The tragic and outrageous case of Dr Hadiza Bawa-Garba in the UK should be a galvanizing call to action for EVERYONE in healthcare.
Below are thoughts from a quality-improvement perspective from patient-safety expert and ENT physician Dr. Giri Venkatraman:
Why the case of Dr. Bawa-Garba is the worst possible thing that can happen to the patient safety movement.
- The case impacts open and honest communication and discussion. When there is a catastrophic event like the death of a child, an open and honest discussion and a root-cause analysis is the primary responsibility of everyone involved. Such a “protected” investigation is not legally discoverable and this fact promotes honesty. If providers involved in the care of patients are not assured of this, (or, as in Dr. Bawa-Garba’s case, her own thoughts were used against her) it would be impossible to correct the error(s) and ensure the cascade of events leading to the bad outcome do not happen again.
- Root cause analyses rarely find a single person or group responsible. Usually catastrophic medical errors are due to system failures. There are instances of gross negligence (e.g. a surgeon showing up drunk) but most medical errors are not caused by such individuals. Dr. Bawa-Garba was certainly a victim of poor systems – understaffing, lack of radiology support, lack of any orientation to a new facility etc. Rather than identifying and correcting these system errors, the British health and legal system tried Dr. Bawa-Garba for manslaughter.
- The case showed a complete lack of leadership. The consultant physician, rather than assuming some responsibility for the catastrophe, instead blamed Dr. Bawa-Garba for not getting him more actively involved. When there are catastrophic events, grief counseling should be offered and leadership should help with open and transparent investigations.
Providing safe care is the responsibility of everyone in healthcare. Despite everyone’s best intentions, bad outcomes and catastrophic events happen. The argument can be made that most safety investigations are useless because they are merely retrospective (with 20/20 hindsight). But the hope in these efforts is to make process or system changes needed to ensure similar errors do not happen moving forward. For example, subsequent to this case, a sepsis bundle was introduced to expedite safer care for similarly ill patients. Safe care depends on everyone on the team being honest and have an element of “psychological security”. The case of Dr. Bawa-Garba was an example of exactly what not to do. Dr. Bawa-Garba was a convenient scapegoat for a system bent on shifting blame, but her conviction does not address the systemic failures that were ultimately responsible for her patient’s tragic death.
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