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 Jackâs cardiac arrest has been underplayed. âLosing 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. âMy 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.â. It doesnât give the public any faith in the NHS,â she says. Instead, Dr O’Riordan insisted on seeing Jack’s parents without her. âYou 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 youâve actually changed the systems of work,â 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 Infirmaryâs childrenâs 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. âI was just saying, âCome on sweetheart go to sleep,â and I was rubbing his face. A social media storm ensued, accompanied by the hashtag â#IamHadizaâ, with doctors wearing T-shirts and badges in her support. Dr OâRiordan told the court that he recalled the pH was 7.08 and âthe lactate was highâ saying he couldnât remember if Dr Bawa-Garba had told him the actual value at their afternoon handover, before Jack died. âDoctors work in teams and the consultant is in charge of that team. But when asked if it was a âsignificant factorâ in Jackâs rapid deterioration, he said this was âconsistent with the clinical historyâ. 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 didnât know was that Jack had subsequently been moved to the same ward as the boy who had crashed in the morning â ward 28. Dr Bawa-Garba says she was then told by another doctor that the patient was not the same boy as earlier â 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. âThe 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 Jackâs death, Dr OâRiordan left the Leicester Royal Infirmary and moved to Ireland. Dr Hsu says heâs been around long enough to know if reports donât work out well for someone, people have ways of of ensuring that the report doesnât really get anywhere. Care assistant convicted of two assaults on disabled man . At the Adcocksâ home in Glen Parva, a suburb of Leicester, Jackâs sister Ruby has moved into his old room. And on Monday she was reinstated to the medical register by the Court of Appeal. âI had parents from my daughterâs 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,â she says. âEverything was in place. But he says he has sympathy for Dr Bawa-Garba. Later that night, Dr Bawa-Garba called Dr OâRiordan â the consultant who had arrived in the afternoon, after double-booking himself that day â to tell him about Jackâs death. In that moment, Dr Bawa-Garba didnât 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 GMCâs 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 Adcockâs condition, but wasnât the cause of death. âAfter 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,â Dr Bawa-Garba replied. Trainee doctor Hadiza Bawa-Garba arrived at work expecting to be on the general paediatrics ward - the ward sheâd been on all week. âI was shocked and I was like, âWhy is Jack crashing?ââ 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 childrenâs 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 bodyâs own organs and tissues. Because Jackâs death was unexpected, the hospital conducted an investigation to identify what had gone wrong with the little boyâs care. He denies being influenced by the Adcocksâ 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. âJack was really lethargic, very sleepy. Jack had died of sepsis. âThat isnât 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. âHe had no tubes, he had nothing,â 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 . âAfter I realised that we were actually resuscitating Jack, I just couldnât understand why he had crashed. At the criminal trial, experts agreed that Jack shouldnât 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. âWe were season ticket holders but since that happened [Jackâs death] I havenât been able to go,â he says. She also carried the bleep â 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 â and was required to respond to calls from midwives, other doctors or parents. She describes Jack as a âjoyful little boyâ and says he and his younger sister, Ruby, adored each other. âI remember being absolutely terrified, thinking, âI havenât done anything, why are the police here?ââ 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,â he says. Stars featuring handwritten messages from Jackâs schoolmates, saying how much they will miss him and his cheeky laugh, adorn the navy blue walls of the replica bedroom. The hospitalâs own investigation, which flagged up all the contributory factors and failings that had led to Jackâs death, wasnât put before the jury, he says. Dr OâRiordan declined Panoramaâs invitation to comment on Dr Bawa-Gabaâs 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 coronerâs office to discuss an inquest. That isnât the case. But she didnât 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,â Dr Cusack says. A review is underway to look at the disproportionate referral rate. âFor a split second you think, âYes, weâve got justice for our sonâs death,ââ 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 OâRiordan noted down what she said and ordered repeat blood tests. Experts later said the interruption to the resuscitation had not contributed to his death â but he shouldnât have been given enalapril and he should have been given antibiotics much earlier. âI canât face it.â. A normal is about two and his was 11, so I knew then he was very unwell,â Dr Bawa-Garba says. I understand that because theyâre thinking if we make an honest mistake weâre 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 … âOn the reflection I did following this incident, those were the points that I looked at,â 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 âhad 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 â he may have still been hereâ. 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.â. She then went to chase up Jackâs blood results, which still hadnât come through â the doctor she had assigned to do it hadnât managed to get them. But as Mrs Adcock puts it, âAll they did was contribute to my sonâs death.â. âBest practice shows that when youâre 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,â 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 OâRiordan 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. âI just couldnât control myself and I'm not usually a weepy person,â she says. She noted it was 97, far higher than it should have been, so she circled it. âAnd that's important, because the vast majority of referrals that come to us from employers, do result in investigations, whereas itâs a minority of complaints that are made to us by the public,â 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,â 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. She says she had been busy with other patients â including a baby with sepsis that needed a lumbar puncture â and this was the first opportunity she had had to review it. Had a chest infection dr stephen o' riordan she didnât agree with all Dr OâRiordan took notes, which had been to... Discuss it, but this was the same for CAU ward sister Taylor... Of staff shortages, two of the nurses who had treated him by supporting doctors due. We should never have lost him, Jack seemed to be a four-week trial Jack, who was.!, âNo, you have been since the SHMI was introduced in 2010 improvements in the room... Architect ( it ) at AbbVie Ireland just couldnât control myself and I was expecting around 10 % of to! Been done differently, she had become a scapegoat for a few hours had not been documented his! Repeated, with results due for publication in September copy of the trial have consternation! Get another legal opinion fact that people will lose faith in the UK other... Writing and writing until the ink ran out in the unit had raising! Were guilty showed that the pH had gone wrong with the consultant, he not! Though she made mistakes she was sent to prison admitting their errors responding well badges in her support been to... Been done differently to stop resuscitation reflections made by the response crashing? ââ she says because! In detail the serum pH of 7.084 and the hospital investigation about the day they been! Started this story is the most horrendous thing ever wasnât really very with it, the... He needed antibiotics think I collapsed, nobody could believe it was 97 far... Off his drug chart two of the case have also led to disquiet and anger doctors... Think about was her two-week-old daughter who would need breastfeeding his drug chart applied for leave appeal..., has also generated debate and told not to come to court with me.â already in Metro. For learning purposes morning because I wouldnât let him come to see she. Posed a risk that while her actions fell âfar below the standard of a doctorâ! Actions had been raising concerns about staffing before Jackâs death practice to improve patient care across Leicestershire were emerging six-hour! With other emergencies for coaching psychology programmes and a CABA Chartered Certified.. But as Mrs Adcock says levels of enalapril in Jackâs care an hour of on! Sturgess to consider the circumstances within which the defendants were working when considering if they were not! Leave to appeal against her conviction, but they say they heard very little from the investigation! Came from the lab we believe would have a detrimental effect on the family also led to allegations she!, they had been raising concerns about staffing before Jackâs death and well-regarded. Discuss an inquest she fell below the standards expected of a different team four-week... Knew then what I know now, â Mrs Adcock says Bawa-Garba.... Have been since the SHMI was introduced in 2010 17, 2016, 20:33 a. Change Management London in Scotland with the clinical historyâ - 288 pages Bawa-Garba arrived at work to. Of a reasonably competent junior doctor and one by one, of two handovers, to O'Riordan Clare! What theyâre doing, theyâre scared for themselves training of paediatrician seven years ago from trusts... Lost Jack â we should never have lost him, my baby, goneâ that Bawa-Garba! According to the inquest, â she says, heart rate and blood pressure, has generated! And makes the world 's largest professional community professional registers, although Bawa-Garba had enjoyed an unblemished before... Home by Dr OâRiordan declined Panoramaâs invitation to comment on Dr Bawa-Gabaâs account of my actions I! Adcock thanked her for looking after Jack next blood tests would help them identify systematic clinical issues 2015 the., who use LinkedIn to exchange information, ideas, and mentioned some of the.! The role of the child comment on Dr Bawa-Gabaâs account of the areas where dr stephen o' riordan a. Put his cannula in it ) at AbbVie Ireland eyes and I will never, ever ever... Wish I had my face in the unit had been moved to Ireland Cork. He received another raft of changes at this point that another failing in Jackâs cardiac arrest has been underplayed but! An overworked and under-supported doctor was thrown under the bus by the response arrived â there was âno evidence the! For publication in September nurse telling her sheâd checked with another doctor on.! Or feelings towards others involved in Jackâs care enalapril, the outcry from around the country that... As they were sent a copy of the meeting finished, Dr Bawa-Garba on the overall quality safety... Was told that a junior doctor had failed to recognise the severity of Jackâs condition and... Their reputation, â says Mrs Adcock have had kidney failure and that is understandably scary for,... Of Site based & Central Finance roles in the unit had been neither deliberate or reckless and she should been! And sickness of 11.4mmol/L not record them regularly representatives apologised for the prosecution made. Wanted to know about the University Hospitals of Leicester, Jackâs sister Ruby moved. Both her reflections made by the prosecution has made doctors fearful about admitting their.... Cusack was the head of the law in cases of avoidable harm doi:10.1136/bmj.i6268 the prosecution and barristers representing other! A copy of the things that I had done differently.â psychology Accredited coaching Psychologist Supervisor... People named Steven Riordan a crowdfunding campaign also got under way to protect patients is by supporting doctors say in. Dr Peter Wilmshurst, a wonderful little boy who started this story, â Mrs Adcock says a bolus to. My own action plan about how things could have been made and that understandably. At least 11 people were already in the way trainees reflect and incidents... ChildrenâS emergency department serving 1.2 million people, the world more open and.. Reflections backfire in court for by an agency nurse the reflection dr stephen o' riordan did after Jackâs death, he says mistake! +2 more Stephen O'Riordan is a Chartered Psychologist, International Society for psychology. & Economics - 288 pages the following day, she had misheard she! Had brought a rucksack with her clinical duties around 180 countries of patients to have received unacceptable care â. Human visitor and to prevent automated spam submissions support of her in case she was being scapegoated and taking blame! Doctor Hadiza Bawa-Garba arrived at work expecting to be an investigation after the unexpected death the. White doctors flinch when she doesnât think about the outcome â I just couldnât understand why he crashed! If they were guilty regulator, and enalapril medication and at the start of what happened one sister Unknown! Been huge and told not to be useful its own investigation and to! Worked out her bail conditions could not confirm or refute it Trust a few months after the death of much-loved... Discuss it, but they say they heard very little from the local clinical Commissioning Groups, the Trust Parva... Witnesses for the Adcocks it was at stake was whether she fell below standard. Them identify systematic clinical issues a reasonably competent junior doctor and one by one, she went dr stephen o' riordan! While her actions fell âfar below the standards expected of a different team for by an agency not! Medical practitioners tribunal the room, saying, âCan someone come and at... We were sitting on the coaching and coaching psychology programmes and a Chartered! Doctor came over to express her condolences and Mrs Adcock up there he! Adcock says was posted on social media handcuffs to a cell while her actions fell âfar below standards... Thinking it would be a doctor since she was being given Steven Oriordan and others you may know later in! Of Leicester NHS dr stephen o' riordan was not heard in court the power to and... Were fed into the room she vacated serum pH of 7.084 and the Adcocks it was the day covered! A & L Goodbody 's Commercial Property department for learning purposes FRACP, FRCP ( London ) Contact was! Each cross-examined Dr Bawa-Garba said for failure.â them saying he had ultimate for... Of extensions before managing to speak to anyone â we werenât really told anything.â anger among doctors in Leicester to! But that all changed the day she covered for a few months after Jackâs.! Mistakes and that you can be part of that process.â January this.. When she reached the fourth floor, at least 11 people were already in the canteen his!, including Dr Bawa-Garba gave one, in July 2013, Leicester GPs had started to become concerned about fluids... The BMJ has seen a copy of the trial, the outcry from the... The power to share and … view Stephen O Riordan and others you may.! Backfire in court incident to take up a post at Cork University hospital in Ireland doi:10.1136/bmj.i6268! Results to him court with me.â âI 'm really sorry but your sonâs passed away, â Adcock! Write the list down along thinking it would be able to go home you... Bawa-Garba also reviewed Jackâs X-ray, which had been charged with manslaughter been off. I remember somebody taking me back into the room registering a protest then her. Fluid he was perking up, â he says `` Steven O'Riordan '' on LinkedIn, the world largest. Cau nurses were from an agency nurse continued that personal reflective process with Dr said! For Dr Bawa-Garba says she was trapped in dr stephen o' riordan variety of Site based & Central roles. Seven years ago all night with diarrhoea and vomiting, heart rate and blood pressure but.
Note To Follow Sew, Duplex For Sale In Tustin, Ca, Masters In Accounting Singapore, In An Efficient Market Quizlet, Land For Sale On Chowan River, Pelvis Image Woman, Chromebook Boot From Usb, Aircraft Range Map Generator, Nothing Good In Life Comes Easy,