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