Ensuring safety under pressure

The implications for clinical practice arising from the tragic death from sepsis of six-year old Jack Adcock at Leicester Royal Infirmary in 2011 continue to send shockwaves through the health service. Last month, the General Medical Council successfully appealed at the High Court to have one of the doctors who treated Jack, specialist registrar Dr Hazida Bawa-Garba, struck off the medical register, overturning an earlier decision by its own tribunal only to suspend her from the register for 12 months. Dr Bawa-Garba had been convicted of manslaughter on the grounds of gross negligence in 2015 and given a 24-month suspended sentence. Professor Tim Orchard, Trust medical director, reflects on the issues raised by this case, the importance of building an organisational culture that is genuinely reflective, resilient and open to learning and how we are working to ensure that such a culture is in place across our hospitals.

At the heart of this case is the avoidable death of a young boy in NHS care. At the same time as expressing our huge sympathy for Jack’s family, the key consideration has to be ‘how do we prevent similar deaths in the future’. I think the answer is to encourage and support doctors and all other clinicians to continually reflect on our practice, acknowledge our mistakes and where we could have done better, learn from that and make sure others learn too.

A potential issue with the GMC’s recent action – and the manslaughter conviction before that – is that it has the very real possibility of making clinicians think more about apportioning blame than learning.

I don’t profess to have any detailed knowledge of this case but, from all accounts, Dr Bawa-Garba had a sound track record as a doctor. On the day of Jack’s death, while she personally made a number of serious errors, ‘system’ issues clearly played a part too - she was covering for absent colleagues, a consultant was not present, the IT system was down and she missed a handover when responding to an emergency call.

Concern about the lack of consideration of these wider system issues was compounded by reports indicating that Dr Bawa-Garba’s own open and honest reflections about her actions were used against her. Dr Bawa-Garba’s medical protection society has issued a statement confirming that her personal reflective notes were not offered in court and that the court “made clear that reflections were irrelevant to the facts to be determined and that no weight should be given to remarks documented after the event”. However, much of the focus does seem to have been on blame and punishment, potentially at the expense of reflection and learning.

Keeping our care safe

It can be very stressful trying to ensure the best quality care when there is high demand, staff shortages or facilities that aren’t up to scratch.

When we are under extreme pressure or, more specifically, when we anticipate we may not be able to manage that pressure or deal with a particular problem, we all have a responsibility to escalate to more senior colleagues, and it is important that junior doctors feel able to escalate to consultants and managers. This doesn’t mean handing the problem off to someone else but sharing the problem – and possible solutions – with others who may be better placed to lead on defining and implementing a response.

More generally, we all have a duty to look after ourselves and each other. We are all part of a team and teams only work effectively if everyone in them is clear about their role and confident in the trust and support of the other members.

When something doesn’t go as it should, it’s essential that it is recorded, no matter how small. Systems and structures in place to help do this in our Trust include the DATIX clinical incident reporting system. This enables us to systematically review incidents as a team so that we can explore all of the factors – not just personal actions – that have contributed so that we can identify what needs to change. It’s to our clinicians’ real credit that we have high levels of reporting of incidents but low levels of harm caused by those incidents.

Through duty of candour regulations, we also have a formal responsibility to inform and explain to patients and their families when things go wrong – helping us to understand the full picture and to maintain trust.

For doctors in training, it’s vital that you monitor your hours and complete exception reports to show where your actual work has varied from your work schedule. If you’re not satisfied with the response, you should talk to the ‘guardian of safe working hours’. Without understanding issues with workload and working hours, we cannot ensure safe staffing. It is especially important to report unavoidable excess hours or lack of breaks. Clinicians are only human – they need food, water and rest, just like everyone else.

For any staff member, if you have tried to raise concerns with your line managers or other senior colleagues and feel that you’re not making enough progress, you should contact one of our ‘freedom to speak up guardians’. We currently have five guardians working across our sites who will provide confidential advice and support to staff– you can find their details on the staff intranet. 

Making our care safer

Personal reflection is central to continuing to grow and improve as a clinician. It’s a part of our professional duty – for example, written reflection is a mandatory part of each trainee doctor’s career progression and is part of the consultant revalidation process. Effective reflection can help us understand our strengths as well as our weaknesses – the Medical Defence Union offers an excellent guide.

We all reflect on what we do at work – going home on the bus, over a cup of tea with the team, waiting for test results or for the next patient. Reflection helps us understand what happened as a case unfolded and why we made the decisions we made. Reflection is personal, but discussing your reflections with experienced colleagues or supervisors can help you identify alternative actions to take in future. Reviewing reflections months down the line can also help your learning and development, and help you make the most of your appraisal. 

Reflection is critical in helping us understand how the systems in which we work impact on our own practice, the decisions we make and the outcomes for our patients. When things go wrong, it is rarely the fault of one individual – in most cases, there’s a system-wide problem. Reflection can help us identify these system-wide issues and, where possible, rectify them before they cause things to go wrong.

Building a culture of transparency and trust

Being involved in cases where things go very wrong is devastating for clinicians as well as for patients and their families. No one wants to cause harm. To avoid it, we have to be continually active in both ensuring safe practice and thinking how we can make our practice even safer.

I really hope that by reflecting on the issues raised by this very difficult and tragic case, we can do something to help avoid other unnecessary deaths in the future. If anything, we must deepen our reflections and share our learning more widely with our colleagues and patients. And, in exchange, we must be able to expect the trust and support we need to become better clinicians.