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
20 February 2018
The correspondence between Nick Ross and the chairman of the GMC exposes many of the failings of the GMC in their justification of their handling of the Dr Bawa-Garba case.
Both the GMC's Chairman, Sir Terence Stephenson and the Chief Executive, Mr Charlie Massey, in their various representations, seek to emphasise the, "heart" of this case. It is not as they suggest, the conviction of a practising doctor in a criminal court, but the distasteful culture of blame and victimisation which has become central to a dysfunctional NHS and its misguided regulators.
The GMC knows, from the very many cases reviewed by them, that when things do go wrong the institution concerned and their lawyers seek to construct a case that will divert any blame form the institution. In doing so they have access to extensive public resources and legal services, denied to doctors and nurses, patients and their relatives. If systemic faults are identified, rarely do they receive the appropriate attention, and it becomes necessary to find someone else to blame. The victim is often a nurse or a junior doctor, rarely a senior and never a medical director.
In my near 30 years as a consultant I have seen NHS managers and their expensive lawyers perfect this system, first by falsifying serious incident reports; by ignoring adverse witness statements and attaching little importance to the disappearance of notes and charts. The practice was unequivocally exposed at Mid Staffordshire. Sir Robert Francis, in his muted report, did identify the improper role of the legal profession in perpetuating the culture of deceit. Lawyers employed by the Trust, financed from public funds, only had a duty to their client, the failing trust, and no duty at all to patients, relatives, staff and the public at large. Seemingly, the lawyer's duty was to protect the reputation of the Trust. Last month the Liverpool Community Health Services Review again exposed similar shortcomings. It was only the intervention of the local MP, and not the CQC or NHS Improvement, that exposed the "culture of fear" and poor patient care.
It may be unthinkable that any doctor could knowingly take part in any process designed to mislead their patients and their relatives, and yet, some do, while the majority do not interfere, rightly fearing the well-rehearsed persecution that may follow. Medical directors are expected to support the institution rather than adhere to their Code of Conduct and do so with impunity. The GMC seeks to give doctors ample, but often misleading advice on how they must speak up where there is evidence of unsafe practice or mistreatment of patients or staff: "We know the strength of feeling expressed by many doctors working in a system under sustained pressure, and we are totally committed to engendering a speak-up culture in the NHS. Doctors should never hesitate to act openly and honestly if something has gone wrong."
In reality, the GMC does little if anything to protect those who raise concerns but rather allow themselves to be used as an instrument to victimise doctors on behalf of management and in the case of Dr Bawa-Garba divert attention from the readily identified systemic failures. When a referral to the GMC is found to be misleading, malicious or an act of victimisation, either by the GMC themselves or the Courts, those responsible are not held to account. Not by the GMC or the Care Quality Commission or any other regulatory authority. This injustice, fully documented in the competent and expertly executed Hooper report has failed to spur the GMC into effective action. Rather, almost 3 years later the GMC' s futile and wholly inadequate response is to collect more information in a "pilot assessment" rather than address the underlying deficiencies in their performance, which are all too obvious.
This culture of deceit, perpetuated by managers and regulatory authorities who believe they are unaccountable and above the law, has been raised with the NHS executive and successive Secretaries of State for Health over the years without effect. The Football Association and Aid Charities failure to protect vulnerable individuals in the interest of preserving the Institutions reputation has finally been exposed and the public are incensed and feel let down. The very same failures are present in the NHS on an industrial scale. The NHS institutions, their specialist lawyers and their regulators are equally guilty of the same negligence and cover-up. It is now time to acknowledge these failures, and insist that the NHS executive and the Secretary of State for Health make radical changes to ensure the operation of an open and just culture. Failure to do so will continue to expose patients and staff to unacceptable harm that threatens the future of the NHS.
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