BMJ 2018;360:k447 doi: 10.1136/bmj.
k447 (Published 31 January 2018)
Views and Reviews
Avoiding blame and liability is vital to learning from
errors and engineering a safer NHS
Medical law needs urgent reform to let doctors maximise learning from every incident
1 1
Helgi Johannsson consultant anaesthetist clinical director , William Rook core trainee year 2, acute
2
care common stem, anaesthesia
1
Imperial College Healthcare NHS Trust, London, UK; 2University Hospitals Leicester NHS Trust, Leicester, UK
Hadiza Bawa-Garba, a trainee paediatrician who was convicted
of manslaughter over the death of Jack Adcock, a 6 year old
boy, was struck off the UK medical register last week after a
High Court ruling, in order to maintain public confidence in the
profession.
In the past 10 years, British medicine has seen much progress
in the development of an open and honest safety culture. We
report and investigate incidents; develop action plans to prevent
repetition; and spread learning wider than our immediate circle
by discussion with colleagues, not only within the hospital but
at conferences, in the medical literature, and even on social
media. We include our patients in this process—we are open
with them, not only about what happened, but also what we are
doing to prevent it happening again.
Doctors are human and make mistakes. It happens to all doctors,
including us. Preventing errors is at the forefront of our practice
and reflecting on our mistakes makes us better doctors. When
a mistake happens it is almost never because of one person and
there are always circumstances that contribute to the error. Short
staffing, high workload, fatigue, and inadequate supervision are
common contributory factors.
Jack Adcock’s death is a tragedy. He received poor care from
Bawa-Garba. He also received poor care from an overstretched
system that meant that Bawa-Garba was covering for several
colleagues, including the consultant in charge of the unit. She
had to work in difficult circumstances, with an IT failure and a
junior team. There are enough contributory factors to make any
doctor shudder and be thankful that it didn’t happen on their
watch.
Medical training is rigorous and taxing—it attracts dedicated
high performing people who are constantly trying to do better
and to learn. When we make mistakes, the pain of those mistakes
can be unbearable. We search our souls, blame ourselves, feel
an enormous sense of guilt. We talk to colleagues as a form of
counselling, we reflect on what happened. Written reflections
show our supervisors and directors that we have learnt from an
incident, and also help us come to terms with what happened.
helgijoh@me.com
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To a doctor, this process can act as a sacrament of penance—an
open, honest reflection in a place of safety.
Bawa-Garba did exactly as the General Medical Council asks
us to and reflected honestly about her performance in Jack’s
treatment. These reflections, provided as evidence of learning
from a critical incident, were then used against her as proof of
poor practice. This is concerning, and a step backwards for
safety in medicine. Should doctors be fearful their reflections
might be used against them? Some may choose to make their
writing vague to the point of being non-identifiable, or simply
provide a note, confirmed by a supervisor, that a reflective
activity has taken place. Although this would be enough
evidence of reflection, it would inhibit the learning from other
peoples’ mistakes that publicity and discussion allows. In
addition, if we avoid public reflection we may well not feel safe
enough to reflect in private.
The health secretary Jeremy Hunt’s statement of concern after
the ruling is a welcome sign of support. The Healthcare Safety
Investigation Branch became operational last year and its core
mission is “to improve safety through effective and independent
investigations that don’t apportion blame or liability.” This is
vital to learning from errors and engineering a safer NHS, yet
the law and the GMC only look at a person’s actions and do not
take account of the conditions that person was practising in. We
feel that medical law has not undergone the same transformation
as medical practice has regarding liability and error. The law
requires urgent reform to prevent practitioners taking the full
blame for system errors and to allow us to maximise learning
from each incident.
The death of Jack Adcock is a tragedy, but the way the
investigation concentrated on individual failure, and used written
reflections as evidence to strike Bawa-Garba off the medical
register, risks more lives by endangering the open, honest safety
culture that is emerging in the UK.
Competing interests: None declared.
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