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At the meeting she was asked to reflect on the circumstances and to sign a trainee encounter form setting out what she should have done differently. Some doctors have expressed concern that its role in Jack’s cardiac arrest has been underplayed. “Losing a child is the most horrendous thing ever. However, he did not perform a senior review of the boy because, he said, he was not specifically asked to by Bawa-Garba. “My hope is that lessons learnt from this case will translate into better working conditions for junior doctors, better recognition of sepsis, and factors in place that will improve patient safety.”. It doesn’t give the public any faith in the NHS,” she says. Instead, Dr O’Riordan insisted on seeing Jack’s parents without her. “You could fire everybody, punish everybody and put in an entirely new workforce, you will have the same injuries and the same errors occur again unless you’ve actually changed the systems of work,” he adds. As the consultant, he had ultimate responsibility for the patients admitted on the CAU that day. “However, we would be concerned if the duty of candour and educational reflection was wrongly influenced by court cases and convictions of medical professionals for gross negligence manslaughter. In the morning Jack was taken to the GP by his mother, Nicola, and referred directly to Leicester Royal Infirmary’s children’s assessment unit (CAU). The BMJ has learnt that, five days after Jack’s death, Bawa-Garba was asked to meet Stephen O’Riordan, the duty consultant at the time of the incident, in the hospital canteen. “I was just saying, ‘Come on sweetheart go to sleep,’ and I was rubbing his face. A social media storm ensued, accompanied by the hashtag “#IamHadiza”, with doctors wearing T-shirts and badges in her support. Dr O’Riordan told the court that he recalled the pH was 7.08 and “the lactate was high” saying he couldn’t remember if Dr Bawa-Garba had told him the actual value at their afternoon handover, before Jack died. “Doctors work in teams and the consultant is in charge of that team. But when asked if it was a “significant factor” in Jack’s rapid deterioration, he said this was “consistent with the clinical history”. At the heart of this story is the tragic death of a much-loved little boy and the loss felt by the family. He then pressed her further and one by one, she listed how she felt she should have done better. His tongue, or his lips, looked blue. What she didn’t know was that Jack had subsequently been moved to the same ward as the boy who had crashed in the morning – ward 28. Dr Bawa-Garba says she was then told by another doctor that the patient was not the same boy as earlier – but was Jack Adcock. "The court heard that O’Riordan was aware before Jack died that he had a serum pH of 7.084 and a blood lactate concentration of 11.4 mmol/L, which he wrote down in his notebook at evening handover. That December he was asked to see officials from NHS England. But that all changed the day she covered for a colleague at the CAU. But suddenly she found herself under arrest and being read her rights. Dr Bawa-Garba spent the next six weeks trying to plan for every scenario. Copyright © 2020 BMJ Publishing Group Ltd     京ICP备15042040号-3, Back to blame: the Bawa-Garba case and the patient safety agenda, https://www.sentencingcouncil.org.uk/wp-content/uploads/Manslaughter_consultation_paper_Final-Web.pdf, Brighton and Sussex University Hospitals NHS Trust: Consultant in Stroke Medicine, Practice Plus Group: General Practitioner, Rush Hill & Weston Surgeries: Salaried GP, Herefordshire and Worcestershire Health and Care NHS Trust: Consultant Psychiatry, Women’s, children’s & adolescents’ health. “The issues were all laid bare - poor staffing levels; communication problems and poor handovers; IT systems not working; no senior staff on duty, with juniors left to do everything," Dr Jenkins says. Stephen O Riordan is on Facebook. But five months after Jack’s death, Dr O’Riordan left the Leicester Royal Infirmary and moved to Ireland. Dr Hsu says he’s been around long enough to know if reports don’t work out well for someone, people have ways of of ensuring that the report doesn’t really get anywhere. Care assistant convicted of two assaults on disabled man . At the Adcocks’ home in Glen Parva, a suburb of Leicester, Jack’s sister Ruby has moved into his old room. And on Monday she was reinstated to the medical register by the Court of Appeal. “I had parents from my daughter’s school asking if I was OK because they were getting leaflets in their letterboxes saying that they should sign a petition to say that I should be struck off,” she says. “Everything was in place. But he says he has sympathy for Dr Bawa-Garba. Later that night, Dr Bawa-Garba called Dr O’Riordan – the consultant who had arrived in the afternoon, after double-booking himself that day – to tell him about Jack’s death. In that moment, Dr Bawa-Garba didn’t recognise her. After an hour of being on fluids to rehydrate him, Jack seemed to be responding well. Dr Bawa-Garba had already started to write down her reflections. The GMC’s Charlie Massey says he understands these concerns. The jury also heard from Dr Simon Nadel, a paediatric intensive care consultant in London, who thought enalapril had aggravated Jack Adcock’s condition, but wasn’t the cause of death. “After this case happened, I reflected on my practice and this can be found in my e-portfolio, and I listed deficiencies that I felt were in the care that I provided on that day,” Dr Bawa-Garba replied. Trainee doctor Hadiza Bawa-Garba arrived at work expecting to be on the general paediatrics ward - the ward she’d been on all week. “I was shocked and I was like, ‘Why is Jack crashing?’” she says. The next day was spent exploring all the points in detail. But the fluid he was losing from having diarrhoea had not been documented by his nurse. She was told to list everything that she could have done differently, she says. The recommendations were wide-ranging but included: - Robust processes for helping staff return to work after periods of protracted leave or maternity leave, - A dedicated presence of consultants on the children’s assessment unit, - New guidelines on the use of agency nurses, - Better visual prompts for staff about abnormal blood results. Sepsis is when the immune system overreacts to an infection and attacks the body’s own organs and tissues. Because Jack’s death was unexpected, the hospital conducted an investigation to identify what had gone wrong with the little boy’s care. He denies being influenced by the Adcocks’ petition, and says the GMC acted out of the need to protect public confidence in the profession, given the seriousness of the conviction. View Stephen O'Riordan’s profile on LinkedIn, the world's largest professional community. The following day, Saturday, the family was invited back to the hospital to meet a group of doctors, nurses and managers from the trust to discuss what had happened. The judges ruled that Dr Bawa-Garba's actions had been neither deliberate or reckless and she should not have been struck off. During the six-hour interview, all she could think about was her two-week-old daughter who would need breastfeeding. “Jack was really lethargic, very sleepy. Jack had died of sepsis. “That isn’t unique to this trust, nor was the difficulty in recruiting doctors and nurses, too few were coming out of training nationally, a fact which the NHS locally and nationally is still struggling with. “He had no tubes, he had nothing,” she says. Stephen O'Riordan | London, United Kingdom | Finance Change AVP at Barclays | 271 connections | View Stephen's homepage, profile, activity, articles The hospital had carried out its own investigation and Dr Bawa-Garba continued to work there. A spokesperson for the Medical Defence Union responded on his behalf, saying that O’Riordan “cannot comment on the issues raised . “After I realised that we were actually resuscitating Jack, I just couldn’t understand why he had crashed. At the criminal trial, experts agreed that Jack shouldn’t have been given the drug in the condition he was in, though all accepted that Mrs Adcock had behaved perfectly responsibly by giving it to him. She wanted to know about the interrupted resuscitation and so they talked about that too. “We were season ticket holders but since that happened [Jack’s death] I haven’t been able to go,” he says. She also carried the bleep – which alerts the doctor that a patient needs seeing urgently on the wards or in the Accident and Emergency unit, across four floors of the busy Leicester Royal Infirmary – and was required to respond to calls from midwives, other doctors or parents. She describes Jack as a “joyful little boy” and says he and his younger sister, Ruby, adored each other. “I remember being absolutely terrified, thinking, ‘I haven’t done anything, why are the police here?’” Mrs Adcock says. Doctors, medical errors, and the justice system doi:10.1136/bmj.i6274; Editorial Shadow of the law in cases of avoidable harm doi:10.1136/bmj.i6268. Join Facebook to connect with Steven Riordan and others you may know. With access to full trial transcripts, witness statements and internal hospital inquiries, Panorama talks to Dr Bawa-Garba and to the parents of Jack Adcock in order to tell the story in detail. At the start of every shift, the nurses and doctors in charge routinely review staffing levels and move resources to where they are most needed,” he says. Stars featuring handwritten messages from Jack’s schoolmates, saying how much they will miss him and his cheeky laugh, adorn the navy blue walls of the replica bedroom. The hospital’s own investigation, which flagged up all the contributory factors and failings that had led to Jack’s death, wasn’t put before the jury, he says. Dr O’Riordan declined Panorama’s invitation to comment on Dr Bawa-Gaba’s account of the meeting. At 16.30 hours Dr Bawa-Garba gave one, of two handovers, to the consultant on-call, Dr Stephen O’Riordan. Dr Bawa-Garba was given a two-year suspended sentence. He holds appointments as Senior Staff Specialist in Gastroenterology and Hepatology at the Prince of Wales Hospital and its affiliated … Join Facebook to connect with Stephen O Riordan and others you may know. Stephen O Riordan 6 results. But the hospital’s report was not heard in court. But then they were asked to cancel their plans and meet the police at the coroner’s office to discuss an inquest. That isn’t the case. But she didn’t consider that Jack might have had a more serious condition. While doctors are responsible for their actions, many feel Dr Bawa-Garba was let down by the consultant on call both on the day that Jack died and subsequently,” Dr Cusack says. A review is underway to look at the disproportionate referral rate. “For a split second you think, ‘Yes, we’ve got justice for our son’s death,’” says Mrs Adcock. When a junior doctor was convicted of manslaughter and struck off the medical register for her role in the death of six-year-old Jack Adcock, shockwaves reverberated through the medical profession. She says Dr O’Riordan noted down what she said and ordered repeat blood tests. Experts later said the interruption to the resuscitation had not contributed to his death – but he shouldn’t have been given enalapril and he should have been given antibiotics much earlier. “I can’t face it.”. A normal is about two and his was 11, so I knew then he was very unwell,” Dr Bawa-Garba says. I understand that because they’re thinking if we make an honest mistake we’re going to be charged. Paediatric Diabetes & Endocrinology. Professor of Medicine (Conjoint, UNSW)Head, Gastrointestinal and Liver Unit, Prince of Wales HospitalSenior Staff Specialist in Gastroenterology and HepatologyPrince of Wales Hospital, Sydney Children’s Hospital, Royal Hospital for WomenConsultant Physician, Gastroenterologist and … “On the reflection I did following this incident, those were the points that I looked at,” she said. Congress Theme – 2020 Vision: Navigating adversity with coaching psychology and positive psychology Welcoming video to the Congress with Dr Siobhain O’Riordan & Prof Stephen Palmer This Four-Day Virtual Congress offers four Masterclasses on Day 1, 2 and 3 and on Day 4, Keynote and Invited Speakers, Skills-based Sessions and Poster Presentations. The tests revealed his blood was too acidic. According to Mrs Adcock, the expert witness at the inquest, Dr Gale Pearson, a paediatric intensive care consultant, stated that if Jack “had been given the right treatment, antibiotics, correct bolus, intensive care, consultant treatment, he would have not died when he died, how he died, the way he died – he may have still been here”. So I made plans that if I was to go to prison he would have to go out and live with my mother in Nigeria.”. She then went to chase up Jack’s blood results, which still hadn’t come through – the doctor she had assigned to do it hadn’t managed to get them. But as Mrs Adcock puts it, “All they did was contribute to my son’s death.”. “Best practice shows that when you’re trying to identify learning, the way to do that is in an open culture, where people can give evidence without fear of sanction or blame,” Mr Furlong says. . They had to consider the circumstances within which the defendants were working when considering if they were guilty. The BMJ has learnt that, five days after Jack’s death, Bawa-Garba was asked to meet Stephen O’Riordan, the duty consultant at the time of the incident, in the hospital canteen. The following day, she says, she was admonished by Dr O’Riordan for making that call and told not to have any more contact with the family because an investigation was to be launched. “The criminalisation of medical error when events are considered singularly rather than as a part of a highly complex system is going to seriously impede learning,” said Jonathan Cusack, the Leicester Royal Infirmary neonatologist who was Bawa-Garba’s educational supervisor after the incident. “I just couldn’t control myself and I'm not usually a weepy person,” she says. She noted it was 97, far higher than it should have been, so she circled it. “And that's important, because the vast majority of referrals that come to us from employers, do result in investigations, whereas it’s a minority of complaints that are made to us by the public,” he says. One doctor said she would pray before she went into work because she was worried something bad would happen. I suspect that many would have died anyway but in some cases my errors are likely to have contributed to poor outcomes and some patient deaths,” he says. The nurse was doing his observations - including his temperature, heart rate and blood pressure - but did not record them regularly. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. All doctors make mistakes and that is understandably scary for patients, he says. 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