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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.

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.

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’.

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Readers' comments (55)

  • Vinci Ho

    Putting aside the sentimentality as a result of this verdict, I would want to discern the facts from this matter like this:
    (1) The original indictment was manslaughter . And I would be surprised the label was anything other than involuntary manslaughter (in contrast to voluntary) because this was criminal (gross) negligence with no intention of committing murder(mens rea) . She had served for her sentence for manslaughter but the question left was whether she could carry on practising medicine or not?
    (2) The legal challenge from GMC was the Medical Practitioner Tribunal Service’s recommendation of 12-month suspension was incorrect and she should be removed from the GMC list to protect the public . According to Lord Justice Ouseley, her personal culpability carried so much bearing in causing death of the patient that she would be a harm to the public if allowed to carry on practising .
    (3) Here is the appetite for an appeal to Supreme Court: Does this personal culpability in this involuntary manslaughter (with no intention to murder) equate to the immediate conclusion that she would be a harm to the society if she was to be allowed to practise medicine after some other sanction(s) ? The 12-suspension was incorrect . What about 24 , 36 , 48 months etc suspension instead? Are the current criteria to judge whether she would be a harm to society practising more medicine ,being properly challenged in court? If John Worboys , the black cap rapist convicted of 19 serious sex crimes, was allowed to be released after 9 years and now being confirmed as no threat to the public , the sanction(s) on this doctor’s career cannot be a permanent one.
    (4) Would be essential to know if there are previous case references to refer to in the legal literature. But , otherwise , this case will set a new example and reference for future cases , which is exactly what MPS was concerned of.

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  • Council of Despair

    This whole situation is very sad. It's very sad for the family and for Dr Bawa-Garba and her family. I hope they are all getting the support that they need but a few points;

    1. The public have been given the impression that we have to provide perfect care - this is impossible. Doctor's have good and bad days and our job is risk based so mistakes occur all the time.

    2. A concientious Doctor will be devestated when errors occur and I'm sure all the clinicians involved are upset over this tragedy. However, because out job is risk based and there is alaways the probability of error if you aim to get rid of doctors without giving them an oppurtunity to learn then you are going to run out of doctors as all of us have or will commit errors in time. It creates a 'lottery' career. You know at some point you are going to make a mistake that will cost you your job so why bother?

    3. this will push all of us to a non-risk taking mode.

    4. this will result in the loss of goodwill - goodwill needs to be two way.

    5. doing things for 'public confidence' doesn't actually make sense. decisions should be based on reason, logic and law.

    I openly, when asked my opinion do not advise medicine as a career in the UK - abroad yes but not here.

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  • Vinci, appreciate your efforts but armchair legalism will achieve nothing. Lawyers stick to their procedures and legal fallacies and the original judgment was one of the latter. A jury made a decision (after fifteen hours apparently). That the jury was denied common sense relevant information and did not have the education and experience to evaluate complex medical situations, seems to be considered irrelevant by the legal profession (inc two high court judges). This is simply not being judged by ones peers. It's a travesty, even if it can be claimed that everything was procedurally correct.

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  • Council of Despair

    Back to blame: the Bawa-Garba case and the patient safety agenda

    GMC own goal me thinks - they will get away with it as no doctor will go against the GMC as someone has already said - Judge, Jury, executioner, and re-executioner.

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  • You're misrepresenting the case somewhat in saying that she omitted to document suspension of enalapril, the implication being that it was left on the kardex and this was why "Jack was subsequently given his evening dose of enalapril around 7pm" - enalapril wasn't on his kardex (ie. was intentionally omitted) and this dose wasn't given by medical/nursing staff but rather by family. Might be worth clarifying in the timeline for the sake of fairness.

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  • Done

  • If the above is correct I am struggling to see where is the gross negligence. Yes there was a muddle/mix up at the end but little more than that.

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  • School leavers considering Medicine as a career need to understand - the NHS may put you in a role where it is impossible to practice safe medicine; if lucky, nothing bad will happen, if unlucky you could go to jail and lose your livelihood.

    The BMA could cease mimicking a jelly-fish and ensure this lesson is widely disseminated.

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  • I don't think the above 'timeline' accurately reflects the systematic failures that were present on the day - the fact that the dr in question was effectively covering for 2 of her colleagues with no consultant cover & in addition was covering 6 wards over 4 floors, taking GP calls, surgical referrals etc., on her first day back from maternity leave, with no induction & a crashed computer system. She then gets blamed for mixing-up patients because the pt with the DNAR order was originally in the bed that Jack was in when he arrested but had been moved without her knowledge. Read the link (signed by 4 consultants)about what happened :

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  • AlanAlmond

    It isn’t safe to work as a Dr in the UK any more.
    A stupid country with f£&jed up medical regulatory system.

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  • can we express no confidence in the GMC?

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