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Independents' Day

Revealed: how reflections were used in the Bawa-Garba case

Jaimie Kaffash and Julia Gregory investigate whether doctors should be worried about their reflective practice

The health secretary, the medical royal colleges and the BMA have been unusually united this week: doctors should be allowed to be honest and reflective with no repercussions.

This has come about as a result of the case of Dr Hadiza Bawa-Garba, the junior doctor who was convicted of manslaughter for the death of a six-year-old boy and struck off the medical register last week.

Much of the concerns centre around the use of Dr Bawa-Garba’s own reflections in her e-portfolio, and admission of culpability – which were reportedly used in the case against her.

We have to make sure doctors learn from mistakes

‘If we are going to keep patients safe, then we have to make sure that doctors are able to learn from mistakes,’ Mr Hunt told the Today programme on BBC Radio 4.

Some have even urged a complete boycott on including reflection in appraisals. BMA sessional GP subcommittee lead Dr Zoe Norris, who is a GP appraiser, told Pulse she wants a change in guidance: ‘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.’

dr hadiza bawa garba jack mount death richard vernalls pa archive pa images pa 22026705 square

dr hadiza bawa garba jack mount death richard vernalls pa archive pa images pa 22026705 square

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

However, MPS – which represented Dr Bawa-Garba – has issued a statement to say that her e-portfolio reflections were never submitted to court, and encouraged all doctors to continue to engage in reflective practice.

Dr Pallavi Bradshaw, senior medicolegal adviser at Medical Protection, said: ‘The judgement from the high court to erase Dr Bawa-Garba from the medical register is disappointing and its implications will understandably be of concern to the healthcare community.

‘One particular area of anxiety was the purported use of Dr Bawa-Garba’s e-portfolio at the criminal trial. This has been widely misreported, as the e-portfolio did not form part of the evidence before the court and jury.’

This is corroborated by the prosecution QC, Andrew Thomas, who told Pulse: ‘As the MPS statement confirms, the reflection document did not feature at all in the Crown Court trial, so there is no question of Dr Bawa-Garba being asked any questions about it.’

So can doctors all feel reassured that their reflections, in an e-portfolio or appraisal, will not be used against them? Yes, and no.

Pulse has seen a transcript of the judge’s summing up and instructions to the jury in Nottingham Crown Court in 2015. The 160-page document makes no mention of Dr Bawa-Garba’s own reflections, and certainly no admissions of culpability.

The court was clear that reflections were irrelevant 

Indeed, as Dr Bradshaw adds: ‘The court was clear that reflections were irrelevant to the facts to be determined and that no weight should be given to remarks documented after the event.’

But there is more to this. It’s true that Dr Bawa-Garba’s reflections in her e-portfolio were not submitted to court. However, elements of her e-portfolio were included in materials seen by expert witnesses.

Dr Martin Samuels, a consultant at Great Ormond Street Hospital and an expert witness for the defence, told Pulse: ‘In the preparation of my report, I did see some of the e-portfolio. It didn’t include reflections, but it did include trainer assessments.’

Dr Jonathan Cusack, Dr Bawa-Garba’s supervisor and a consultant neonatologist at Leicester Royal Infirmary told Pulse he had ‘full sight and helped her write her reflections’, but he was asked not to bring documents to court when he gave evidence at the trial in 2015.

‘I was asked to give evidence with no documents, ‘ he said. ‘I was just cross examined about Hadiza,’ he says.

He says that Dr Bawa-Garba actually wanted her e-portfolio reflections to be in the defence’s bundle of evidence, but Pulse understands from the MPS this did not happen.

But it is clear that Dr Bawa-Garba’s verbal reflections were used in court, in the form of evidence given by Dr Stephen O’Riordan, the consultant on-call on the day Jack Adcock died.

Dr Samuels said that he was aware that the parties in the case had sight of a document prepared by Dr O’Riordan after he had a reflective meeting with Dr Bawa-Garba: ‘That was prepared and widely available.’

An MPS spokesperson also said: ‘Dr Bawa-Garba did indeed meet duty consultant Dr O’Riordan after Jack’s death to discuss the incident and learnings – this is standard practice. Dr O’Riordan’s own notes following this discussion formed part of his witness evidence.’

It is unclear what weight the jury put on this evidence, as it is not mentioned in any of the judge’s summing up or sentencing statements, but the idea that a doctor’s personal reflections to a senior member of staff can be used in this way will cause much disquiet among doctors who are encouraged to have a ‘duty of candour’ at all times.

It also has implications for the safety of the health service and how the system learns from tragic events – such as Jack Adcock’s death. If doctors feel that their co-operation may be used in a criminal trial and/or help end their medical career, how honest will they be?


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Readers' comments (18)

  • We have been saying this for a while that reflections could be used against us but no one listens' for one keep them to a minimum but always get told off by appraisers for not reflecting enough.i think maybe I was right in the long run.

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  • Your reflections can indeed be used against you in a court of law . We are trained to reflect and be introspective, and the culture created by medical training in the UK expects us to be self effacing and remorseful in events that did not go well . We are under pressure to always state ' what could I have done better 'even if nothing could have been done differently ! Otherwise we will not pass ARCP panels .The same is now expected in revalidation portfolios and appraisals.

    Hence these self immolatory reflections have incriminatory phrases and elements which can be used against us in court , especially if viewed by lay people /lawyers.It is rich fodder to incriminate !

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  • Took Early Retirement

    Yup- Zoe is correct, but don't wait for guidance. Stop reflection NOW. (Or at least recording it.) It's navel-gazing anyway.

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  • The tragedy of the cardigan writ large. How did Shipman (" on reflection may be I shouldn't have murdered my patients") lead to all this forced reflection hogwash?

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  • Shame on Pulse and the rest of the medical press for misreporting this issue and causing mass hysteria. Your headline should make it clear that Dr Bawa Garba's e-portfolio was not considered by the trial jury at all. Your article begins by perpetuating the myths that you, the press, created. The way this whole tragic case has been reported has been irresponsible and unbalanced. Whether we like the verdict or not, Dr Bawa Garba was convicted of a very serious offence by a jury applying the criminal threshold of 'beyond a reasonable doubt'. Are doctors above the law?

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  • I agree misleading headline.Does not make it clear until the end of the article that the e portfolio did not play any part in the consideration of the jury.

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  • Hey, "Misreported", trial by jury of doctors in situations like this is dubious to say the up on the Jayant Patel case in Queensland. He was dubbed DrDeath by the local media BEFORE his trial. Juries are TOO easily swayed by emotions. It was totally obvious the manslaughter charges to Patel could not be substantiated and it was a witchhunt with racist undertones and their were huge systemic failings left unaddressed AND he was set free on appeal.

    The mitigating circumstances in Bada-Garba case are enormous- undeniably so.

    Where the hell was her consultant, by the way??

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  • Thank you Monty for your response. Using words like ‘racist’ and ‘witch hunt’ demonstrates that unlike the jury (you say is swayed by emotion) you are much more logical and dispassionate.

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  • I am completely baffled by this case. Did not a single other doctor see this child from 1130 to 2000 hours. Are there no other Housemen, SHOs, Registrars, Consultants in a tertiary paediatric centre like Leicester Infirmary? If the child got better, then surely Dr Bawa had no reason to be concerned. If he got worse, was there not one single other doctor informed ? Are there ward rounds ? What is going on? And finally, from m understanding this child with shock, although improving was given Enalapril, that could be argued to have caused a catastrophic drop in Blood pressure, when it had NOT been prescribed by Dr Bawa? Are we now expected to tell ALL relatives Not to give medication ?
    It is just baffling. What is this, only ONE doctor for over 8 and half hours ?

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  • Bornjovial

    *.*, the consultant on-call on the day Jack Adcock died. Did he review patients in ward rounds?. Why was he away from the hospital that day. How come his notes were used when he should be questioned as well?

    The judge and Jury make decision on the information provided to them.
    I am not sure the information provided was accurate, without bias (of self preservation) and complete.

    I suspect the original manslaughter verdict may not stand the rigor of retrial.

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