Dr Hadiza Bawa-Garba: What led to six-year-old Jack Adcock's death?

Junior doctor's conviction sparks outrage from medical community who raised concerns over apparent failure to consider exceptional pressures faced by NHS staff

Lucy Pasha-Robinson
Tuesday 30 January 2018 18:36 GMT
Hadiza Bawa-Garba: Doctor at centre of sepsis death case should be able to return to work Court of Appeal rules

The case of Dr Hadiza Bawa-Garba rocked medical circles after she was stripped of her medical licence following the death of a six-year-old boy with Down’s Syndrome.

The junior paediatrician was convicted of manslaughter by gross negligence and given a two-year suspended sentence for mistakes which led to Jack Adcock’s “needless death” in 2011.

But the decision has sparked anger from the medical community, with many raising concerns the High Court case failed to look at medical realities, including exceptional pressures faced by NHS staff and system-wide failings.

Here’s a timeline of the key events surrounding Jack’s death and Bawa-Garba‘s conviction:

18 February 2011

Jack is admitted to the Children’s Assessment Unit (CAU) at Leicester Royal Infirmary following a referral from his GP.

He has Down’s Syndrome, a known heart condition and has been suffering from diarrhoea, vomiting and difficulty breathing.

He is treated by Bawa-Garba, a specialist registrar in year six of her postgraduate training (ST6).

The trainee had recently returned from maternity leave and was solely in charge of the emergency department and acute Children’s Assessment Unit that day as there was no senior consultant available.

Jack Adcock

There was also an IT failure which led to delays in obtaining test results.

Bawa-Garba did make mistakes, including failing to ask a consultant to review Jack’s condition during the afternoon handover meeting and confusing him with another patient causing her to briefly put a stop to CPR – though this was not deemed to have contributed to his death.

She also failed to specify that the Enalapril medicine Jack took for his heart condition should be discontinued, and his mother gave him his evening dose at 7pm.

At 8pm, Jack “crashed” and Bawa-Garba responded.

At 9.20pm, Jack died of a cardiac arrest as a result of sepsis.

2 November 2015

Nurse Isabel Amaro, 47, of Manchester, is given a two-year suspended jail sentence for manslaughter on the grounds of gross negligence.

Prosecutor Andrew Thomas QC said her record-keeping was “woefully incomplete” and failed to monitor Jack’s vital signs.

He said: “The prosecution say that these were major failings which contributed significantly to the overall deficiencies in Jack’s care.

“If nurse Amaro had brought any of these to the attention of her senior nursing and medical colleagues, this should have led to urgent reassessment and initiation of further treatment to improve Jack’s condition.

“It was a needless death.”

She has since been struck off the register and is no longer able to work as a nurse or a midwife in the UK.

4 November 2015

At Nottingham Crown Court, Bawa-Garba is convicted of manslaughter on the grounds of gross negligence.

Mr Thomas said she has “failed to discharge her duty” as the responsible doctor.

“In short, she neglected her duty to care for Jack,” he said.

Hadiza Bawa-Garba arriving at Leicester Magistrates Court

“It was not just a momentary lapse. The prosecution say that Jack’s care was neglected over a protracted period of time: her failings were compounded by a failure to go back and reassess Jack despite clear indications that his underlying condition was continuing.

“These were not just simple breaches of duty, but really serious breaches amounting to gross negligence.”

14 December 2015

Bawa-Garba is handed a two-year suspended sentence.

8 December 2016

Bawa-Garba’s appeal against her sentence is denied at the Court of Appeal.

13 June 2017

Bawa-Garba is suspended from working for 12 months by the Medical Practitioners Tribunal Service (MPTS). It rejects an application from the General Medical Council to strike her off the register, saying: “In the circumstances of this case, balancing the mitigating and aggravating factors, the tribunal concluded that erasure would be disproportionate.”

8 December 2017

The GMC appeals the MPTS ruling at the High Court. It argues it was “wrong” to allow Bawa-Garba to continue to practice medicine.

25 January 2018

Bawa-Garba is struck off the medical register after a successful appeal by the GMC. Lord Justice Ouseley said: “The Tribunal did not respect the verdict of the jury as it should have. In fact, it reached its own and less severe view of the degree of Dr Bawa-Garba’s personal culpability.”

But Health Secretary Jeremy Hunt warns he is “deeply concerned” about the implications of the decision.

The medical community voice fears surrounding the impact of a “blame culture” in the NHS. Thousands of doctors sign a letter warning there will be wide-ranging consequences from the ruling which they say will make doctors working in the overstretched NHS more risk-averse and less likely to admit mistakes.

26 January 2018

Medics raise over £200,000 to fund an independent legal team to review Bawa-Garba’s case and potentially challenge the original ruling of causing manslaughter by gross negligence.

“For large numbers of the medical profession who have read this account, the clinical circumstances surrounding Jack’s death sound exceptionally horrific, with Dr Bawa-Garba struggling against all odds to keep her young patients safe and undertaking the roles of 3 or 4 doctors in the absence of her supervising clinical consultant,” the medics in charge of the fundraising page wrote.

“It seems clear to us that even the most competent junior doctor would struggle to keep children safe under such conditions.”

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