Professor Russell Viner, President of the Royal College of Paediatrics and Child Health (RCPCH), said:
When a child dies, the impact on the family is unimaginable. The trauma also deeply affects those healthcare professionals who have looked after that child. The recommendations in this review, if enacted, have the potential to reduce the number of preventable deaths by shifting the culture within the NHS away from blame and towards learning from errors.
Mistakes are sadly inevitable but the consequences of those mistakes need not be so catastrophic if the right systems are in place to mitigate them.
The case of Hadiza Bawa-Garba has had a profound effect on paediatricians and the wider medical professional. The accounts of systemic errors, short-staffing, IT issues and lack of support for this particular trainee that contributed to the tragic death of a child have led trainees to tell us they carry a sense of trepidation before the start of every shift. Many have experienced ‘that shift’ that could easily have ended in disaster.
It is heartening that the review stresses that the public recognise the pressure on healthcare professionals who are working in an overstretched system and also that serious harm to patients is very rarely the result of an error made by one individual. We support the recommendation that, when there is significant criminal investigation into an individual, the systems around them must also be investigated. This is not about shifting blame or accountability, but recognising that individuals operate within a wider environment and should not become scapegoats – and that failings of the system at large need to be addressed.
The report states, and the GMC (General Medical Council) has accepted, that its handling of the Bawa-Garba case has damaged its relationship with the medical profession. This was undoubtedly the sense from many of our members. We therefore wholeheartedly support the recommendation that the GMC should not be able to appeal decisions by the Medical Practitioners Tribunal Service – and we call on government to make the necessary legislative changes promptly to ensure this is the case. As we said during the Bawa-Garba case, the GMC must be clear with the public and the medical profession about its role in investigations if trust is to be rebuilt.
The RCPCH also supports the recommendation that police investigating cases should have access to independent medical advice to help with decisions on whether to take investigations further. Individuals involved in criminal proceedings must have proper support in place and it should be made clear what is expected of them. Coupled with this, there must be transparency both for clinicians and the public as to how decisions are made. If this doesn’t happen, there is a grave risk that future clinicians will be put off entering the profession, further exacerbating existing workforce pressures.
The emphasis of the report on reflection is absolutely right; only through reflecting on errors can clinicians learn from mistakes and outcomes for patients improve. The threat of criminal investigation does not result in fewer errors and only through building a culture of trust and reflection can progress be made.
The RCPCH supports the recommendations in this review and our concerns have clearly been listened to. We stand ready to work with the GMC and other agencies to ensure they are implemented, and to support our doctors during investigations. We are also committed to helping ensure that every paediatrician returning to work after a period of absence has the necessary support in place to reduce the likelihood of errors occurring.
This is a welcome report – but the burning question now for those who own the actions is how quickly will they be delivered? With other Medical Royal Colleges, we will move urgently to do our part.