Claims Online July 2021
Jul 1 2021
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Prosecutions and convictions of healthcare professionals for gross negligence manslaughter (GNM) are rare. In 2015, a trainee paediatrician Dr Bawa-Garba was found guilty of GNM as a result of the death of 6 year old Jack Adcock who developed sepsis in 2011. Despite the conviction it was ruled that Dr Bawa-Garba should remain on the medical register. However, the General Medical Council took the case to the High Court and in January 2018 she was struck off the register.
Whilst Dr Bawa-Garba has now been granted the right to appeal the decision, this case sent shockwaves through the medical profession. Healthcare professionals were very concerned that honest errors could result in prosecution for GNM, even in the face of broader organisation and system failings. There was a particular concern that this fear had a negative impact on reflection and learning by healthcare professionals which is essential in improving patient care. In February 2018, the Health Secretary Jeremy Hunt commissioned Professor Sir Norman Williams to conduct a rapid policy review.
The Purpose of the Rapid Review
The purpose of the review was to consider:-
1. how to ensure healthcare professionals are adequately informed about:
2. how to ensure the vital role of reflective learning, openness and transparency is protected where the healthcare professional believes that a mistake has been made to ensure that lessons are learned and mistakes are not covered up; and
3. lessons that need to be learned by the General Medical Council (GMC) and other healthcare professionals’ regulators in relation to how they deal with professionals following a criminal process for GNM.
In his report, Professor Sir Norman Williams made a series of recommendations to support a more just and learning culture in the healthcare system. Key recommendations include:-
The heart of the review is to promote a just and learning culture to improve patient safety. Changes will be seen in revised guidance to promote consistency throughout the profession. A clearer understanding of gross negligent manslaughter will be welcomed, with only rare cases leading to criminal investigation in exceptionally bad circumstances. In addition, systemic issues and human error will be assessed alongside individual actions to promote a fair and more proportionate approach to more thorough investigations.
An open culture of learning is key to improving patient safety. Healthcare professionals need to be confident that they will be supported when they air their concerns, rather than being blamed and the review stresses a need for a balance to be struck. It is hoped that the recommendations will help reduce the climate of fear prompted by the Bawa-Garba case and it now remains to be seen whether and how quickly the recommendations are implemented. We also await the outcome of Dr Bawa-Garba's appeal against her erasure from the register.