Second letter to the GMC chair regarding Hadiza Bawa-GarbaBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k667 (Published 13 February 2018) Cite this as: BMJ 2018;360:k667
All rapid responses
Nick Ross is quite wrong to say clinical mistakes are rare in medicine [BMJ 17th Feb 2018]. They are not. They are very common. And arguably indeed, they have been an integral part of medical advances through the history of medicine, however unwanted.
All medics make mistakes. They may be acts of omission, or commission. They may come from poor training, incompetence, negligence or bad judgement. They may come from innocent adherence to very bad consensual practice, as with HIV infection of hemophiliacs with contaminated blood, or oxygen-induced retrolental fibroplasia. They may be out-rightly criminal. And in serious cases the consequences can be disastrous with lifelong impact. Patients and families have everlasting heartache. Doctors can be wracked with such a sense of unworthiness, and so unable to talk to anyone that they take another way out. Too often in my own sphere with a potassium flush or at the end of a rope.
So what is to be done? Certainly not the excessive requirements of and burdensome handling by the Care Quality Commission and Revalidation. Were either introduced after a controlled study to see if they did any good, by the way? No. Too often they can feel “like a kick in the teeth” or “particularly unsupportive” as an article in the same BMJ issue reports the actions of the CQC in one practice. Words that just scream vindictiveness to me. This just leaves doctors feeling unwanted, unloved, humiliated, paranoid and distrustful of each other, and breaking down that all important professional glue in the process. And so many just go away and cower in the corner or leave the profession altogether. Together actions of the CQC and re-validation have likely done far more harm than the GMC in the Bawa-Garba case.
Yet mistakes must be minimized. Improvement is always necessary. It's the means of doing this that is difficult. Or is it? I think an utterly anonymous central register with everyone encouraged to report their mistakes in real time could be a powerful tool for revealing the pattern and frequency of mistakes; and properly analyzed to avoid these through education or changes in practice. Current technology can certainly support a professional “social media” platform dedicated to an issue like this.
Competing interests: No competing interests
The case of Dr Hadiza Bawa-Garba has left many medical students like us, soon to become doctors in the NHS, with a sense of trepidation. We wholeheartedly empathise with the family’s grief over losing their 6-year-old son, Jack Adcock. Important concerns have been raised by our peers regarding the General Medical Council’s (GMC) decision pertaining to Dr Bawa-Garba. We hope to add our perspective as medical students to the discussion of this case.
Throughout medical school, the value of reflection as an educational tool has been continuously impressed upon us. Although there is uncertainty surrounding the extent to which written and verbal reflections were used in the trial, it is disconcerting to think that reflective practice, a valuable tool for trainee development, could be used in a court setting. We feel uneasy about a future that impedes reflective practice and have no doubt that doctors will be more conscious about what is included in their portfolio in the future. We fear such practice may also extend into medical schools, where students are cautious about reflecting openly on mistakes. This may not only impact a student’s educational development, but may further act as a negative driver against ensuring probity in light of errors in practice .
We therefore fear a shift in focus amongst medical students, where avoiding litigation is prioritised over reflection and learning. Ultimately, this could engender a culture of defensive medicine which could take precedence over the best interests of the patient and the public . The consequences of defensive medicine include, but are not limited to additional costs to the NHS, along with patients being subject to unnecessary and potentially risky procedures .
We find it disheartening that despite what appears to be a clear series of systematic errors, the principal fault in this case was placed on individual members of staff. A blame culture in the workplace coupled with a constant fear of litigation results in poor working conditions and reduced job satisfaction. To add to this, the handling of cases involving Dr Bawa-Garba, Mr David Sellu, Dr Chris Day and others cause significant confusion and uncertainty among medical students.
The cumulative result of these feelings is a rise in the likelihood of doctors moving away from the UK or considering a career other than medicine , something which we have increasingly seen discussed by our colleagues. Lambert et al. identified that recent UK-trained medical graduates are more commonly considering medicine outside the UK .The GMC have stated that they are here to ‘protect the public, and not to protect doctors’ as well as ‘maintaining public confidence in the profession’ . While this may be their aim, should the outcome of this case drive more doctors away from the NHS then this may have the paradoxical effect of an increasing frequency of medical errors due to understaffing. The public and physicians already perceive understaffing to be a significant factor in causing medical errors .
Medical school has taught us methods to deal with pressurised environments, yet this case infers the need to carry out jobs equivalent to multiple doctors’ workload. We have not identified an area of the medical curriculum which prepares us for such quandary. Dr Bawa-Garba was described as being an ’above-average doctor’, which leaves us in a state of uncertainty as we question what it takes to successfully cope with the strenuous workload of the NHS and the repercussions of being unable to do so.
In conclusion, at the heart of this case is the tragic death of 6-year-old Jack Adcock and we reiterate our empathy towards the family’s loss. The case has provided many notable points of discussion, however, the overarching sentiment is one of fear and uncertainty which have been exacerbated by a lack of clarity surround the case. The ramifications of cases like these have a wide-scope impact on not only the public, patients and physicians, but also medical students – the next generation of doctors.
 A. S. Detsky, M. O. Baerlocher, and A. W. Wu, “Admitting mistakes: ethics says yes, instinct says no.,” CMAJ, vol. 185, no. 5, p. 448, Mar. 2013.
 T. Bourne, L. Wynants, M. Peters, C. Van Audenhove, D. Timmerman, B. Van Calster, and M. Jalmbrant, “The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey,” BMJ Open, vol. 5, no. 1, pp. e006687–e006687, Jan. 2015.
 M. S. Sekhar and N. Vyas, “Defensive medicine: a bane to healthcare.,” Ann. Med. Health Sci. Res., vol. 3, no. 2, pp. 295–6, Apr. 2013.
 A. Sharma, T. W. Lambert, and M. J. Goldacre, “Why UK-trained doctors leave the UK: cross-sectional survey of doctors in New Zealand.,” J. R. Soc. Med., vol. 105, no. 1, pp. 25–34, Jan. 2012.
 T. W. Lambert, F. Smith, and M. J. Goldacre, “Why doctors consider leaving UK medicine: qualitative analysis of comments from questionnaire surveys three years after graduation.,” J. R. Soc. Med., vol. 111, no. 1, pp. 18–30, Jan. 2018.
 General Medical Council, “FAQs: outcome of High Court appeal – Dr Bawa-Garba case – Medical professionalism and regulation in the UK,” 2018. [Online]. Available: https://gmcuk.wordpress.com/2018/02/02/faqs-outcome-of-high-court-appeal....
 R. J. Blendon, C. M. DesRoches, M. Brodie, J. M. Benson, A. B. Rosen, E. Schneider, D. E. Altman, K. Zapert, M. J. Herrmann, and A. E. Steffenson, “Views of Practicing Physicians and the Public on Medical Errors,” N. Engl. J. Med., vol. 347, no. 24, pp. 1933–1940, Dec. 2002.
Competing interests: No competing interests
GMC could do with reading recommendations from Francis Report: page 65
Lessons learned and related key recommendations: all could be applied to the GMC.
The negative aspects of culture in the system were identified as including:
• A lack of openness to criticism;
• A lack of consideration for patients; (current response will make NHS less safe)
• Looking inwards not outwards;
• Misplaced assumptions about the judgements and actions of others;
• An acceptance of poor standards; (cf: inconsistent approach to sanctions)
• A failure to put the patient first in everything that is done. (current response will make NHS less safe)
Competing interests: No competing interests