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

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

• verstretched 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

Law Teamwork Workforce Culture Candour Mistakes S ystems Communicat ions Time

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

• u