Margaret McCartney: Doctors and families must be able to work together for safer careBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k443 (Published 31 January 2018) Cite this as: BMJ 2018;360:k443
- Margaret McCartney, general practitioner
A little boy, Jack Adcock, is dead. This is horrendous, and accounts of the background to the case clearly show mistakes and shortcomings that could and should have been avoided. But how?
Jack’s treatment included clinical mistakes and numerous systemic ones, particularly regarding staff absence and IT systems. This was the “Swiss cheese” model writ large and fatal: the holes in the system aligned and let tragedy happen.
The overwhelming feeling among many doctors reading accounts of the case background1 is, “There but for the grace of God go I.” There’s no suggestion that Hadiza Bawa-Garba was doing anything except working …