Sunday, 27 December 2015

A Worrying Change

At the beginning of November 2015, two people were convicted of manslaughter. They were Isabel Amaro and Hadiza Bawa-Garba, and they were convicted of the manslaughter of Jack Adcock. But Isabel Amaro is a nurse and Hadiza Bawa-Garba is a doctor, and Jack Adcock was a six year old boy in their care.

Jack was admitted to Leicester Royal Infirmary, on Friday the 18 February 2011, with diarrhoea and vomiting, and breathing difficulties. Jack had Down’s Syndrome. He died eleven hours later after a cardiac arrest, due to Sepsis, secondary to pneumonia. This was a very ill child.

Both Isabel Amaro and Hadiza Bawa-Garba missed his deteriorating condition. He had abnormal blood results, high levels of urea and creatinine in his blood, and he was showing signs of septic shock. When he had a cardiac arrest his lips had turned blue. Dr Bawa-Garba had not contacted her consultant about his condition and when he arrested she stopped the crash team, mistaking Jack for another patient who was not for resuscitation.

This was serious misconduct and negligence by both these women, but was it manslaughter? Did these two women deliberately neglect Jack’s care to the extent that he died? There is no evidence of this.

We don’t know the full details of what happened when Jack Adcock died. How busy was the ward? (In her evidence Dr Bawa-Garba said that she’d not had time for a break) How many other patients where Isabel Amaro and Hadiza Bawa-Garba also looking after? How many of them were also very ill? How many other staff were on duty that day? Was the ward short staffed? (Isabel Amaro was an agency nurse so the ward was down at least one member of permanent staff)

Many of us nurses have been on duty when it has been busy and our unity or team has been short staffed. For many NHS nurses this is now a common working condition. This is the time when things can go wrong, drugs errors can occur, lapses in care can happen. Staff are pressured, stressed and short of time, with more and more demands being made on them. They are only human. As resources are squeezed and pressures increase more and more nurses and doctors will be working under these conditions. This is now the reality in Jeremy Hunt's NHS.

Negligence and misconduct should never be tolerated but is a manslaughter charge the right response? But our courts do not deal in the complicated factors that busy and under staffed units are being put through, and are they always the right place to deal with lapses in healthcare practice? They deal in the rights and wrongs of one person's actions, they rarely deal with complicated institutional failings (Because what else are the stresses being put on NHS staff today?)

When working on a busy and short staffed hospital ward do nurses now have to take care so that we don’t end up charged with manslaughter?

Drew Payne


Unknown said...

Both of them did not not miss his ' deterioration' There was none. He got better. That was why he was transferred to a general ward. Si Thomas QC prosecuting said ' due to their neglect, Jack Adcock's condition declined to a point of no return before transfer to another ward'
This statement is insane, absurd and illogical nonsense.
Jack was unresponsive and blue on admission with a pH of 7.08. An hour later, his pH was 7.24 [ 50% IMPROVEMENT in deficit]. He was sitting up and drinking. Nurse Amaro stopped her obs. because he had got so much better. He was transferred because he was better, not deteriorated!! If he had indeed declined from unresponsive, he would have been comatose, and could not be transferred. Who transferred him ? How can his mother give him his NORMAL medication if he was so abnormal, due to decline.
This is the most absurd crackpot case I have ever seen. Poor Jack was done by his ACEI. As a Physician, I have seen that before. Josef Kuriacose.

Unknown said...

Furthermore, Sir Thomas in pointing Dr Bawa- Garba's failure said ' You were mislead by his improvement'. Sadly and illogically, she agreed. You should not be convicted of ' neglect of decline' at the same time as being guilty of being ' mislead by improvement'.
Besides, at the point you are 'mislead by improvement', you would need the ability to time travel into the future at that point.
Only in Britain, could such a case go through appeals and hundreds of articles and TV shows and miss the fundamental. Jack Adcock got better under Dr Bawa- Garba's care and would not have got the ACEI, had he remained there. It was only because he was transferred that he got it!!