Who is to blame when something goes wrong in a hospital and a patient suffers injury or a setback, or even dies, as a result? Is it an individual or team or, given the complexity of healthcare, have the flaws been in a wider system, and hinged on available resources, not just clinical decisions?

Dr Hadiza Bawa-Garba’s role in the death of six-year-old Jack Adcock in 2011, and especially the series of legal and disciplinary processes that triggered, would have sparked renewed debate about these profound and troubling questions at any time.

But they came against the backdrop of the understaffing that is increasingly visible across the NHS, the trainee paediatrician’s conviction for gross negligence manslaughter and erasure from the medical register, and her insistence that Jack’s death involved inadequacies in her hospital over which she had no control, as well as her own admitted failings.



Quick Guide What is sepsis and what causes it? Show What is sepsis? Sepsis is not blood poisoning, as many people think. It's an out-of-control response of the body to infection and most common in young and old who have fragile or impaired immune systems. In severe sepsis, the immune system goes into overdrive in an attempt to fight off an infection – most commonly pneumonia – and the body’s organs shut down. Sepsis can be, but is not always, a complication of septicaemia, which is severe blood poisoning. It is difficult to diagnose and life-threatening if not caught quickly. Those who survive can suffer severe disabilities. What are the signs? It varies depending on the age of the sufferer. In children under the age of five, people should look for whether they appear “mottled, bluish or pale”, whether they are “very lethargic or difficult to wake” and if the child is “abnormally cold to touch”, says the NHS. Fast breathing, a rash that does not fade and fits or convulsions are also warning signs. In anyone older, early symptoms include: a “high temperature (fever) or low body temperature” and chills, as well as fast breathing and heart rate. Sepsis is often mistaken for flu, so sufferers are advised to seek medical help if they get those symptoms after having had an infection or an injury. How common is it? The Global Burden of Disease study says there were almost 50 million cases worldwide in 2017 and 11 million deaths – 85% of them in low and middle-income countries. It affects babies and small children most – more than 40% of deaths were in children under 5. In the UK there were nearly 48,000 adult and child cases that year. UCL experts say about 150 children die each year. What causes it? Elderly people in affluent countries with chronic conditions such as heart failure and type 2 diabetes and newborn babies in low income countries are particularly at risk from sepsis because they have weak or under-developed immune systems, which allow an infection to spread around the body. That can be any serious infection, such as flu, pneumonia, Group B strep or a hospital-acquired infection. The immune system fights back, but the chemicals it releases to fight the infection affect the entire body, causing widespread inflammation, damaging tissue and interfering with blood flow. That can lead to low blood pressure and less oxygenation of organs, which may shut down as a result.

Bawa-Garba’s case assumed huge significance for medical practice, patient safety and also the chances of the NHS recruiting and retaining the number of junior doctors it needs to care for patients properly, many of whom were alarmed by her being “scapegoated”.

The tribunal decided that Bawa-Garba’s conduct in Jack’s case was neither deliberate nor reckless and that she posed no danger. Photograph: Nick Ansell/PA

As one of them – Dr Rachel Clarke – put it, Bawa-Garba suffered “persecution and scapegoating. Bawa-Garba made mistakes, but her unit was understaffed, chaotic, lethal bedlam. She was hung out to dry”.

The three appeal court judges referred several times to the “systemic failings” evident at Leicester Royal Infirmary in explaining their decision to overturn Bawa-Garba’s ban on working as a doctor.

Jack, who had Down’s syndrome and a heart condition, was admitted to the hospital in February 2011.

Six-year-old Jack Adcock died at Leicester Royal Infirmary in 2011 after he developed sepsis. Photograph: Family Handout/PA

Bawa Garba was on her first shift back after maternity leave, and was the most senior doctor in charge of the children’s assessment unit. The consultant who should have been around for her to discuss Jack with was covering another department, because of gaps in the medical rota.

Two of the three nurses on duty were from an employment agency. Problems with the hospital’s IT system meant she did not receive the result of blood tests she had ordered for six hours. And she was very busy dealing with other sick children, one of whom had to have a lumbar puncture. Doctors across the NHS encounter similar circumstances in their units worryingly often.

Jack ultimately died of sepsis, a virulent blood-borne infecton that is acknowledged to be both a major cause of avoidable death but also very hard to detect. Bawa-Garba is by no means the only health professional to miss what turned out to be signs of it.

The appeal court pointed out that “the full context of Jack’s death” involved the decision-making of other staff at the hospital, as well as these “systemic failings”, not just Bawa-Garba’s conduct.

That is what the paediatric registrar had argued all along in her appearances in court and also during both a medical practitioners’ tribunal hearing and the General Medical Council’s subsequent appeal against the MPT’s decision that a one-year suspension from practising was the right punishment.

The tribunal decided that Bawa-Garba’s conduct in Jack’s case was neither deliberate nor reckless and that she posed no danger. Yet the GMC, which regulates doctors, still decided that public confidence in the profession meant she should be struck off. Its standing with doctors is a major casualty of the Bawa-Garba saga.

It is hard to quantify the short- and long-term damage done in terms of the chilling effect on all levels of doctors across the NHS at seeing the paediatrician being convicted and banned.

But the case again shows that lapses in patient safety are often not as simple as errors of individual judgement. As Chaand Nagpaul, the chair of the British Medical Association, put it: “Lessons must be learned from this case which raises wider issues about the multiple factors that affect patient safety in an NHS under extreme pressure rather than narrowly focussing only on individuals.”