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Criminalising doctors

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k479 (Published 01 February 2018) Cite this as: BMJ 2018;360:k479
  1. Navjoyt Ladher, clinical editor,
  2. Fiona Godlee, editor in chief
  1. The BMJ, London, UK
  1. Correspondence to: N Ladher nladher{at}bmj.com

What must we learn from Jack Adcock’s death?

Fear is toxic to both safety and improvement, and health systems must abandon blame as a tool. So wrote Don Berwick in his report after the Mid Staffs care scandal.1 He called for a commitment to learn from mistakes and to act on that learning. “Rules, standards, regulations and enforcement have a place in the pursuit of quality,” he said, “but they pale in potential compared to the power of pervasive and constant learning.”

Recent events have set those wise words at nought. Last week the tragic case of 6 year old Jack Adcock, who died from sepsis in 2011, reached what may be its final punitive phase, with the erasure of a trainee paediatrician from the medical register. Jack Adcock’s mother has said she wanted justice for her son and to ensure that no one else would suffer in this way.2 Sadly the opposite is more likely. This case, and a growing number of …

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