Doctors being investigated after the death of a patient should expect official investigations to take into account their working environments and pressures, a GMC-commissioned review has urged.
This was just one of a number of recommendations in the independent review of gross negligence manslaughter and culpable homicide, led by former consultant cardiothoracic surgeon Leslie Hamilton.
The review is one of several commissioned by the GMC following anger and concern at its treatment of Hadiza Bawa-Garba, a paediatric trainee found guilty in 2015 of gross negligence manslaughter for the death of Jack Adcock, a six-year old boy.
The MPTS (Medical Practitioners Tribunal Service) had in 2017 decided to suspend Dr Bawa-Garba for 12 months but she was removed from the register in 2018 after the GMC successfully appealed that decision in the high court.
The GMC’s right to appeal MPTS rulings remains in place but is in the balance following the Government’s decision to remove it.
Dr Bawa-Garba can now return to work in July provided she adheres to a range of conditions after winning her bid to be reinstated to the Medical Register in a court of appeal case last year.
However, the review says the outrage and consternation in the medical profession was described as ‘toxic fear’, as it called for a ‘just and fair treatment of staff’ for the benefit of doctors and patients.
‘The catalyst for this was the death of Jack Adcock,’ review chair Mr Hamilton told the press briefing. ‘A trainee doctor made unintentional errors. All doctors could identify with her and the circumstances, staff shortages and IT problems. Doctors were suddenly afraid, they lost self-confidence, lost faith in the GMC and no longer trusted the system.’
The Hamilton review says that the ‘vulnerability felt by many doctors reflects their sense of working in healthcare services that are under considerable strain and where individuals trying to do their best for their patients can too easily be blamed for mistakes arising from wider system failures’.
It adds: ‘Healthcare providers have a responsibility for the environments in which doctors practise and when things go wrong to the extent that a doctor faces criminal investigation, the appropriate external authorities should scrutinise the systems within the department where the doctor worked.’
Mr Hamilton told The Doctor that it did not want to be prescriptive about this scrutiny role but considered the Care Quality Commission could do it in England.
‘There needs to be a focus by a review body,’ he added. ‘More than what is happening at the moment.’
CQC chief inspector of hospitals Ted Baker described the review as important but indicated it would not extend its investigative work.
‘We fully support the focus it places on creating a “just” culture where learning is shared when things go wrong and staff are supported to speak up about concerns,’ he told the BMA.
Concerns raised about providers were already treated as ‘intelligence’ and acted upon where necessary, he added. ‘In line with the recommendations made in this report we will continue to ensure this level of scrutiny going forward.’
Other recommendations in the review include:
- A consistent approach to investigations in all healthcare providers
- The chief coroner is consulted before any gross negligence manslaughter cases escalated to the police and Crown Prosecution Service
- Improved quality assurance of medical expert evidence in gross negligence manslaughter and culpable homicide cases
- That the GMC urgently repairs its relationship with the profession.
GMC chief executive Charlie Massey told the briefing he accepted all the review’s recommendations and would take on the role of ensuring their implementation. ‘It is important that the system as a whole is engaged with these recommendations. We are committed to rebuild our reputation with the profession. Work is already under way on some of the issue in the report.’
Mr Massey said it would consider its response to the Hamilton review alongside two others. One is examining why doctors from black and minority ethnic backgrounds are referred to the GMC more than others. The other review aims to pinpoint the causes of poor wellbeing faced by medical students and doctors.
BMA council chair Chaand Nagpaul said: ‘When an error is made in a medical environment that is so serious that a patient loses their life, though incredibly rare, it is a tragedy, causing unspeakable distress to the person’s family and loved ones, as well as to the health professionals involved.’
Doctors welcomed the review’s conclusions, he added. ‘It takes on board many of the points the BMA raised in its own submission – not least on the need for a just culture based on learning rather than blame – and builds on the important work from Professor Sir Norman Williams last year.’
‘This culture shift is vital to help avert such tragedies, and give the public confidence in the health service, while reassuring doctors and other staff that they will not be unfairly blamed when things went wrong.’
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