Part I. The Case of Dr Hadiza Bawa-Garba
The case of Dr. Hadiza Bawa-Garba–a trainee pediatrician in the British NHS [National Health System]–convicted for homicide for the death of a child from sepsis, and hounded by the GMC [General Medical Council] is every junior doctor’s primal fear. It is every doctor’s primal fear everywhere. When I was practicing surgery, I was informed by my attorney for a malpractice case that there was a strenuous effort on the part of justice departments, district attorney’s offices, and prosecutors who encountered medical malpractice cases, to find a prosecutable criminal murder case against a doctor. Several attempts were made, but the vast majority of them remained civil malpractice cases. Here is one that made it to the criminal side.
On Friday, February 18, 2011, Dr. Bawa-Garba had recently returned from a 13-month maternity break to the Leicester Royal Infirmary in a British hospital. She was the on-call pediatric registrar—the second in command for the care of sick children there. The British training system has a significant difference compared to the American internship/residency program. As a registrar, Dr Bawa-Garba was both a master and an apprentice at the same time. i.e. she was both student and responsible physician with all the serious responsibilities that entailed. It was a juxtaposition of roles necessary for the survival of acute care in the NHS for the patient, physician, and NHS alike. There is a chronic shortage of attendings [consultants] in the NHS; so, trainees in many hospitals must fill both positions, or else the NHS will collapse.
On that fateful day, Dr. Bawa-Garba was making critical decisions and also doing the scut work [She was doing doctor, medical assistant, nursing, and cleanup duties at the same time. To borrow an aviation analogy, she was flying the plane and serving food to the passengers.]
Dr Bawa-Garba’s supervisor, Dr O’Riordan, was not in the hospital. He was spread thin, having to teach in a nearby city. The situation of the “attending not being in the hospital”, is not atypical in the NHS. It so happens that the young physician’s colleagues [ie, other registrars, and potential sources of help] were also away on educational leave.
Ideally and properly, a pediatric registrar is assigned to cover the wards, the emergency department, and/or the CAU [Children’s Assessment Unit]. On that fraught day, Dr Bawa-Garba covered all three at the same time. To compound the difficulty, she was new to the hospital with no formal induction–ie, no explanation where things are and how things routinely get done in the hospital. She was expected to handle it all smoothly and safely without help.
Normal hospital and ER function is expected to be hard work and to include serious decisions with backup. However, in many hospitals around the world—and especially in the NHS that optimal condition is unusual; and what is usual in British hospitals is remitting and relapsing chronic understaffing. That abnormal level of function has become the “normal”. Dr. Hadiza Bawa-Garba was set to work that day amidst anarchy–the new normal [in fact the “old normal”, as well].
Athough the analogy is not exact, a registrar is the near equivalent of a senior resident in the United States.
Registrars in Great Britain are the principle decision-makers in hospitals by default. My surgical internship functioned the way it was supposed to; I was a student early on and was granted more serious decision making and responsibility as I matured as a surgeon. I recall being relieved when a resident or attending came to see my patient. Later–in my neurosurgical residency–we had a resident dominated system and hierarchy with gradual but definite increase in proficiency and responsibility. However, on Friday, February 18, 2011, that junior registrar in England had to function as both a senior resident and an attending.
