Despite check-lists, protocols and guidelines, mistakes happen. As long as human beings carry out jobs, mistakes will happen. To err is human. Safety is an outcome of a person’s attitudes and actions within a given environment. Both, the person and the environment have a strong impact on each other and the outcomes. The bad mood of one person affects the whole team. Similarly, a stressful milieu for any reason such as lack of time and resources has a direct impact on the performance of each person in it.
In my 19 years in the NHS, the working conditions and morale amongst the staff have gradually worsened. When things go wrong, clinicians, being visible on the frontline are expected and often willing to take responsibility. Holes in the system and staff morale are hidden. Only on a closer look are they clearly seen.
I sit in a unique position where I work for the same organisation that is at least partly, if not fully responsible for the fact that my son is not in this world any more. Yet, I know and see many doctors and nurses work way beyond their call of duty. However, our very own GMC took the case of a paediatric registrar, Dr Bawa-Garba to the High Court, supposedly in the best interest of the public. She had looked after 6 year old Jack Adcock before he tragically died of severe sepsis under her care. Her Counsel summerised:
“The events leading to [Dr Barwa-Garba’s] conviction did not take place in isolation, but rather in combination with failings of other staff, including the nurses and consultants working in the CAU that day, and in the context of multiple systemic failures which were identified in a Trust investigation.”
Yet, the high court convicted her of ‘manslaughter by gross negligence’.
A blog by concerned UK paediatric consultants stated that:
“On this day: Dr Bawa-Garba did the work or three doctors including her own duties all day and in the afternoon the work of four doctors.
On this day: Neither Dr Bawa-Garba (due to crash bleep) nor the consultant (due to rosta) were able to attend morning handover, familiarise themselves with departmental patient load and plan the day’s work.
On this day: Dr Bawa-Garba, a trainee paediatrician, who had not undergone Trust induction, was looking after six wards, spanning 4 floors, undertaking paediatric input to surgical wards 10 and 11, giving advice to midwives and taking GP calls.
On this day: Even when the computer system was back on line, the results alerting system did not flag up abnormal results.
On this day: A patient who had shown a degree of clinical and metabolic recovery due to Dr Bawa-Garba’s entirely appropriate treatment of oxygen, fluids and antibiotics was given a dangerous blood pressure lowering medication (enalapril) which may have precipitated an arrest.”
The case has now been put to the Court of Appeal.
So, whose fault is it? No handover, no induction, no senior support, temporary nursing staff, poor IT services, shortage of doctors … whose fault is it? Obviously the doctor’s. Why this huge disparity in the way in which hospital doctors are treated as opposed to the others? It’s not ok for the sickest of patients to die in a hospital whereas fit and healthy young men and women are allowed to die in the community with not an eye-brow raised.
Parity of esteem? Bollocks!