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Appraisal guidance needs 'immediate update' after Bawa-Garba case

Prominent GPs have reacted to a controversial High Court ruling concerning a junior doctor by saying it raises serious questions about how doctor's reflections are used and recorded, and that new guidance is now needed urgently.

The call comes after judges yesterday ruled in favour of the GMC and said Dr Hadiza Bawa-Garba should be struck off the medical register - against the ruling of the GMC's own Medical Practitioner Tribunal Service.

Dr Bawa-Garba was convicted of manslaughter on the grounds of gross negligence by Nottingham Crown Court in November, according to reports this was partly on the basis of evidence used from her own e-portfolio.

But the case has attracted considerable attention as many doctors have warned that it penalises the doctor for systemic trust failures and criminalises clinical error. 

Health secretary Jeremy Hunt said yesterday that he was 'deeply concerned' about the unintended consequences regarding doctors' ability to learn from their mistakes.

Today, the BMA has said it 'will be arranging meetings with the GMC and government in the coming weeks to discuss this case and the wider implications that flow from it'.

BMA sessional GP subcommittee lead Dr Zoe Norris, who is a GP appraiser, went further, telling Pulse: 'It’s impossible for this case not to affect patient safety. We have all been trained to be open, honest, and reflecting on the care we provide our patients.

'How can I ask colleagues to do this, knowing it can be used against them? Knowing that no matter the number of patients they have seen, how understaffed and over stretched they are, it won’t protect them from criminal charges and the GMC.'

She went onto call for an update to guidance which doctors must adhere to complete their appraisals.

She said: 'We can no longer reflect openly and honestly, so the chances to learn from our mistakes is gone. There must be an immediate change in guidance for appraisers, and doctors, to protect us all.'

The RCGP, which is responsible for appraisal guidance, said it would not comment on whether it would review this, stating only that it supported a statement the Academy of Royal Colleges put out regarding the case.

The Academy statement said: 'All staff must be encouraged and be able to reflect honestly, openly and safely, and without the fear of recrimination as part of the vital learning process. The threat of this being used in a potentially negative way may potentially promote a lack of candour as well as loss of learning opportunities.'

It added that it recognised 'that medical Royal Colleges and faculties have a role to play in helping to ensure that all doctors in training are fully supported by both clinical and educational supervisors, that there are mechanisms for safe reflective learning and standards are set that include all parts of the system'.

BMA chair Dr Chaand Nagpaul said the case had raised 'questions and concerns about how doctors' reflections, which are an important tool for learning and professional development, are used'.

He said: 'It is important that patient safety is not undermined through clinicians being deterred from engaging with reflective practices about patient care for fear of reprisal. It is vital that we promote a culture of support and openness in the NHS that addresses the root causes of the pressures undermining doctors' ability to do their best for patients.

'The BMA will be arranging meetings with the GMC and government in the coming weeks to discuss this case and the wider implications that flow from it. The goal must be to build an environment where doctors and all healthcare staff have the resources, facilities and support to provide patients with the quality of care they deserve, as well as empowering them to raise concerns if they believe they are working in unsafe conditions.'

House of Commons Health Committee chair and former GP Dr Sarah Wollaston also said she was concerned about the ruling, in response to the health secretary's comments: 'I agree there are unintended consequences from this case and whilst ministers cannot intervene in judicial process for this case there will need to be a review not only of system pressures but to make sure clinicians can learn from errors rather than fearful of discussing them.'

The GMC said on Twitter that it would soon be clarifying its own guidance on how doctors should reflect. The tweet said: 'Doctors' reflections are made for the purpose of learning and development. We don't ask doctors to provide their reflective statements if we are investigating a concern about them.

'A doctor may provide these to demonstrate they have shown insight - but this is very much up to them. We'll soon publish more detailed guidance on reflection, making clear that for education, training and revalidation purposes, reflective notes - which are potentially disclosable in court/tribunal proceedings - should normally be anonymised because the focus should be on learning.'


Readers' comments (32)

  • David Banner

    I know of one GP who reflected that he needed to improve his record keeping as he was forgetting to write up home visits. Cue an investigation from NHSE. The moral is to only mention the most trivial fluff and keep it bland, appraisal is NOT confidential, merely another avenue to persecute doctors too naive to realise that their honesty will be seized as evidence for the prosecution.

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  • I never put anything negative in my appraisal. Anything negative just dies inside me.

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  • Just Your Average Joe

    The day the medical profession was open to manslaughter charges when errors were made - despite every effort to act in good faith is the day doctors needed to change practice and become defensive and protect their reputations and careers from outside attempts to tie a noose around their necks when things go wrong, even though they were a small cog in a larger system endemic with failures.

    Why this poor doctor was made the scapegoat, not the hospital management, or the commissioners at NHSE or the home secretary or even PM for allowing failures such as this on their watch?

    The elephant in the room is clear, when you see how reflections for self review and learning can be handed to lawyers, who like sharks use her own doubts to tear her apart, breaching her right not to incriminate herself as those thoughts were not supplied under any warning that they may be used against her in the future.

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  • This comment has been moderated

  • This case speaks volumes about the support available to Drs working in the NHS. It is sad that the GMC feels so strongly that the latest judgement is truly justice,... but justice for who? For the public -that staffing levels in hospitals & the NHS will now be adequate to ensure similar incidents are prevented.
    For health professionals - if you can not work under such pressures, you either leave the UK or leave the profession, if not GMC may one day force you to leave.
    For the GMC - now the GMC can boldly give a full copy of this case to every new Dr to read before they apply for full registration, as example of the kind support the Dr should expect from their regulatory body. It is just very sad.

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  • It was only a matter of time before Charlie was at the helm whilst the GMC shot itself in the foot. Well done GMC you have just the destroyed the trust of a whole profession! Rather than pursuing this very unfortunate Dr, who was put in an impossible position by her employer and oddly absent Consultant, the GMC should have been reflecting on the circumstances both of the incident and the criminal case. Why did the prosecution go to such lengths to exclude the hospital investigation findings? Why did the judge agree to this, thus preventing the jury from hearing all the relevant evidence? This injustice and the hands on from the GMC simply stink.

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  • Council of Despair

    It's important to make this case known to all doctors. I can't see the GMC recovering from this - they simply have no credibility now.

    All prospective medical students should be told about this case (and others) - digest the implications before joining medical school.

    I can not wait to change career

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  • Two years ago I was the subject of a meretricious complaint to the GMC. It was thrown out after their medical assessor reviewed the case notes without the need for me to make any representation at all. Nevertheless in the middle of this process I was required to submit reflection on the complaint to my Responsible Officer at the local branch of NHSE. I found that a troubling idea at the time, more so now.

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  • Vinci Ho

    No doubt , the culture of the world is changing . The expectations on the ‘guardians’ of the world are radically altered. With the evolution of IT technology, social media and hence, globalisation, the reflection of competing notion of virtues any authority(government) should honour or reward , is subjected to even more open and liberal challenges . One can argue the word ‘transparency’ has got a new meaning . Clearly , our prosecution and judiciary system is under huge pressure to ‘get it right’ time to time. As a strong believer of the old doctrine of independent judicial system , I chose not to comment until this verdict was reached.

    One thing I am not sure is how general public understands the difference between murder and manslaughter, with motive(s) and without intention in homicide. Ian Patterson was struck off the GMC list because he harmed(no necessarily killed)so many patients with motives and clearly would be unsafe to let him practise medicine again in future.
    Gross negligence is an involuntary manslaughter(correct me if I am wrong ) carrying no intention to kill.
    It is difficult to revisit the original indictment in 2016 as her appeal to higher court was already rejected.
    But the action of GMC was extraordinary and questionable:
    (1) If the ‘rules’ stated GMC sanction was immediate erasure whether the indictment was murder , voluntary manslaughter or involuntary manslaughter, why was the doctor not erased immediately after the indictment?
    (2) The answer was perhaps because the power of doing that lied in Medical Practitioner Tribunal Service . And if you remember recent report in here about another case :

    There appears to be a ‘power’ struggle between GMC and tribunal services.
    As I wrote before , GMC has an old fashioned superhero-protector complex to fulfil that it clearly wants to ‘centralise’ all power in itself. This will serve the appetite of this ‘ Right OR Wrong ; Left OR Right; nothing in between’ climate of the world.
    (3) The conclusion of this present verdict is as long as one being found guilty when a patient died , one will be struck off GMC list PERMANENTLY , no matter what .
    (4) Whether the reflection process in appraisals(hence , revalidation)needs modification is only scratching the surface . Like many first generation appraisers(quit 5 years ago) , I lost the belief in the original telos of a genuinely reflective exercise which was replaced by a tick-boxing one anyway. If this case means anything, it simply adds more flaws into an exercise which has already lost people’s faith.
    (5) The system failure involved in this case , also well demonstrated the poor availability and distribution of resources(you should all know my definition of resources by now)in NHS. The fallacy of austerity and efficiency saving (not a lot people want to mention that openly these days) in NHS had a good translation in this case. All authorities ,including the government, ‘understandably’ wanted to distance themselves away .
    As it was written in Analects, ‘’When the higher authority had lost its way , people deserted losing their faith . After discerning all the details from the matter, we should only show sympathy rather than schadenfreude for those who committed a crime under such circumstances and climate.’’
    (上失其道 ,民散久矣。如得其情,則哀矜而勿喜。)Well , the higher authority here is ,of course , GMC .
    I am all for a legal challenge to Supreme Court if that is feasible and decided.

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  • Vinci Ho

    And the sake of the extraordinary irony that we , doctors , are the one funding and subscribing GMC , all of us should give our comments on this case.

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