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Bawa-Garba: timeline of a case that has rocked medicine

What happened and when

18 February 2011

A six year old boy is admitted to the Children’s Assessment Unit (CAU) at Leicester Royal Infirmary following a referral from his GP. Jack Adcock, who had Down's Syndrome and a known heart condition, had been suffering from diarrhoea, vomiting and had difficulty breathing.

Dr Hadiza Bawa-Garba was a specialist registrar in year six of her postgraduate training (ST6) with an 'impeccable' record. She had recently returned from maternity leave and this was her first shift in an acute setting. She was the most senior doctor covering the CAU, the emergency department and the ward CAU that day. She saw Jack at about 10.30am.

Jack was receiving supplementary oxygen and Dr Bawa-Garba prescribed a fluid bolus and arranged for blood tests and a chest x-ray. At 10.44am the first blood gas test was available and showed a worryingly high lactate reading. The x-ray became available from around 12.30pm and showed evidence of a chest infection.

Dr Bawa-Garba was heavily involved in treating other children between 12-3pm, including a baby that needed a lumbar puncture. At 3pm Dr Bawa-Garba reviewed Jack's X-ray (she was not informed before then that it was available) and prescribed a dose of antibiotics immediately, which Jack received an hour later from the nurses.

A failure in the hospital's electronic computer system that day meant that although she had ordered blood tests at about 10.45am, Dr Bawa-Garba did not receive them until about 4.15pm. It also meant her senior house office was unavailable.

During a handover meeting with a consultant which took place about 4.30pm, Dr Bawa-Garba raised the high level of CRP in Jack's blood test results and a diagnosis of pneumonia, but she did not ask the consultant to review the patient. She said Jack had been much improved and was bouncing about. At 6.30 pm, she spoke to the consultant a second time, but again did not raise any concerns.

When she wrote up the initial notes, she did not specify that Jack’s enalapril (for his heart condition) should be discontinued. Jack was subsequently given his evening dose of enalapril by his mother after he was transferred to the ward around 7pm.

At 8pm a ‘crash call’ went out and Dr Bawa-Garba was one of the doctors who responded to it. On entering the room she mistakenly confused Jack with another patient and called off the resuscitation. Her mistake was identified within 30 seconds to two minutes and resuscitation continued.

This hiatus did not contribute to Jack’s death, as his condition was already too far advanced. At 9.20pm, Jack died.

2 November 2015

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

4 November 2015

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

14 December 2015

Dr Bawa-Garba is given a 24 month suspended sentence.

8 December 2016

Dr Bawa-Garba's appeal against her sentence is quashed at the Court of Appeal.

13 June 2017

The Medical Practitioners Tribunal service says Dr Bawa-Garba should be suspended for 12 months and rejects an application from the GMC to strike her off the register. It says: ‘In the circumstances of this case, balancing the mitigating and aggravating factors, the tribunal concluded that erasure would be disproportionate.’

8 December 2017

GMC takes the MPTS to the High Court and argues its own tribunal was 'wrong' to allow Dr Bawa-Garba to continue to practise.

25 January 2018

The GMC successfully appeals at the High Court bid to have the MPTS decision overruled, leading to Dr Bawa-Garba being struck off the medical register. Lord Justice Ouseley says: '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.’ Health secretary Jeremy Hunt says that he is 'deeply concerned' about its implications.

26 January 2018

Prominent GPs tell Pulse that the ruling raises serious questions about how doctor's reflections are used and recorded, and that new guidance is now needed urgently.

30 January 2018

An influential international doctors group accuses the GMC of treating black and minority ethnic doctors ‘differently and harshly’, following the High Court case.

In light of the Dr Bawa-Garba case, the GMC announces a review of how gross negligence manslaughter is applied to medical practice, which was initially led by Dame Clare Marx and later taken over by Leslie Hamilton after Dame Clare was appointed the next GMC chair. Meanwhile, an influential international doctors group accuses the GMC of treating black and minority ethnic doctors ‘differently and harshly’, following the High Court case.

31 January 2018

Dr Bawa-Garba’s defence body releases a statement saying e-portfolio reflections were not used against her in court, despite ‘wide misreporting’ that they were. But Pulse uncovers that her reflections were used in court, from a document submitted as evidence by the on-call consultant on the day.

6 February 2018

Former health secretary Jeremy Hunt announces a review into the application of gross negligence manslaughter charges in medicine in light of the Dr Bawa-Garba case.

7 February 2018

Following a crowd funding campaign, which raised over £335,000, Dr Bawa-Garba decides to appeal the ruling, and considers appealing the manslaughter conviction from 2015.

12 February 2018

The GMC refutes claims that there was discrimination in its decision to launch a High Court bid. In response to an open letter from the British Association of Physicians of Indian Origin (BAPIO), the GMC said the accusations were ‘troubling and without merit’.

19 February 2018

The GMC is criticised by their regulator, the Professional Standards Authority (PSA), for striking off Dr Bawa-Garba from the medical register. The PSA said the bid was ‘without merit’, according to an unpublished review of the case.

13 March 2018

GMC chair Professor Terence Stephenson says he is ‘extremely sorry’for the distress caused to the medical profession by the Dr Bawa-Garba case.

19 March 2018

University Hospitals of Leicester NHS Trust releases its serious incident report in to the death of Jack Adcock, which was completed six months after his death. The report says that there was no ‘single root cause’ behind the six-year-old's death.

29 March 2018

Dr Bawa-Garba is granted permission to appeal the High Court’s decision to allow the GMC to strike of the junior doctor. Meanwhile, the BMA applies and is later permitted to advise the Court of Appeal in the case.

23 April 2018

The GMC announces the launch of its review into why black and minority ethnic doctors are more likely to face complaints from employers than their white colleagues, which is to be co-led by researcher Roger Kline and Dr Doyin Atewologun.

11 June 2018

Department of Health and Social Care’s ‘rapid review’ into medical gross negligence manslaughter concludes that the GMC should longer be able to appeal decisions made by its own tribunal regarding fitness-to-practise decisions.

27 June 2018

The BMA supports a vote of no confidence in the GMC in light of the Bawa-Garba case at its Annual Representative Meeting.

3 July 2018

Despite the conclusions of the DHSC's 'rapid review' in gross negligence manslaughter, the GMC tells Pulse it is not intending to halt appeals against its own fitness-to-practise tribunal until the law is changed.

25-26 July 2018

Dr Bawa-Garba’s appeal of the High Court decision that saw her struck off the medical register is heard in the High Court over one and a half days. Dr Bawa-Garba said after the hearing that she is ‘whole-heartedly sorry’ for her mistakes, while Jack’s mother Nicola Adcock says she ‘will cause a public uproar’ if Dr Bawa-Garba is reinstated.

13 August 2018

The Court of Appeal judges rule in favour of Dr Bawa-Garba, restoring the MPTS decision that she should be suspended from the medical register rather than erased. The judges said the matter has been passed to the MPTS 'for review of Dr Bawa-Garba's suspension'. 

20 December 2018

The Medical Practitioner Tribunal Service (MPTS) decides to extend the suspension of Dr Hadiza Bawa-Garba by a further six months, saying the measure is 'appropriate' to 'protect the public'.

13 March 2019

The MPTS announces a two-day review hearing for Dr Bawa-Garba set for 8 and 9 April 2019. The hearing will decide whether her fitness to practise remains impaired and whether she is deemed fit to return to work. 

8 April 2019

The MPTS rules that Dr Bawa-Garba' the fitness to practise remains impaired, due to her lack of face-to-face patient contact while she was under suspension, agreeing that the risk of her putting another patient at an unwarranted risk of harm is low.

9 April 2019

The MPTS decides that Dr Bawa-Garba will be able to return to practice from July 2019 - under certain conditions - but she does not intend to return to work until February 2020, when her maternity leave finishes. The MPTS argues that the public interest has been served already by her cumulative suspension and that any higher sanction would be 'disproportionate and punitive'.

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Readers' comments (57)

  • @Glasgow-Trainee . Thank you for the link. Having read the whole document including point 33 my faith in the judicial process has been shaken.

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  • Simply outraged at this whole case against this Dr. If she ever reads this I suppose I just want her to know she has my full support. Disappointed to put it mildly in the GMC and the course of action they have taken.

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  • Quite simply the MPTS decides ' in the circumstances' that suspension is the fairest sanction.
    However, the jury had taken a ' more severe view', and the judges feel that the jury view is more important in this matter than the MPTS view.
    From my perspective, I could have easily made a similar error as Dr. Garba in those circumstances ie covering 3 other colleagues, computers down etc. No matter how good I may be at medicine, no matter how caring I am, circumstances such as severe lack of staff, facilities, computer results can contribute to my error, for which I will be severely punished.
    So, let it be known widely, we doctors can be convicted of manslaughter and struck off for circumstance deficit. Should anyone do Medicine, if we are to be punished for circumstance?

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  • It seems she worked at least 6 years in this country. Does she has any other negligence on her record in past or following this case to label her negligent for rest of her life?

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  • I have to agree that the statement in the timeline ‘When she wrote up the initial notes, she did not say that Jack’s enalapril (for his heart condition) should be discontinued’ is inaccurate. Omitting enalapril from the Kardex is a clear indicator that it should be discontinued. Yes an argument can be made that this should also have been documented in the medical notes, but given that the enalapril was given by a relative who would not have access to the notes it is hard to see how this would have altered the outcome? It seems the jury concluded that Dr Bawa-Garba’s decision to stop enalapril should have been communicated to the family, but given her numerous responsibilities that day and the pressure she was under I think many of us would have done the same thing. We assume kardexes are respected and I find it hard to understand how she can be held culpable for an unprescribed medication being given without her knowledge. Shakes my faith in the fairness of our justice system! The article above should be amended to reflect the true circumstances around the administration of enalapril as it is misleading.

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  • We have added in more information regarding this

  • Council of Despair

    i'm really confused - what error did she actually make?

    i think many of us would have made similar decisions in the same circumstances so in that case should we all be struck off?

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  • A very sad case but looking beyond from a doctors perspective I can't believe that a year 6 paediatric trainee registrar in the System not a new or a locum doctor commits a mistake in what might not be a barn door case of sepsis in a child who already had health issues and being made a scapegoat, case reopened despite the doctors and even the health secretary opposing it, the GMC should be there to support and protect doctors not punish them for any mistakes...how can one convict a doctor working in good faith umdr man slaughter...shameful state of affairs I am afraid and makes the health professionals more and more vulnerable and unprotected and most of all unsupported.

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  • Having now read more widely about this case I have made a donation to Crowd Justice and hope enough money is raised to not only enable Dr Bawa - Garba to overturn the latest ruling but also to engage a top legal team to look at the way the evidence was presented in her manlaughter trial . She was originally refused an appeal but it is hard to see how the jury reached their conclusion unless the evidence was presented in an oversimplified manner that ended up misleading them. The timeline presented in this article is a good example of how presentation of facts can be misleading.

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  • All doctors urgently need to redefine what they regard as ‘a safe workload’.
    We all know that the NHS will ground to a halt when we do this, as it means we will not accept workloads that cause us stress.
    So be it.
    We have received the message, load and very clear.
    And I would like to get something straight here- are we actually witnessing all this over the fact that a doctor is being held to blame over a dose of enalapril administered by someone else, a relative, when it wasn’t for administration on the kardex?
    And what about the portgugese agency nurse Isabel Amaro

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  • There’s multiple other criticisms in a massive chain of factors, but what’s ruffling feathers specifically about the enalapril part of the story is the absolute certainty on the part of the judge that it isn’t a novus actus interveniens. I hate the victim blaming side of bringing it up, but it’s daft to a) blame the doctor for not considering the possibility that an in prescribed med would get given when she’s too stretched to communicate it as being withheld but has correctly intentionally omitted it from the kardex which would be a safe practice in most hospitals and b) dismiss its role in causing a septic kid with renal failure to crash. Isobel Amaro has been punished significantly but just didn’t get the public shaming that Dr B-G has received but shouldn’t be dragged through the mud any further as it benefits no one. The whole point in the backlash from doctors is the isolation of an individual as scapegoat for systemic problems and we should avoid committing the same sin as the GMC.

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