Dr Bawa-Garba: lessons learned for professional regulation. Alan - PowerPoint PPT Presentation

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Dr Bawa-Garba: lessons learned for professional regulation. Alan Clamp | Professional Standards Authority Jack Adcock 18 February 2011 0930: Jack admitted to Leicester Royal Infirmary. 2121: Jack declared dead. Investigation Internal

Dr Bawa-Garba: lessons learned for professional regulation. Alan Clamp | Professional Standards Authority
Jack Adcock
18 February 2011 0930: Jack admitted to Leicester Royal Infirmary. 2121: Jack declared dead.
Investigation Internal investigation identified:  Errors by Dr B-G  Errors by nursing staff  A series of system failings A total of 23 recommendations.
Expert views  Interruption to resuscitation did not contribute to death.  Enalapril was an aggravating factor.  Jack should have been given antibiotics much earlier.
The criminal case  July 2013: inquest referred the case to the CPS .  December 2014: Dr B-G charged with manslaughter by gross negligence.  November 2015: Dr B-G found guilty and received a two-year suspended sentence.
Regulation  June 2017: Tribunal suspended Dr B-G for one year.  January 2018: General Medical Council appealed the decision in the High Court – sanction changed to erasure.  August 2018: Dr B-G appealed to the Court of Appeal and was reinstated to the register (suspension order in place; conditions added).
Response to the case [1]  Many doctors argued that Dr B-G was unfairly punished for mistakes made while working in an overstretched and under-resourced NHS .  “ We can’ t believe that she is allowed to practice again after a conviction like this” (Nicky Adcock).
Response to the case [2]  “ I am sorry for my failure to recognise sepsis. I apologise for the pain I have caused the family. The pain will live with me for the rest of my life.” (Dr Bawa-Garba)
Themes Time Teamwork Culture Candour Law Workforce S ystems Mistakes Communicat ions
Where are we now?  Court deference to panel decisions (and vice- versa )?  Different outcomes for different professions?  The importance of context in regulatory decisions?  Was this a case of gross negligence manslaughter?
Review of GNM (June 2019)  Origins in the case of Dr B-G.  ‘ Personal and system accountability must be balanced with learning and prevention of harm’  We need ‘ better and fairer’ regulation.  It is time for regulatory reform.
Jack Adcock
S peaker Contact Information  Alan Clamp, Chief Executive, Professional S tandards Authority.  alan.clamp@ professionalst andards.org.uk  www.professionalst andards.org.uk
Thank Y ou

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