Intended for healthcare professionals


Paediatrician found guilty of manslaughter after boy’s death from septic shock

BMJ 2015; 351 doi: (Published 05 November 2015) Cite this as: BMJ 2015;351:h5969
  1. Clare Dyer
  1. 1The BMJ

A hospital doctor has been found guilty of manslaughter by gross negligence after the death from septic shock of a 6 year old boy with Down’s syndrome.

Hadiza Bawa-Garba, a specialist registrar in paediatrics, was accused, together with the agency nurse Isabel Amaro, of “truly, exceptionally bad” treatment of Jack Adcock, who was admitted to Leicester Royal Infirmary with diarrhoea, vomiting, and breathlessness between 10 am and 10.30 am on 8 February 2011.

Bawa-Garba, 38, diagnosed gastroenteritis and ordered chest radiography and blood tests, and the boy was given fluids for dehydration. The tests showed that he had a widespread bacterial infection, and he was put on antibiotics in late afternoon.

But the doctor failed to notice indications in the test results that showed that his kidneys were failing. Later that night the boy went into cardiac arrest. Attempts were made to resuscitate him, but Bawa-Garba ordered them to be stopped after mistaking Jack for another boy who had a “do not attempt resuscitation” notice in his notes.

A junior doctor noticed the mistake after a minute, and the resuscitation attempt resumed, but Jack was pronounced dead at 9.21 pm.

Andrew Thomas QC, prosecuting, told the jury during the month long trial at Leicester Crown Court that the mistake did not cause Jack’s death because he was already past “the point of no return.” But he added, “The relevance is that it shows that [Bawa-Garba] had simply not given Jack sufficient attention during the day, to the point that she did not even recognise who he was.” She also missed “seriously abnormal” blood test results that showed that Jack’s organs were shutting down.

Thomas told the jury that the doctor had neglected her duty to care for Jack. “It was not just a momentary lapse. The prosecution say that Jack’s care was neglected over a protracted period of time.

“Her failings were compounded by a failure to go back and reassess Jack, despite clear indications that his underlying condition was continuing. These were not just simple breaches of duty but really serious breaches amounting to gross negligence.” Bawa-Garba told the jury that she had worked for 12 hours without a break.

After five days of deliberation, the jury found her guilty by a 10-2 majority. Amaro, whose record keeping was described by Thomas as “woefully inadequate,” was also found guilty, and the two are expected to be sentenced before Christmas. Another nurse, Theresa Taylor, was cleared.

After Jack’s death, Bawa-Garba kept her job with University Hospitals of Leicester NHS Trust but was employed in a role that did not involve contact with patients. After she was charged with manslaughter, she was suspended from practice by an interim orders panel of the Medical Practitioners Tribunal Service, pending a full fitness to practise hearing.

But the High Court overturned the suspension, ruling that conditions allowing her to go on working in the NHS but without patient contact, pending trial or a final determination by the tribunal service, were sufficient.1

A senior doctor from the trust told the Medical Practitioners Tribunal Service panel that she was “a competent and able doctor who recognises that she missed important features of this child’s illness on this occasion.”


Cite this as: BMJ 2015;351:h5969


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