Blame culture

Today we woke up to the news that the GMC has won its appeal to the High Court and has struck off Dr Bawa-Garba.

Imagine, if you can, returning to your job after a prolonged leave of absence (maternity leave in this case), beginning your role afresh in a new environment with which you are not familiar, and being told that your colleague couldn’t be in today, and could you please do their work too? Additionally, you find out that your boss is uncontactable, the other members of your team all started two weeks ago and are just finding their feet, and the IT systems are down. Someone in a different team makes a mistake for which you are punished, and at the end of a gruelling workday, you make an entirely avoidable mistake, which leads to catastrophic consequences. Are you no longer qualified to do your job? Do you lack the qualities and experience necessary to carry out your daily duties? Or are these exceptional circumstances and an entirely understandable lapse in judgement?

This is what happened to Dr Bawa-Garba. She made a mistake, on the back of incredibly hard working conditions over the course of a 13 hour shift, and a six year old boy died. Initial investigations into the case found that her mistake may not have influenced the end result of the resuscitation effort – the outcome may well have been the same. As so often happens in medicine, the SUI team found multiple contributory factors leading to this horrific outcome, and ruled that no specific person was at fault. However, Dr Bawa-Garba was convicted of manslaughter, suspended from the GMC register for a year, and has now been completely struck off.

We hold clinicians to a higher standard than most. It is understandable – our mistakes carry higher stakes. There are horrendous consequences to our failings. However, can we blame individual doctors for an outcome in a working environment that no sane person would find acceptable?

We, as doctors, often work shifts where you go 13 hours without eating, drinking, weeing, or sitting down. I have often joked, whilst on call, that I am treating a patient for hypoglycaemia or acute kidney injury, but that my blood tests may well be worse than theirs. We prioritise the need of our patients consistently above our own basic human needs. We work in conditions that you would be sued for trying to impose on any other profession. And the worst thing is we impose those conditions on ourselves. We consistently state that our working arrangements are unsafe; no one in their right mind would think that staffing a 500-bed hospital overnight with a medical team of three people is a good idea. Even on days when the rota is fully staffed, and all the systems are working, it is a disaster waiting to happen. Medical ward cover consists of running from one fire to the next, never feeling like you are winning. How are you supposed to prioritise your need to eat when a succession of patients are literally, trying to die on you?

But hungry, exhausted, overstretched doctors make mistakes. It should not be news that we weren’t at our best when our last meal was 12 hours ago. I remember finishing one day on call in the maternity ward and passing out walking to my car. On reflection, I hadn’t had a meal since dinner the previous night. I was concerned about my ability to drive and called a cab home. Forty-five minutes previously, I had been responsible for resuscitating a patient.

During my time as an intensive care doctor, I frequently covered a ward of 14 critically unwell patients, with no consultant cover on site. I started the job with no induction to the computer-based notes system, and no idea how to review medications or change doses. No understanding of how the filtration machines or ventilators worked. The fact that the patients and I survived those on-calls is a testament to the excellent standard of nursing care. The nurses on that unit saved me more times than I can recall. But it should not be the nurse’s responsibility to educate the doctor. By that logic, there is no point in me being there. I reflect on that unit, and the fact that nobody died as a direct result of my lack of training or experience is frankly baffling.

Should you make an example of someone who did nothing more wrong than any one of us has done on countless occasions but got away with due to circumstance? The CEO of the GMC released a statement concluding, “We are committed to engendering a speak-up culture”.

How do you expect to foster a culture of speaking out, when you victimise people attempting to reflect on, and learn from, their mistakes? Doctors are human. We will all make errors in our careers. I have made management decisions that have contributed to a patient’s death. We are a cohort of professionals that go into medicine to improve people’s health and lives. Nobody can make us feel worse about our failings than we already do. Nobody can criticise us more than we berate ourselves. We worry about doctors’ mental health. We worry about a culture where no one wants to accept responsibility or blame. And then we have a doctor with an exemplary record, who reflected on a complex case, gave evidence to an investigation panel, and then had her reflective evidence used to bring a court case against her.

We are all Dr Bawa-Garba. Similar situations are happening across the NHS on a startling scale. The people responsible for safe staffing and rostering are not those living with the effects of shortages on the frontline. The people who have made a scapegoat out of this doctor get home at 5 pm each day and never have to hold a person’s life in their hands while trying to remember the last time they had something to eat.

We want to acknowledge the truly awful tragedy that has happened to the family of J.A. For the background on this case read Chris Day’s account here.