Sunday, February 18, 2018

What were the mistakes in Dr Bawa Garba Case?

Dr KK Aggarwal
Recipient of Padma Shri

In 2015, Dr Bawa-Garba and the two nurses were charged with manslaughter by gross negligence following the death of Jack Adcock, a 6-year-old boy with Down syndrome in 2011.

The case against the pediatric resident was that she wasn't just clueless but grossly negligent.

Wrong working diagnosis: Missing diagnosis of sepsis

At 10:30 am, Dr Bawa-Garba assessed Jack Adcock, a 6-year old boy with Down syndrome who was referred by the general practitioner (GP) for nausea, vomiting, and diarrhea and low BP. It is not wrong to treat on the lines of hypovolemia.

She made a presumptive diagnosis of fluid depletion from gastroenteritis and administered an intravenous fluid bolus immediately and started him on maintenance fluids. She requested a chest radiograph; sent off bloods for blood count, renal function, and inflammatory markers; and drew blood gases, which showed that Jack was acidotic with a pH of 7 and a lactate of 11.

The metabolic profile confirmed her working diagnosis of shock from gastroenteritis; but, judging from the tests she ordered, pneumonia was in her differential. After the initial fluid bolus, Jack seemed to be trending in the right direction, metabolically. The repeat blood gas showed he was less acidotic, with a pH of 7.24, heading towards a normal pH of 7.4.

Delay in getting and reading chest x-ray

Fact: At 3 pm, she looked at the chest x-ray, which showed Jack had pneumonia. She prescribed antibiotics, which were given at 4 pm. The radiograph had been exposed at 12:30 pm.

Radiographs are not routinely interpreted by radiologists; there aren't enough radiologists in the NHS.

Delay in starting antibiotic

Argument: Had Jack received antibiotics within 30 minutes, rather than 6 hours, his chances of survival would have increased dramatically.

Fact: Antibiotic was given the time pneumonia was confirmed. Starting antibiotics in every case presenting in such situation may amount to misusing the antibiotics.

Also missing sepsis cannot be called manslaughter; at the most it can be an error.

Not calling her senior

Fact: At 4:30 pm, she met Dr O'Riordan, her boss, in the hospital corridor. She showed him Jack's blood gas results and explained her plan of action. Her boss did not see Jack.

When asked why he did not see Jack, Dr O'Riordan said that Dr Bawa-Garba had not asked him to; she had not impressed upon him Jack's clinical urgency.

Was the onus not on the consultant to sniff out trouble?

Guilty of homicide for mistaking normalizing pH after a fluid bolus for hypovolemic rather than septic shock

Facts: The jury heard about Jack's delayed treatment. But they did not hear about the other patients who were receiving care in the same hospital from Dr Bawa-Garba.

Jack's blood gases were deemed characteristic of sepsis. If they were so characteristic, why did Dr O'Riordan, the peripatetic consultant of the day and Dr Bawa-Garba's supervisor, not instantly diagnose sepsis when he saw the blood gases?

If a resident, who was doing the work of three registrars, can be found guilty of homicide for not understanding acid-base physiology, what does it say about the competence of her supervisor?

Failing to prevent enalapril being given 

In the ward, Jack received enalapril. Dr Bawa-Garba had not prescribed enalapril, and she clearly stated in her plan that enalapril must be stopped. Nor was enalapril given by the nursing staff—they stick to the doctor's orders. An hour after receiving enalapril, Jack had a cardiac arrest.

Fact: The drug was given by the mother and the allegation was that the team did not tell the family not to give any drug outside the hospital practice. Is it not the law?

DNR mix-up

After vigorous attempts at resuscitation, interrupted for a minute by Dr Bawa-Garba mistaking Jack for another child who was not for resuscitation, Jack was pronounced dead.

Fact: The interruption for only for a few seconds and could not have been the cause of failed CPR.

Writing honestly in the e-process log

She was honest and wrote her feelings in the e-process log which was later used against her as evidence.

After Jack's death, Dr Bawa-Garba was distraught, and her consultant encouraged her to record her failings in her electronic portfolio. Trainees are encouraged to record their mistakes. She could have, if she wanted, written about the system failures of that day. But that would have been making excuses, and you don't stick around in a field like pediatrics if you're the sort who points fingers at others. But was this not her mistake?

The most merciless expert witness was none other than Dr Bawa-Garba herself. Her electronic portfolio became her confession. She erred because she had confessed to erring.

Was it the failure of a doctor?

The trust led an internal inquiry that identified several system issues that contributed to Jack's death. Medical errors can be caused by system issues and physician factors. The American patient safety movement has taken the high road and placed the blame for medical errors on systems. The Tort system targets both individuals and systems. The truth is that both can contribute.

Not raising an alarm on inadequate staff and system failures

Dr Bawa-Garba's supervisor, Dr O'Riordan, was not in the hospital but teaching in a nearby city.

Dr Bawa-Garba's colleagues (i.e., other registrars) were also away on educational leave. Normally, a registrar each is assigned to cover the wards, the emergency department, and the Children's Assessment Unit (CAU).

On that day, Dr Bawa-Garba covered all three. She was new to the hospital but with no formal induction (i.e., no explanation where things are and how stuff gets done in the hospital). She was expected to get along with the call and find her way around the hospital.

Registrars are the principle decision-makers in hospitals; they function as both a senior resident and an attending.

Should she have raised an alarm and wrote about the deficiencies in the system?

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

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