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'No single root cause' found after Bawa-Garba SUI investigation

University Hospitals of Leicester NHS Trust found that there was no ‘single root cause’ behind the death of six-year-old boy, which ultimately led to a junior doctor being struck off the medical register

The serious incident report, which was completed six months after the incident on 24 August 2011 but was only released to Pulse after a request under the Freedom of Information Act, found six causes for Jack Adcock’s death in February of that year.

These included a failure of medical staff to understand abnormal blood results, the ambiguity of the observation and escalation tools in use, and a failure to ‘fully appreciate the child’s overall clinical picture and underlying medical history’. 

This comes after much of the case against junior doctor Dr Hadiza Bawa-Garba considered her failure to prioritise the child when he arrived at the Children’s Assessment Unit with diarrhea and vomiting

However, the report said that a review of the hospital’s ‘paediatric observation priority score tool’, which is used to triage patients was ‘not sufficiently robust or easy to interpret’. 

Meanwhile, the investigation noted that the senior alert review system was implemented ‘without a robust system of education training and assessment’.

The report added that this led to ‘ambiguities in the completion by the staff’ and the documentation was subsequently ‘reviewed and new documentation introduced’.

During Dr Bawa-Garba’s trial, the jury also heard how she failed to flag up the six-year-old’s condition to the consultant.

However, in addition to poor documentation, the report said that at the time of the incident ‘there was not a consistent process of when, how and to whom to escalate concerns’.

But the report did also reveal significant failings on the part of Dr Bawa-Garba. 

When the blood test results system, iLab, broke down on the day Jack was admitted, test results were relayed verbally over the phone by laboratory staff.

When receiving the verbal information from the lab Dr Bawa-Garba was not told that any of the results were abnormal and it was later revealed in a subsequent interview that she relied on the iLab system to identify abnormal results.

The report said: ‘When recording results from the iLab system all abnormal results are highlighted with the normal range on the right hand side of the results.

‘When receiving the verbal information from the laboratory staff SpR ‘A’ was not informed that any of the results were abnormal.’

The report added that after the incident the hospital conducted a ‘spot check’ of all junior medical staff to ascertain whether they could identify the normal blood test parameters.

It was found that not only did they have an understanding of blood results without the use of iLab, they knew the actions that needed to be taken in the event of any abnormality.

However, Dr Zoe Norris, chair of BMA's GP sessional subcommittee, said: 'The very existence of a flagging system for abnormal results supports the fact that few of us are able to recall all the abnormal ranges for all possible test results.

'These flags exist precisely to reduce error when clinicians are looking at large volumes of results, and highlight where action would be needed.'

She added that the report includes several small errors 'which all have escalated into the perfect storm'.

She said: 'I challenge anyone reading it to not remember an incident or case when they didn’t write down a reading at the time, changed an oxygen setting without documenting it, or put a patient to the back of their mind while they cared for others.'

Dr Norris previously spoke in favour of a motion at the LMCs Conference in Liverpool, which declared that GPs have ‘no confidence in the GMC as a regulatory body’, in light of the Dr Bawa-Garba case.

Root causes behind the death of Jack Adcock:

1. The failure of medical staff to understand and communicate the significance of abnormal blood results

2. The failure of nursing staff to recognise the significance of abnormal observations and record and monitor according to clinical need

3. Ambiguity of the observation and escalation tools in use in Children’s Hospital

4. Poor communication of clinical condition between staff because of an absence of effective systems for handover (medical and nursing)

5. Failure to fully appreciate the child’s overall clinical picture and underlying medical history due to a failure to engage a timely cardiology review

6. Failure to follow guidelines (Leicestershire Medicines Code) for non-prescribed medication because of custom and practice for administering non prescribed regular medication

Source: University Hospitals of Leicester NHS Trust

Readers' comments (15)

  • The hospital investigation is hopelessly biased which rather calls into question the validity of these reports:
    1. Probably quite difficult to do given the known IT systems failure. It looks like the significance was in fact appreciated as the ABG was repeated and found to improve.
    2. Doing repeat obs on children is not the same as adults. They often resist and examination is opportunistic. It is common on acute paediatric units for obs to stop when children appear clinically to improve.
    3. Many of these 'Warning Scores' are often confusing and over-sensitive. Hence SHOs talk of patients 'MEWSing' and such like. They mainly exist for the benefit of trust lawyers.
    See recent EMIS warnings for a good example.
    4. Handover is often one of the first things that breaks down in a staffing crisis when everyone is literally too rushed to stop.
    5. Paediatric cardiologists are not commonly found and often a ward referral may take time (days in adult medicine).
    6. Hospitals like NICE write reams of guidance, much of which is only brought out to protect their backs when things go wrong! It is impossible to know it all. Custom and practice is important in medicine and underpins the basic principles of how we work efficiently.

    I could go on but you get the idea.

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  • Dear All,
    "No single cause" for the ultimate tragedy but a "Single" provider victim identified and left out to answer for the ultimate sanction. Will the Trust now own up and say "we should be sharing the blame for the death"?

    Paul C

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  • Dear All,
    Oops forgot to observe; number one failing, not enough staff on duty or roistered at the time. Is that the responsibility of the roistered staff?, No, but lets blame them nonetheless.
    Paul C

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  • No single root cause to blame.
    Fortunately for the hospital and the GMC a black female was available to shoulder the burden

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  • No single root cause and she has to shoulder all the blame? How about giving Enalapril in sepsis as a cause. If staff has given it, I bet will be raised as a big root cause. Can anyone still have faith working in such a system?

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  • End of the line?

    Surprise Surprise
    By the corporate NHS Leicester
    and its amply funded legal team
    who managed to get the prosecution to omit all the facts from the court.

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  • End of the line?

    Rest in peace
    Bawa Garba (Medical Career)
    Nurse Amaro (Nurse career)

    (in)Justice had to be seen to be done

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  • Somehow the hospital gets off scot-free in this report, produced by the hospital.
    Surely root causes here are understaffing, lack of provision of sickness cover, making a doctor work beyond any reasonable expectations without any support or senior cover, lack of proper induction for a new doctor etc etc - all of which were the hospital's responsibility.

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  • So, Angus, its all down to sexism and racism:a charge that is either so substantive and serious that you should report it as a Hate Crime, or a response so infantile a "knee jerk" that we can ignore your prejudices,and instead, review the multi-factorial evidence.

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  • @Robin Jackson
    Just stating the facts.
    You are just joining the dots.
    As far as the case details are concerned it doesn't matter what colour she is, she was framed.
    And can you be so sure that a white 'well bred' male wouldn't have got off with it?

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