The recent press reporting of the High Court’s decision to overturn the strike off order for Dr Bawa –Garba is welcome news. She was found guilty of manslaughter by gross negligence on November 4th, 2014 and later struck off from the GMC in January this year, despite an independent tribunal stating no benefit would come from her erasure. Whilst admissions of her part in events leading to the tragic death of this young boy are not to be ignored, she was one of many persons holding responsibility during his care and this was reflected in the latest appeal whereby the High Court agreed that a 12 month suspension subject to review was more appropriate.
The judgement by chief justice Lord Burnett, Sir Terence Etherton, and Lady Justice Rafferty said: “The Court of Appeal unanimously allows the appeal and it holds that divisional court was “wrong” to interfere with the decision of the tribunal.(1 & 4)
“The Court of Appeal sets aside the order of the divisional court that Dr Bawa-Garba should be erased from the medical register and restores the order of the tribunal that she be suspended from practise for 12 months, subject to review. Monday’s ruling confirms that the tribunal service was right to take account of the wider context and mitigating factors in forming its judgement. “(1&4)
However, there has been little press in regards to the nurse, Ms Isabel Amaro who was also found guilty of manslaughter by gross negligence and as like Ms Bawa – Garba given the same suspended sentence in November 2014. Two years later she was then then struck off from the Nursing and Midwifery Council in July 2016. The ward sister (Sister T), Izzy’s supervisor on the shift in question was acquitted of all criminal charges, but subject to an interim conditions of practice order in 2015 (8). A second nurse, who cared for Jack in his last 2 hours, gave evidence at the trial but no action was taken against her – she at the time of the trial had moved abroad. The cases bring into question how is culpability placed when such system failures occur and is it right to proportion blame of manslaughter by gross negligence to clinicians who are merely trying to do their job despite unworkable conditions. A rapid policy review (2)occurred in February this year which recommended that;
- The General Medical Council should have its right to appeal fitness to practise decisions by its Medical Practitioner Tribunal Service removed. This will help address mistrust that has emerged between the GMC and the doctors that it regulates. The Professional Standards Authority will retain its right to appeal these cases to ensure public protection, in the same way that it does for the other eight regulatory bodies for healthcare professionals;
- The General Medical Council and General Optical Council will no longer be able to require registrants to provide reflective material when investigating fitness to practise cases. This change will help ensure healthcare professionals are not afraid to use their notes for open, honest reflection which supports improvements in patient care; and
- Concerns about the over representation of Black, Asian and Minority Ethnic healthcare professionals in fitness to practise cases to be investigated, understood and addressed.
Doctors in their thousands rallied in support of Dr Bawa-Garba with the realisation that it could have happened to any of them and this support continued with a successful online campaign that raised the necessary funds for her court appeal . Some doctors threatened to resign if the case was not re-examined and the power of her peers worked.
But where does this leave this nurse? As for Nurse Isabel (Izzy) Amaro there has been no such campaign of support until now.The Royal College of Nursing provided minimal support and have not been seen to drive any further justice for Izzy in the same way that the medical profession did for Dr Bawa-Garba. What does this say about the healthcare community? Are they scared to speak out? The nursing profession seem to have turned their back on Izzy, glad that it is not them and apathetic to ask questions. Izzy is now left alone, with physical and psychological damage as a result of her treatment, trial by press and backlash of abuse that came with this following the death of this young man.
We are deeply sorry for the tragic death of a child but we feel that true justice can only be served by an impartial review that shows the contributing factors in full and helps to protect patients from harm by addressing systemic failures. This can not occur through the targeting of individual Healthcare Professionals. Individual practitioners must be held accountable for their own actions for sure, but the wider causative factors must also be considered if we are to learn and avoid another incident such as this.
The following article is collated following a review of information currently in the public domain and is our impression of how such a day could have occurred. We are by no means trying to defend anyone or even blame anyone, but are merely trying to look at the wider picture that this case casts on the profession and how we can best care for our patients given the current resource constraints.
Isabel Amaro has given her full permission for this article to be written and trusted us to be honest and truthful. She has not been involved in its writing however.
So, imagine as an agency nurse you turn up to work on a medical assessment unit (CAU). You are trained in adult medicine, and have been qualified for 17 years with feedback attesting to a high level of performance. Your shift on CAU was allocated in order to help the unit out in a crisis. As an adult nurse you would not normally have expected to look after paediatric patients without at least one other experienced RSCN supervising. You have worked 13 shifts previously at the hospital and so are familiar with its infrastructure, staffing is generally poor but as far as agency shifts go at least you have continuity of working there before – many friends end up working on different hospitals every other day! This agency nurse is Izzy Amaro but it could have been you.
In February 2011, you turn up for work. You are nervous, you are not a paediatric nurse and the ward sister ( sister T) doesn’t seem able to give you the support you need in order to do so, she is extremely stressed, has her own caseload and is extremely overworked. There is only one other qualified nurse working that day who is new but is a Registered Sick Children’s Nurse. This worries you but you maintain your professionalism and you get on with the job to the best of your ability. The ward is an acute assessment unit . There are up to 80 admissions a day of patients ranging from recently born to 16years of age and today looks like it will be no different. The unit also takes emergency admission, calls from Midwives and GP’s with sick children triage and determining assessments required. But the unit is not only an assessment unit, there are 15 short stay beds. There is lots going on and always lots of relatives and new mums around to reassure and care for. Patients can be from both a medical or a surgical need.
Added to the poor staffing levels, there is the added stress of a breakdown in IT facilities across the whole hospital. This means you and the others are constantly having to phone the lab to try to get results, the whole hospital is doing the same, it’s difficult to get through. You are tasked with this amongst other duties. It is frustrating and worrying. You escalate about being unable to get results quickly, but are told to keep trying. When the IT system comes back on it still is not working as it should. You do not have the relevant passwords to access the IT notes and results and so cannot not look them. It’s a nightmare. No one listens to your difficulties and you are also trying to do this whilst caring for many other young children. You escalate again. You and your colleagues are extremely stressed. The day has only just started and already is terrible!
The registrar that day was Dr Hadiza Bawa-Garba, a high flying doctor, with an unblemished record who had done considerable work for charitable causes and just returned from 13 months maternity leave. You are pleased she was covering the unit as she seemed very competent and approachable. However, you are not aware that Dr Bawa – Garba had received no Trust induction and little support from the CAU registrar that day as they were on training, away from the wards. Dr Bawa-Garba was requested to cover CAU as well as her own ward duties. Working under her are a foundation doctor and SHO. Both had only rotated to paediatrics that month. The consultant covering CAU was teaching outside the city. You observe that the doctors were extremely busy and are unable to spend a great deal of time with any one patient. Where is the consultant? You are told he is unavailable. Where is the registrar? You are told they are unavailable?
On 18th February 2011 the patients included many high dependency children. At 10.15 a six year old boy called Jack Adcock is admitted to CAU from his GP, having been off school the previous day unwell(6) with severe gastroenteritis and difficulty breathing. Jack was born with Down’s Syndrome and had recently had a procedure for a congenital heart condition. He was on medication regularly which included Enalapril. You are told as an agency that you are not allowed to do intravenous medication and some other additional duties that patient’s required. As a result this caused delay in some patient’s treatment and was additionally very frustrating as you can’t provide complete care and continuity is poor. You raise concerns over the numbers of sick children you have to care for that day, you feel this is ignored. You are told by the ward sister to only escalate areas of concerns to her and no one else. You attempt to raise concerns again and again about the welfare of Jack and other patients, but told “to get on with the job”. The culture of the ward, is that of being too busy to “carry anyone” and frantic.
Jack had a temperature of 37.7 degrees centigrade on admission, was dehydration and difficulty breathing. (3) A blood gas showed a Ph, 7.0, base deficit, -14, lactate 11 mmols. You raise this with both the doctors and ward sister. Jack was prescribed oxygen, a fluid bolus, blood tests and chest x-ray were ordered the results of which came back at 12.30 showing a chest infection (3) however, Doctor Bawa-Garba did not get around to reviewing them until 3pm due to the hospital IT system being down. After fluids, Jack starts improving around 12.30 – 3pm, Dr Bawa-Garba tells you she is cautious to give him too many fluids due to his heart condition, this seems fair enough. As Jack is improving you prioritise the other patients and stop monitoring his oxygen saturations. Blood results are still not back due to the IT system failure – they come back 4.15pm. You have a conversation with the other nurse on duty when she queries why the Enalapril has not been prescribed. You are unaware that the doctor has acknowledged to herself that Jack should not be prescribed his Enalapril due to his heart condition, she has not documented this in the notes as is called away to another emergency. Maintenance fluids and IV antibiotics are prescribed. You cannot administer the antibiotics as you are an agency nurse. You remind the ward sister and the other nurse of the importance of giving them. You assume they would give the IV antibiotics immediately It transpires later that the antibiotics were not given for over an hour. You are busy with other patients, Jack is sitting up drinking out of his beaker and appears much more stable. He is reluctant to let you put the blood pressure cuff on him and is wriggling around refusing. You will try again soon. His nappies are loose and you are having to change them frequently – you must tell the doctor when she is back on the ward.
Jack seems better, further blood gases are taken and have improved. Everyone breaths a sigh of relief – there are a number of sick children on the unit that shift but Jack appears to be improving. At this point he is transferred out of CAU and your care to one of the wards. Another nurse takes over his care. Jack’s mum gave, his routine dose of enalapril, after checking with the nursing staff (4&7) at 7pm. (3)Approximately one hour later he suffered a collapse, he has a cardiac arrest and the team despite their efforts are unable to save him.
Jack’s death is devastating – what went wrong? He was fine when he left CAU – how could this happen? …
You agree to work a twilight shift the next day but then fly out to Portugal to sort out affairs following a family bereavement. The hospital team assure you they have your back and will look after you during the enquiry that will no doubt follow. You leave the hospital saddened, confused and frustrated at the day’s events but feel you did the best you could have in the midst of such overwhelming circumstances. You hope the family are receiving the support they need. On return to the UK everything changes…
Have you had walked in Izzy’s shoes ? Do you feel it could have been you? At the recent appeal for Dr Bawa-Garba the judge introduced that the trust investigation may not have been sufficient and has ordered a review. The NMC is certainly making steps to change the way it conducts Fitness to Practice procedures, however this is too late for Izzy and the damage has been done. Izzy had no legal representation at her hearing, she had no peers to support her. She was vulnerable at the time of the hearing, was incarcerated at Peterborough prison for two and a half months whilst her case was coming to trial because she was seen as a risk to herself . This prison sentence started drastic physical and mental decline for Izzy.
Izzy deserved better, she deserved a profession to safeguard her, help her recover and learn and move forward
This article has been written in consultation of members of the online campaign IAMNURSEAMARO (https://www.facebook.com/Iamnurseamaro) and the online support group NMCWatch (www.nmcwatch.co.uk)
- https://www.bbc.co.uk/news/resources/idt-sh/the_struck_off_doctor 8.
- Nurse found guilty of manslaughter after Leicester child death. Nursing Times 4th November 2015