Margaret McCartney: Clinical errors need a systemic responseBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k812 (Published 26 February 2018) Cite this as: BMJ 2018;360:k812
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If doctors are held to account for their own personal wrongdoings, when failures are generalised and systemic and clearly related to inadequate funding and resources for the NHS, shouldn’t the Secretary of State for Health be held to account in a court of law?
Competing interests: No competing interests
I am really pleased to read Dr. McCarney's comment about the GMC. We (BME Advisory committee of the GMC) have been working with the GMC for the last 10 years and we have made some progress but not as much as I would have liked to see. But, I have no doubt, Mr. Massey, and the GMC, is determined to learn lessons from this tragic incident.
In a recent meeting with Mr. Massey, I am absolutely convinced that the Dr. Bawa-Garba tragedy has affected him and many others and I am so grateful to many doctors that also it is senior White colleagues who have taken this forward.
Dr. Bawa-Garba is not the first BME doctor to be scapegoated and I have collected many such cases. More than 400 BME doctors have contacted me over the last 10 years and I am saddened to see how many BME doctors have been treated badly by some of the Trusts and there is absolutely no accountability for some of the Clinical Directors, Medical Directors, HR and in some cases CEOs
One has to look at the plight of Whistle Blowers and many BME doctors who stood up for their rights and the rights of their patients and they have been crucified. Dr. Chris Day's case tells us all how bad situation is in some of the Institutions.
I am a born optimist. I am very proud of our NHS and this great nation of ours. Most BME doctors do very well and there are fairness and justice as to how most doctors including BME doctors are dealt. Anger with the Bawa-Garba case itself tells us how upset many of our wonderful colleagues and senior leaders are. I recently met Mr. Jeremy Hunt and also Mr. Simon Stevens and all of them are very upset about this case.
I really feel bad for Jack's family, the child who died. Imagine what the family must be going through. However, we cannot continue with such a gross injustice to any groups of doctors or nurses. The Bawa-Garba incident gives us a very good opportunity, and we must make sure all lessons are learned.
If at all, this case should have been corporate manslaughter! Why the MPS and the Trust allowed Dr. Bawa Garba to be charged with manslaughter is beyond me but I am not a legal expert. Why the GMC decided to appeal against the FTP decision is also beyond me.
If this case is not challenged and if the decision stays, this has huge implications for patient safety and future doctors, nurses and all of us.
I sincerely hope, we learn lessons and make sure that we protect patients and support all staff to provide the safest and the best care.
I have always argued that protecting patients and supporting staff are the two sides of the same coin.
When I was the Medical Director of Wigan, we reduced harm to patients by 90% simply by creating a culture of staff happiness and staff support and staff and patient engagement and duty of candor and good governance.
Success is when we all work together for a common purpose, and our purpose is our patient, the fellow human being.
Care for staff and they will care for patients. Sadly today in NHS we have a 'Them and Us' culture and culture of bullying, harassment and victimisation. In such a culture patients and staff both suffer.
Competing interests: This is purely personal view and not a view of any organisation I work or worked for in the past
I have been actively involved in raising awareness of the implications of the erasure of Dr Bawa Garba by the GMC for several months since I organised a letter in The Times(1). I told the Daily Mail that "what happened to Jack Adcock is an absolute tragedy, but the GMC has turned it into a disaster"(2) and I called the GMC's decision to pursue this case "questionable"(3). Although I have highlighted mistakes that the GMC has made in this case and stand by the statements I have made(4), I also have made an important error in this campaign.
I previously, whilst welcoming the Norman Williams' review, have called for Charlie Massey, the CEO of the GMC, to stand down(5). That, I now believe at this stage, would be an ill-advised move. The GMC has made many errors - even beyond this case, the failure to deal with convicted sex offenders and fraudsters being the most obvious examples. However, many of these cases predate even Mr Massey's appointment. As Margaret McCartney pointed out "Putting the blame on one person allows us to believe that the bad apple has been removed from the barrel. But it's the barrel that's the problem"(6). Calling for Mr Massey's resignation was an inappropriate gesture which I now regret. Having spent nearly 20 years trying to enable staff to raise concerns over patient safety without fear of retribution(7), it is vital that all of us learn the lessons of this case without threat and acknowledge any errors that we have made.
As others have stated "1990s: Bristol heart scandal; 2000s: Mid Staffs hospital; 2018:Hadiza Bawa-Garba. Events that changed the practice of medicine. Utterly."(8). Whether that change is a positive one depends on us, clearly blame is not working, we should try learning from error.
1. Nicholl D and 774 others. Medicine on Trial. The Times December 5th, 2017. https://www.thetimes.co.uk/article/doctors-defend-colleague-hadiza-bawa-...
2. So was she a scapegoat? Daily Mail, 17th February, 2018.
Competing interests: No competing interests