The doctor who thwarted the charge of the general medical council – part 1 thcb

After Dr. Hadiza Bawa-Garba was convicted for manslaughter for delayed diagnosis of fatal sepsis in Jack Adcock, a six-year-old boy who presented to Leicester Royal Infirmary with diarrhea and vomiting, she was referred to the Medical Practitioners Tribunal (MPT). The General Medical Council (GMC) is the professional regulatory body for physicians. But the MPT determines whether a physician is fit to practice. Though the tribunal is nested within the GMC and therefore within an earshot of its opinions, it is a decision-making body which is theoretically independent of the GMC.

The tribunal met in 2017, 6 years after Jack’s death, to decide whether Dr. Bawa-Garba, after the manslaughter conviction, should be allowed to practice medicine again, whether she should be suspended for a year, or her name be permanently erased (“struck off”) from the medical register.

The GMC wanted Dr. Bawa-Garba to be struck off from the medical register because they felt that her care of Jack fell so short of the expected standard, that her return to practice would not only endanger patients but undermine public confidence in the medical profession. The GMC expected the MPT to agree with its uncompromising stance, and the MPT might well have, and probably would have, but for the efforts of Dr. Jonathan Cusack, a consultant neonatologist at Leicester Royal Infirmary (LRI), and a former supervisor and mentor of Dr. Bawa-Garba’s.

Cusack is unassuming even by British standards. You will not find him on social media or taking selfies. A soft-spoken northerner with a steely nerve and an uncompromising deference to facts, Cusack is both old-school and new-school. He has that unassailable integrity which is immeasurable but instantly recognizable. But he’s also savvy – and understands the British medical, regulatory and legal systems inside out. If Dr. Bawa-Garba’s license is reinstated, Cusack’s role would be akin to that of the code breakers in the Second World War. Dr. Bawa-Garba trusts him implicitly. Her legal team can’t function without him.

Cusack was loyally involved in both the rehabilitation of Dr. Bawa-Garba’s clinical confidence after Jack’s death, and her trial. I met him after the first day’s appeal hearing in the pub opposite the Courts of Justice. Originally hesitant to speak to me, being the ostentatious expat Brit that I am, he agreed to an interview on the condition that I not make too much of a song and dance about his contribution. I promised that I wouldn’t. I lied.

JC – It wasn’t as high as hypovolemic shock in her differential. I recall you wrote in your piece that the fact she got a chest-ray meant that infection was also in her differential. I agree with that assessment. Also, she obtained a CRP, which was a foresight that she may need to distinguish between bacterial and viral infections. CRP is not a part of the routine blood panel – you have to request it separately.

JC – The ph in and of itself isn’t specific for septic shock but is indicative of shock in general. A case can be made that an elevated lactate is suggestive of sepsis, but lactate can be elevated in conditions other than sepsis. Also, 2011 was before we knew a whole lot about sepsis and lactates. It was before mass awareness of sepsis. Lactate wasn’t routinely obtained in ill patients, then. In any case, after the fluid bolus, Hadiza reassessed Jack. He had perked up, was playful, and far more resistant when Hadiza repeated blood gases.

SJ – And depending on the outcome, that is in hindsight, this is either confirmation or confirmation bias – a mark of clinical acumen or a flaw of judgment. Regardless, it’s fair to say that a doctor who is cautious about fluid administration because of patient’s heart disease, rechecks a patient’s status within an hour, gets specialized blood tests such as CRP, isn’t an indifferent doctor, isn’t a slacker, but a highly thoughtful doctor.

JC – By the time the chest x-ray was done, and it was done after the second set of blood gases were analyzed, she was, understandably, more certain about her diagnosis of hypovolemic shock because the ph had improved and Jack was perking up. But also bear in mind she was being beeped incessantly, as she was covering more than just the CAU, more than what is safe for a single registrar to cover. She was running around the hospital.

SJ – I can actually picture that. Running up and down flights of stairs to various wards in various parts of the hospital, dashing to the nearest phone to answer her beep, accumulating scraps of paper. It’s easy to forget that chest x-ray that you ordered but you don’t know when it was done, because you’re not told that it was done, let alone that it had an abnormality. For contrast – at my institution, when pneumonia is suspected by the emergency department, a radiologist is supposed to report the chest radiograph in 30 minutes, and call the physician if there is pneumonia.

JC – There was another consequence. When Hadiza phoned pathology for Jack’s results, a frustrated individual, frustrated at being phoned for results all day, recited all of Jack’s results, including creatinine. Normally, what happens is that the results populate in the patient’s records and the abnormal results are highlighted. Jack’s creatinine was mildly elevated. She was told the creatinine, non-judgmentally – i.e. she was not told that it was elevated. When you’re reliant on a system which flags abnormal results it’s easy to miss a mild abnormality when it’s not flagged.

JC – He had perked up substantially. He was laughing and being playful. Whatever was going on inside his circulation unbeknownst to everyone, externally he no longer appeared ill. Here’s an indication that everyone believed that Jack was on the mend – Jack’s father returned home in the evening. He wouldn’t have done that if Jack hadn’t perked up.

JC – I’ll expand on O’Riordan’s role a bit later because his role in this case is significant. It’s important, also, to understand what was happening on the nursing side. The pediatric nurses are excellent at LRI. As happens far too often in the NHS, acute services are often short of nursing staff. Jack was being looked after by an agency nurse – who wasn’t a pediatric nurse.

SJ – This seems like a systems issue rather than Dr. Bawa-Garba’s responsibility. A pediatric registrar can’t possibly be expected to watch over every single element of care of every single patient – this is humanly impossible and inhumane to demand. The system works when every member of the team does what they’re supposed to be doing – i.e. does their job.

JC – Unfortunately, Hadiza was blamed for not spotting the failings of the nursing staff. She reassessed Jack, at 6 pm. She did not look at his observation chart – perhaps because she felt she did not need to. Jack was playful, like a 6 year old should be, and seemed to be heading in the right direction. She didn’t feel the need for consultant review because Jack seemed to be getting better.

JC – We know from the autopsy that Jack died from Steptococcus A septicemia. We don’t know his vital signs around 7 pm, or his ph. But, that he was mentally alert and playful, meant that his circulatory system may have been in compensation mode, meaning that his homeostatic mechanisms – the ones which constrict the arteries and maintain the blood pressure, may have been in overdrive mode, and may have been at the end of their tethers, and may have only just been successfully maintaining his blood pressure.

JC – Yes, then what happened was that Jack was transferred to the ward. After the transfer he received his maintenance dose of enalapril. An hour later he went into cardiac arrest. The cause of Jack’s death was Group A Streptococcus. However, many doctors are concerned that what delivered Jack the fatal blow was the enalapril. To recap, enalapril is an angiotensin converting enzyme inhibitor. It dilates the arteries. It undid the compensatory overdrive of Jack’s circulatory system, the overdrive which was so important in maintaining his blood pressure.

JC – This is complicated. Hadiza stopped the enalapril. She deliberately did not prescribe it on the drug chart. LRI has a policy that family members can give maintenance drugs to patients without them being written on the drug chart. Hadiza was not aware of this policy. Jack’s mother asked the nurse to give the enalapril. The nurse asked one of the junior doctors, who said it was fine for Jack’s mother to give the enalapril.

JC – Hadiza had been on her feet for thirteen hours by the time Jack went into cardiac arrest. Anyone would have been tired at that point. But the issue wasn’t just tiredness. Earlier in the day a pediatric oncologist told her over the phone that a child with brain tumor was “not for resuscitation.” The child was going to be moved to a palliative care facility. Hadiza scribbled the ward and bed the child was in, and committed that information to memory.