cgi-bin/format.cgi?doc=%2Few%2Fcases%2FEWCA%2FCrim%2F2016%2F1841.html&query
Rinku Sengupta
--------------------------------------------
On Mon, 5/2/18, joseph ana <[log in to unmask]> wrote:
Subject: Re: Off-topic? Dr Hadiza Bawa-Garba, a patient-safety cultura no EBM
To: [log in to unmask]
Date: Monday, 5 February, 2018, 22:49
What is happening to
our good old and cherished NHS UK? I still think that for
every bad situation there are loads of good ones that many
of us know of and can attest to. But Juan is right, system
failure happens before individual ones follow in most cases.
Disappointed not to read about what happened to the managers
who let the resident work in such horrendous conditions. Are
the system and managers let off ? What happened to
them?
Joseph
Ana.
Africa Center for
Clin Gov Research & Patient Safety
@
HRI West Africa Group - HRI WAConsultants in Clinical
Governance ImplementationPublisher: Health and Medical
Journals 8 Amaku Street Housing Estate,
Calabar
Cross
River State, Nigeria
Phone No. +234 (0) 8063600642Visit Website: www.hriwestafrica.com
E-mail:
[log in to unmask]
On Monday, 5 February 2018, 20:45:52
GMT, Michael Power <[log in to unmask]> wrote:
There was a
good reason that “respondeat
superior” became a legal principle.
There is an
ungood reason that "respondeat superior” is evaded by
employers.
Michael
On 5 Feb 2018,
at 18:56, Juan Gérvas <[log in to unmask]>
wrote:
-my comment
about this case which is chilling health professionals
around de world
-in
Spanish: http://www.actasanitaria.com/e
rror-medico-mortal-que-convier
te-a-una-residente-de-pediatri a-en-criminal/
-copy
bellow and attached
-of
course, i am a Spaniard so sorry for my English and my
(probably) mis-understanding of the process
Deadly
medical error that turns a Pediatric resident into a
criminal
Juan
Gérvas, retired rural general practitioner, CESCA Team,
Madrid,
Spain
[log in to unmask]
www.equipocesca.org
@JuanGrvas
Case
report
Friday,
February 18, 2011,
children's emergencies at the University Hospital of
Leicester,
United Kingdom.
At 10.30 the
pediatric resident ("register")
in charge of the children's emergencies, and of the
entire children's
hospital, including hospital beds and the ICU, as the
"consultants"
were not present and the two companions of at the same level
they had
permission, valued a six-year-old male referred by his
general
practitioner (family doctor), with poor general condition,
diarrhea,
vomiting and dyspnea. The patient had a history of cardiac
surgery,
was under treatment with enalapril and had Down syndrome.
With the
initial diagnosis of gastroenteritis shock, the resident
ordered
parenteral rehydration and support oxygen. Thinking of
pneumonia, he
asked for a chest x-ray and a blood test, including
gasometry.
The
resident had a younger resident and a student and, after
this case,
she worked without rest attending other urgent patients. In
addition,
the electronic system worked badly and had to call by
telephone to
receive the results of analysis and other tests.
At 15.00 h.
the
resident examined the child's X-ray. Such a chest x-ray
had been
received at 12:30 but the resident had not been notified,
despite the
fact that showed the presence of pneumonia. Therefore
prescribed
antibiotics, which were administered at 16.00 h. The
resident
received no information about the oxygen being withdrawn
neither
about the fever affecting the patient.
At
16.15
h. the resident received the tests that had arrived at 10.44
h, with
renal alterations, a high CRP, pH of 7 and lactate of 11.
Subsequent
analyzes showed the normalization of pH.
At 16:30 the
resident met
her chief "consultant" in the corridor and told
her the
case and the analytical results, without requiring further
help. At
18.30 pm he commented again.
At 7:00 p.m.,
the patient went to
hospital beds and the mother gave him enalapril. The
resident
had
clearly recommended not administering it.
At 20.00 there
was an
emergency call to take care of the patient, due to cardiac
arrest.
The resident went immediately and confused the patient with
another
in which there was order not to do cardiopulmonary
resuscitation, so
he suspended this activity for a few seconds until he was
warned of
the error and reanimation resumed.
At 21:20 the
patient died (due
to septicemia and cardiogenic
shock).http://thehealthcareblog.com/b
log/2018/01/30/to-err-is-homic ide-in-britain-the-case-of-dr-
hadiza-bawa-garba/
http://www.54000doctors.org/bl
ogs/whos-interests-are-the-gmc
-really-trying-to-serve-in-the
-bawa-garba-case.html?
Dr.
Hadiza Bawa-Garba, the resident of
pediatrics
The
resident of pediatrics is Nigerian, Muslim with hijab and
black. It
had an excellent curriculum. She was tanned in almost all
areas of
pediatrics since it was her sixth year of residence. In
fact, its
"register" name alluded to its professional
situation of
great responsibility in which it is expected that she
dominates
uncertainty and makes sound decisions without having to
bother the
"consultant", who is usually located but rarely
intervenes.
The resident
of pediatrics had been thirteen months of
maternity leave and had just joined the university hospital
in
Leicester, which she did not know and of which they did not
make a
presentation.
The
penalty
The
first review exempted the resident who continued working in
the
hospital. The second review, in court, four years later, in
November
2015, sentenced her to two years in prison and one year
without
professional practice for "homicide due to gross
negligence"
(the sentence to the nurse, Portuguese, was similar but in
both cases
did not require entry into
prison)
http://www.pulsetoday.co.uk/yo
ur-practice/regulation/gmc/baw
a-garba-timeline-of-a-case-tha
t-has-rocked-medicine/20036044 .article
The
resident challenged the ruling and the GMC court reaffirmed
the
ruling in June 2017 (the General Medical Council, GMC, is
responsible
for registre doctors and defending patients against their
mistakes
and excesses).
However, the
board of directors of the GMC
considered that the punishment was insufficient and, against
the
decision of its own court, took the case to the Supreme
Court (High
Court) that agreed with the suggestion of the board of
directors to
remove the license from doctor so she could never again work
as a
physician, as Dr. Hadiza
Bawa-Garba
http://blogs.bmj.com/bmj/2018/
01/30/charlie-massey-we-are-co
mmitted-to-making-health-servi ces-a-place-for-learning-not-
blaming/
http://www.dailymail.co.uk/new
s/article-5310161/Ruling-docto
r-convicted-boy-s-death-struck -off.html
The sentence
came out on January 25, 2018 and caused an
earthquake in the National Health Service of the United
Kingdom.
Thousands of doctors signed a letter against the sentence,
warning of
the dangerous precedent against the safety of the patient
because the
judgments and legal punishments focus on the professionals
not on the
problems of the
system
http://researchonline.lshtm.ac
.uk/3172373/1/Shadow%20of%20th e%20law_GOLD%20VoR.pdf
http://www.54000doctors.org/bl
ogs/whos-interests-are-the-gmc
-really-trying-to-serve-in-the -bawa-garba-case.html?
http://shibleyrahman.com/nhs/t
he-perfect-storm-around-gawaba
rba-was-a-long-time-coming/
In 24 hours
the doctors collected 230,000 euros to continue the
judicial process and pay a new defense to Dr. Hadiza
Bawa-Garba.
"As
doctors, we know that any of us could be the next Dr. Hadiza
Bawa-Garba" and at the time they remembered that 30% of
the
doctors are from non-white ethnic groups, which is not
reflected in
the leadership of the
GMC
http://www.independent.co.uk/v
oices/hadiza-bawagarba-british
-doctor-jack-adcock-manslaught er-gmc-nhs-crisis-latest-
a8189096.html
The
system holes
In the study
of medical
errors, a distinction is made between systematic problems
and
personal problems. The key is to study the errors avoiding
burdening
the faults on the doctors because many times they are only
part of a
chain of failures, of systematic "holes" that make
possible
the error with damage when there are personal problems. It
is the
model developed by Dante Orlandella and James T. Reason
(University
of Manchester) in 1990 and later revised in 1995 and 1997.
This model
establishes that the emergence of a failure or error and its
consequences, in terms of losses and damages, it owes to
certain
fragility conditions -active or latent- inherent in the
systems,
which are capable of altering their capacity to defend
themselves
against error. This model uses the metaphor of the slices of
Swiss
cheese, equating the substance, the cheese, with the
defenses or
barriers that contain a system to avoid that errors occur,
and the
holes with the conditions of vulnerability. In their
approach, the
authors state that when the slices are aligned, so that
several holes
-or conditions of fragility- coincide, it is when the error
occurs.
The task, of course, is to reduce these conditions and
prevent them
from aligning
http://www.bmj.com/content/320
/7237/768
"When a
patient suffers a damage or adverse event, there is
the so-called retrospective bias: everyone looks to see what
happened
and only see the doctor or nurse who attended him, do not
see other
factors that intervened so that the adverse event could
occur.
The
bias is like looking through a hole that only allows them to
see the
professional who treated the patient. You can not see the
working
conditions, the human and material resources, the
organization,... In
order for an adverse event to occur, all the defenses or
barriers
that should have prevented it, both human and system, must
fail. The
first barrier or defense of the system is the organizational
one, the
second the supervision, the third the unsafe conditions and
the
fourth the unsafe acts. The safe systems minimize the risk
of damage
even if there are failures in some of the defenses, since
the others
prevent it
"
http://sano-y-salvo.blogspot.c
om.es/2015/03/practicas-segura
s-en-sistemas-seguros.html
Unsafe
system
In the case of
Dr. Hadiza
Bawa-Garba, the cheese was more than bored. For pointing out
some
holes:
1. The
resident returned to work after a long maternity
leave that would have required a "soft
landing".
2.
Nobody explained to the resident how the hospital worked,
nor how
best to solve the specific problems during her duty.
3. On the day
of the events, the resident was alone because the other two
residents
of the same category, "register", were missing
from
work.
4. The
category of "register" is relatively new
and allows to load on residents with experience a clinical
weight
that facilitates savings in fees to
"consultants".
5. On
the morning of the incident the head of the resident, the
"consultant" was teaching in another city.
6. The
"distance to authority" is enormous in the United
Kingdom,
so that the figure of the "consultant" was not
real help
for the resident.
7. The work
overload of the resident is
documented on the day of the event.
8. The nurses,
also
overburdened, did not identify the progressive deterioration
of the
patient.
9. The
resident was involved in special urgent cases that
required her direct skills such as lumbar punctures, not
delegable to
other professionals present.
10. The
computer system did not work
so that the results had to be received and claimed by
telephone,
directly.
11. The x-ray
was not reported because there was no
staff for it.
12. The
information flows were deficient as seen
with respect to the delivery of the evidence to the
resident.
13.
The orders were met late as it was seen in the interval of
one hour
between prescribing antibiotic treatment and administering
them.
14.
Caregivers often establish a safety curtain but in this case
the
mother administered the enalapril that probably precipitated
the
final aggravation.
15. The
mistake of confusing the patient and
stopping cardiopulmonary resuscitation was the end result of
hours of
work without rest, excessive responsibilities and poor diet
and
hydration.
SynthesisA
single trainee was held accountable when there were so many
systemic
errors in this case. We have a first victim, we cannot
change his
death, but we can avoid cruelty with the second victim of
the error,
the mother and Dr. Hadiza Bawa-Garba. Task errors by
emergency
physicians are associated with interruptions, multitasking,
fatigue
and working memory capacity. We can profit the opportunity
and
improve the system to avoid the same error
(integrating
second victims' experiences into safety culture and
root-cause
analyses).
http://qualitysafety.bmj.com/c
ontent/early/2018/01/19/bmjqs-
2017-007333?rss=1&ssource=mfr&
hootPostID=c216ec1e148463f7be5 f83c0d1dce8a8
https://journals.lww.com/journ
alpatientsafety/Abstract/publi
shahead/A_Transactional__Secon d_Victim__Model_Experiences.
99393.aspx
It is the
medical obligation to identify the errors and their
consequences. After identifying them you have to explain
them, ask
for forgiveness for the damage, repair it as much as
possible and
take measures to avoid its
repetition.
http://equipocesca.org/etica-d
e-las-pequenas-cosas-en-medici na/
Society has to
accept that medical work entails errors and that
such errors tend to have more to do with the system than
with
professionals.
A culture of
safety for patients is established,
avoiding the generalized criminalization of doctors and
stopping the
damages in domino caused by second and third victims
(professionals,
caregivers, etc) without avoiding the repetition of damages
to the
first victims
(patients)
http://sano-y-salvo.blogspot.c
om.es/2017/06/primeras-segunda s-terceras-cuartas.html
http://www.bmj.com/content/359
/bmj.j5534
The #BawaGarba
case demands a new culture in medical training so
that residents are not forced to work in unsafe conditions,
as
recognized, for example, by the Royal College of Physicians
of
Ireland
https://www.rcpi.ie/news/relea
ses/royal-college-of-physician s-of-ireland-to-review-
protocols-for-trainees-in- light-of-dr-bawa-garba-case/
NOTES
1.
Who among us has not made mistakes with harm to patients?
Http:
//www.bmj.com/content/360/bmj.
k485
2. "Every
surgeon [doctor]
carries inside a small cemetery to which he will pray from
time to
time, a cemetery of bitterness and sorrow ..." R.
Leriche. "La
philosophie de la Chirurgie". Part II, chapter I.
https://primumnonnocere-edita.
blogspot.com.es/2017/07/leccio
nes-de-un-maestro-rene-leriche .html
3. "Bank
of clinical cases of errors that hurt but they
teach" #siapGranada Testimonies about painful events
for
patients, for their relatives and for the doctors who
attended
them.
http://sano-y-salvo.blogspot.c
om.es/2015/04/errores-que-duel en-pero-ensenan-20.html
4. And if the
circumstances are such that it is forced to work in
conditions that go against the safety of professionals and
patients
the logical thing is to refuse to do so, stop working, make
the
corresponding urgent complaint in the Court and return to
the post of
work not to miss in presence [against what the GMC advises
in the
United Kingdom] http://www.bmj.com/content/360
/bmj.k448
https://gmcuk.wordpress.com/20
18/ 02/02 /
faqs-outcome-of-high-court-app eal-dr-bawa-garba-case /?
Utm_campaign
= 9132068_GMC% 20news% 20-% 20January% 20% 28resend% 29
&
utm_medium = email & utm_source = General% 20Medical%
20Council &
dm_i = OUY, 5FQCK, HWPYSM, L1VA5,1
5. United
Kingdom. Doctor in
the ICU. Call to warn that there is little staff and
endanger the
lives of patients? Think twice! The terrible case of Dr.
Chris Day.
http://www.dailymail.co.uk/new
s/article-4503734/The-dedicate d-NHS-doctor-tried-gag-
destroy.html
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