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GPs are right to be cautious about appraisal reflections

Dr Jonathan Cusack, who gave evidence in court in defence of Dr Hadiza Bawa-Garba, says doctors can have no confidence their reflections will not be used against them in criminal proceedings

dr jonathan cusack 3 x 2

Reflective practice is the cornerstone of postgraduate medical education, although the term ‘reflection’ is often ill-defined in medical education literature, and reflective practice has not been shown to improve clinical outcomes for patients.

Despite this, the concept of reflective practice as part of professional development is now well established, and there is a good theoretical basis in most modern theories of learning.[1]

Professional regulators including the GMC require doctors to ‘regularly reflect on your standards of practice and the care you provide’, and educators to develop the reflective skills of medical students.

Recent events in the case of Dr Hadiza Bawa-Garba sent shock waves through the medical profession. While the GMC talks of encouraging learning from mistakes and the importance of a ‘just culture’, their actions have sent a very different message to the profession.

The GMC has worryingly said that third parties such as the Royal colleges may be required to disclose reflective documents

The involvement of criminal courts and gross negligence manslaughter laws in a complex case with multiple systems failings has significantly set back the patient safety agenda in the UK.

Dr Bawa-Garba made mistakes. She has always admitted to these, and apologised verbally and in writing. The Medical Practitioners Tribunal Service – set up by the GMC – felt that she had learnt from her mistakes and since the events in 2011, she had fully remediated.[3]

Despite this, the GMC used its recently granted power of appeal to overturn its own independent tribunal arm and seek punitive erasure of Dr Bawa-Garba from the medical register, a stance that its regulatory body, the Professional Standards Association, has said is ‘entirely without merit’.

Dr Bawa-Garba reflected extensively on the clinical care she gave. Documents containing her reflective comments were seen by a prosecution QC prior to his extensive cross-examination and therefore fed into the criminal court process. The GMC have stated that reflective practice was not used, and have issued a factsheet for the profession.[4] However, the Medical Protection Society, which previously represented Dr Bawa-Garba, has admitted that it ‘may well be the case’ that reflections fed into the trial.[5]

This debate has done nothing to reassure frontline doctors. The news that half of doctors have stopped or adapted their appraisal reflections in light of the case, as revealed by Pulse, is alarming – but understandable. When Dr Bawa-Garba wrote her reflective comments, she was not expecting this to be part of a criminal trial some five years later.

Royal colleges and Health Education England were quick to write to doctors to clarify that we should have no concerns about reflective practice, despite Academy of Medical Royal Colleges guidance reminding doctors that reflective documents are potentially disclosable to the courts. Similarly, the RCGP chair Professor Helen Stokes-Lampard wrote to all members highlighting the importance of reflection, while acknowledging GPs’ concern about the GMC’s handling of this case.

Yet when the Royal College of Paediatrics and Child Health sought to clarify the situation with the GMC, it was worryingly told that third parties such as the Royal colleges may be required to disclose reflective documents.[6]

Where does this leave us?

As an intensive care consultant and an educator, I firmly believe that we develop our judgement and clinical skills by reflecting on cases that went well, and on cases where we could have managed things differently. This must continue: future patient safety depends on us learning from mistakes.

Dr Bawa-Garba’s case has raised important questions that are now subject to a Government inquiry. I hope that an outcome of this is that documents produced with the intention of learning from mistakes will be subject to legal privilege, and not disclosable without the consent of the doctor.

Until such a time, doctors remain vulnerable. I would encourage GPs to:

 - Reflect regularly, with colleagues that you trust

 - Document very carefully: only write down what you would be happy to have read back to you in court

 -  Keep all reflections completely anonymous and generic

 - Record what you learnt, rather than what you think you did wrong.

Reflection is important but be careful: what you say may be taken down and used in evidence against you.

Dr Jonathan Cusack is a consultant neonatologist at University Hospitals of Leicester NHS Trust and honorary senior lecturer at University of Leicester. Dr Cusack was formerly educational supervisor to Dr Bawa-Garba.


1. Sandars, J. The use of reflection in medical education: AMEE Guide No 44. Medical teacher 2009; 31: 685-695

2. General Medical Council. Good medical practice (2014)

3. Medical Practitioners Tribunal Service. Record of Determinations 

4. GMC. Fact sheet: Dr Bawa-Garba’s case

5. Dyer C and Cohen D. How should doctors use e-portfolios in the wake of the Bawa-Garba case? BMJ 2018; 360: k572

6. Royal College of Paediatrics and Child Health. News statement


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Readers' comments (8)

  • It is disappointing but unsurprising how many major institutions have given completely double-speak advice and “reassurances” regarding reflection in recent times. Thanks for being so straight.

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  • What people haven't realised is that none of this data is legally privileged. It doesn't have to be shown to a judge or jury to form the basis of a case against you. If you write, 'I looked through the research and learned more about x' or I would do y differently next time then you've already supplied an argument that you acted negligently to be used against you, not just in court but also in any of the many complaint processes you may have to answer to. To make matters worse the amount of data collected is massive, insecure, and can be widely analysed and shared, such is the nature of cloud based systems. Privacy is a thing of the past.

    There is no place for reflection in modern UK medicine, it's simply to risky. You're far better off writing short notes on a topic and committing them to memory.

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  • David Banner

    Finally we have the truth.
    Beware those confessions festering in your appraisal folder that ambulance-chasing litigators will gleefully exploit. If your appraiser is a stickler, then reflect on trivial fluff.
    Only a naive fool would reflect on a late cancer diagnosis rather than a “How dare you call me obese?!” complaint.

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    Once you submit your appraisal .. thats it .. you cannot go back and redact the past comments...
    Either your own .. or your appraisers perception or understanding..
    What if you were to change the appraisal providing service after each revalidation marker?

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  • Missed cancer diagnosis while trying to help is equivalent to Gross negligence manslaughter. Not much difference to sticking a knife in someone intentionally. That is how we are treated now. Reflect at your own peril for a nice jail sentence.

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  • Dr Cusack, is it true that the evidence that the mother, off her own bat, gave a crucially deleterious drug to the child at a crucial moment in the natural history of the illness on that day was NOT put to the court because (and I have read various formulations) it would have needlessly upset the family of the deceased child at the time?

    You were there. What is the truth?

    I think it is fair to reflect that the omission ' upset' Dr BG's cause

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  • Secure environments GP

    Some of us have been saying this for years. This poor doctor has been desperately mistreated and let down by an intolerable system stacked against hard working doctors trying their best in toxic underfunded NHS.

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  • Dr Cusack, Please let us know the mistakes that Dr BG admitted to making. I, for one, and many others cannot see what they were.
    Every paper states the same thing. What mistakes, please ?
    From my perspective, if the blood tests were so obvious, why did the Consultant not spot it immediately?
    Was poor Jack getting better or not? I read he was bouncing about at 1630. Was he ?
    Whose decision to transfer Jack to another ward? And why? Was he much better?
    If he was well enough for transfer, was it quite simply the ACEI that caused catastrophic hypotension ? How can we say it was not so certainly?
    Every doctor whose has read these articles in the papers think it was the ACEI that killed an improving child.
    So please tell us the mistakes in the context of her work in 2011.

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