Facilitator notes · Healthcare, 2011 · About 45 minutes
Leicester Royal Infirmary, 2011: the care of Jack Adcock
On 18 February 2011, six-year-old Jack Adcock died of sepsis at Leicester Royal Infirmary, on a day when a children’s assessment unit was short of doctors and several of the systems around its staff failed. The case, often known by the registrar’s name as the Bawa-Garba case, led to criminal convictions and a long argument about blame and learning in healthcare. In The Long Shift the group takes the seats of a paediatric registrar, a nurse and an on-call consultant, and makes their decisions with what they knew at the time.
For the facilitator. In the session this event stays masked, as The Long Shift, until the reveal at the end, so the group meets it as the people involved did, with only what they knew at the time. Keep this page for yourself before the session.
Content note: a child dies. This is a real event that is still painful for Jack’s family and for the clinicians involved. Some people in the room may have been through something similar: tell the group before you begin, and let people step out.
Run The Long ShiftAll scenarios
What happened
The boy was Jack Adcock, aged six. The registrar was Dr Hadiza Bawa-Garba.
Jack’s condition deteriorated in the evening and he had a cardiac arrest. Resuscitation was briefly hampered by the mistaken belief that he was a different child with a do-not-resuscitate order; the registrar realised within about two minutes and resuscitation resumed. Jack died at 21:20 of septic shock caused by a streptococcal pneumonia.
In 2015 Dr Bawa-Garba and the nurse were convicted of gross negligence manslaughter and given suspended sentences. A medical tribunal suspended Dr Bawa-Garba for a year, finding she posed a low risk. The General Medical Council appealed and the High Court struck her off. In August 2018 the Court of Appeal restored the suspension, holding that there is no presumption of erasure where serious harm has occurred. She later returned to practice.
Jack’s family have spoken publicly about their loss. Whatever the room concludes about the systems, a family lost a child.
What the group does
Over this session we’ll sit in several seats: a paediatric registrar, a nurse, and an on-call consultant.
- An ordinary day. Nothing goes wrong. We see how a busy unit normally runs.
- The incident day. The same kind of unit on a day when several things are missing. Information arrives in the order it arrived for the people involved.
- The reveal and debrief. Including what happened afterwards in the courts and the regulator.
It needs a screen everyone can see and about 45 minutes. A facilitator is optional, and nobody needs to sign in or know the field.
What went right
The debrief looks at what people did well as well as what went wrong: most days, the same adaptations are why things go right.
- The registrar kept a short-staffed unit running for a full shift, covering work normally shared between more doctors, with many sick children.
- She correctly left Jack’s heart medicine off the drug chart.
- She recognised the pneumonia as soon as she saw the X-ray and prescribed antibiotics immediately.
- She passed the abnormal results and the pneumonia to the consultant at handover.
- In the arrest, she recognised the do-not-resuscitate mistake within about two minutes and resuscitation resumed.
- The tribunal that heard her case took the systemic failures into account, and the Court of Appeal upheld its right to do so.
What the debrief opens up
Its sections:
- The system around the registrar
- One event, several verdicts
- Reflection and fear
Some of the questions it asks the group:
- On the ordinary day, what were the results system and the medicines custom doing for us in the background? What happened when they were missing?
- At handover, each person expected the other to flag concern. Where does that happen in our handovers?
- When something goes wrong on a short-staffed day, do we examine the gaps people were covering, or only what they did?
- Who in our organisation ends up accounting for outcomes produced by the whole system?
Ways to debrief it
Each real incident can be debriefed three ways, chosen on its briefing screen: the standard debrief, a quick 20 to 30 minute debrief, or a learning team. To run a learning team on something from your own work, use the learning team guide.
Further reading
- Learning from error, or punishing it. This case alongside RaDonda Vaught’s. What we see happen to one person who told the truth shapes what everyone else is willing to say. Learning from Error, or Punishing It?, Tom Geraghty.
- Learning potential, not harm. The NHS’s Patient Safety Incident Response Framework treats an incident as a window into ordinary work, and recognises that an incident’s potential for learning doesn’t track the harm it caused. PSIRF: The Patient Safety Incident Response Framework, Tom Geraghty.
- Silence in a hierarchy. Why, in hierarchical healthcare, the interpersonally safest thing to do can be to stay silent, and what aviation’s crew resource management offers. People can’t speak up well when they are working at capacity. Evolution of Leadership and Management in Healthcare: Lessons from Aviation and Crew Resource Management, Tom Geraghty.
- Slack. Why a team running close to full can’t absorb the unexpected: past about 80 per cent busy, waits stop growing gently and start to spiral. Queuing Theory, Slack and Utilisation, Tom Geraghty.
- Blame. Blame as accountability without context, and whether we want to learn from this one event or from all the ones still to come. Blame, Tom Geraghty.
- Accountability. “To be accountable is not the same as to be punishable.” Why consequences and accounts are separate questions. Accountability, Tom Geraghty.
Key papers
- Criminalising error. A review of prosecutions after professional mistakes in aviation and healthcare, and what they do to reporting and learning. Dekker (2011), The Criminalization of Human Error in Aviation and Healthcare: A Review, on the Psych Safety field guide.
- Learning from mistakes. The study that found psychological safety before it had a name: whether nurses discussed drug errors depended on how their managers handled mistakes. Edmondson (1996), Learning from Mistakes Is Easier Said Than Done, on the Psych Safety field guide.
- Communication failures. Junior doctors described hesitating to raise a doubt in front of seniors, and divisions between teams that left nobody clearly responsible for saying the difficult thing. Sutcliffe, Lewton & Rosenthal (2004), Communication Failures: An Insidious Contributor to Medical Mishaps, on the Psych Safety field guide.
- Workarounds instead of fixes. Frontline staff work around failures to get care delivered, and the problem that caused them is never fixed. Time pressure and the cost of escalating keep it that way. Tucker & Edmondson (2003), Why Hospitals Don’t Learn from Failures, on the Psych Safety field guide.
Sources
- Bawa-Garba v General Medical Council [2018] EWCA Civ 1879, Court of Appeal judgment, 13 August 2018 (paragraph numbers given where cited)
- Court of Appeal, summary for the media, Bawa-Garba v GMC, August 2018
- Wikipedia, “Hadiza Bawa-Garba case” (secondary summary; used for staffing and timeline detail not set out in the judgment)
- Gross negligence manslaughter in healthcare: the report of a rapid policy review (the Williams review), June 2018; summary of recommendations by Capsticks