The lexicon of a “just culture” in the NHS has become popular over recent months, notably in the publication of Being Fair: Supporting a just and learning culture for staff and patients following incidents in the NHS by NHS Resolution.

We are taught that to create this culture, when things have gone wrong, we need to focus on three questions (Dekker 2017): Who is hurt? What are their needs? And whose responsibility is it to meet those needs?

There is much to celebrate in the increased focus on “just culture”– not least that this has become accepted parlance within the NHS mainstream and more widely in the regulatory community. The phrase can be found in the National Patient Safety Strategy from NHS England/NHS Improvement.

It is advocated in the General Medical Council-commissioned review on gross negligence manslaughter and culpable homicide. There is A just culture guide, from NHS Improvement, which “encourages managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way”.

Yet from the perspective of patients and families, the narrative to date can seem somewhat one sided. In our view, a “just culture” has to give equal importance to being fair to staff and patients.

In the aftermath of a patient safety event resulting in serious patient harm or death, the response of the organisation to the patient or family is crucial. Yet too often, rather than the restorative approach Dekker calls for, harmed patients and bereaved families experience a response that in many cases significantly exacerbates their grief, trauma and distress.

Given the notion of justice encompasses concepts of fairness and equity, the pursuit of a just culture must also ensure further harm to patients and families is avoided.

At recent events hosted by AvMA and The Doctors’ Association UK, harmed patients and families sat side by side with clinicians and researchers. It was moving and heartening to hear the empathy felt by both “sides” expressed for all affected by the fallout from patient safety incidents.

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After a junior doctor was convicted of gross negligence manslaughter for mistakes made whilst working under intolerable pressure, a campaign for a just culture in the NHS was launched by DAUK. This campaign, Learn Not Blame, is lead by Dr Cicely Cunningham, a DAUK executive committee member. Listen to Cicely being interviewed by BBC World Service for The Why Factor in this episode about blame.

https://www.bbc.co.uk/programmes/p070n3g0

“In 2015, Dr Hadiza Bawa-Garba was convicted of gross negligence manslaughter for her part in the death of six-year-old Jack Adcock from sepsis. She was subsequently struck off the medical register after the doctors’ regulatory body, the General Medical Council, argued that the conviction meant that she could not be fit to practise. The court of appeal ruled on Monday that Bawa-Garba should be reinstated. I believe it was the right decision.”

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The case of Bawa-Garba vs GMC has become a lightning rod for a profession at breaking point

Doctors await the judgement of Bawa-Garba vs GMC with trepidation. Our thoughts are very much with Jack’s family, as they seek justice for Jack who was six years old when he tragically lost his life to sepsis. Our thoughts are also with Dr Hadiza Bawa-Garba, who under immense pressure that day, was sadly unable to save Jack’s life.

The case has become a lightning rod for a profession at breaking point. (1) Many of us are working on critically understaffed wards and in under-resourced departments, with an increasingly unmanageable workload. On the day Jack died, Dr Bawa-Garba was doing the job of 4 doctors; covering 6 wards, across 4 floors, responding to numerous paediatric emergencies, whilst supervising 2 junior doctors new to paediatrics, without a functioning IT system, and in the absence of a consultant. All when just returning from 14 months of maternity leave.

The message from the GMC at Dr Bawa-Garba’s appeal was clear; that these systemic failures should not have been taken into account when determining whether an otherwise excellent doctor should be struck off. We now find ourselves in the unprecedented situation where doctors feel that on any given day in the NHS, that they too could be criminally convicted and pursued by their regulator in the courts to ensure that they will never practice medicine again. The GMC has shown it cannot be trusted to take a balanced and non-punitive approach in the context of system failures. (2)

Dr Samantha Batt-Rawden, Chair of The Doctors’ Association UK said “This is desperately sad case, and one which has rocked the medical profession. The concerted action by the GMC against Dr Bawa-Garba has not only halted progress on the safety agenda, but set it back decades. We are hopeful that the judgement on Monday will be in Dr Bawa-Garba’s favour, and an otherwise competent and dedicated doctor will be able to return to the profession she loves. A positive outcome for Dr Bawa-Garba today will represent a shift away from a culture of fear and blame, to one of learning, that the NHS so sorely needs”.

Dr Cicely Cunningham, Learn Not Blame (3) Lead of The Doctors’ Association UK said “The NHS desperately needs an open, transparent, learning culture, where harm is minimised by learning from error and failings. Scandals such as Mid-Staffs, Gosport, and Morecambe Bay repeatedly demonstrate how a culture of defensiveness and denial can escalate into widespread cover-up leaving families fighting for answers. The climate of fear amongst the medical profession created by the GMC’s actions over Dr Bawa-Garba only makes it more likely that this will happen again. If the High Court ruling is overturned, this will be one small step in the right direction towards a just culture.”

CONTACT

Contact@dauk.org

Dr Samantha Batt-Rawden

Chair, The Doctors’ Association UK

07875379150

Dr Cicely Cunningham

Learn Not Blame Lead, The Doctors’ Association UK

07906834463

DAUK will be attending Hadiza’s appeal and will be present for comment following the judgement.

NOTES TO EDITORS

1.On 28th February The Doctors’ Association UK (DAUK) wrote a letter to Mr Charlie Massey, Chief Executive of the GMC expressing overwhelming concern regarding the handling of the Bawa-Garba case. This letter was signed by over 4500 doctors and several MPs. The letter can be found here.

2.In April DAUK submitted evidence to the Williams Review on gross negligence manslaughter, in which we recommended that the GMC be stripped of the right to appeal decisions of the MPTS. This review concluded that the GMC’s right to appeal had had “significant unwelcome and unintended consequences” and upheld our recommendation that the GMC should lose this power. Our full submission can be found here.

3.Following the case of Dr Hadiza Bawa-Garba DAUK launched our campaign Learn Not Blame, seeking to change the way medical error is approached in the UK. Our aim is to transform the current culture of blame and fear, into one of learning. We believe this is vital for patient safety, and have received cross-party support for the campaign, as well as backing from our peers. More information on the campaign can be found here.

The General Medical Council’s serious error of judgement in aggressively pursuing Dr Hadiza Bawa-Garba’s erasure from the medical register in the High Court has set the safety culture back decades.

The case of Dr Hadiza Bawa-Garba has united the medical profession in fear and anger. A paediatrician in training, with a previously unblemished record, was convicted of gross negligence manslaughter for judgements made whilst doing the jobs of several doctors at once, covering six wards across four floors, responding to numerous paediatric emergencies, without a functioning IT system, and in the absence of a consultant. All when just returning from 14 months of maternity leave.

Yet it was the GMC’s aggressive pursuit of an otherwise highly regarded doctor, against the advice of the Medical Practitioners Tribunal Service (MPTS), that has prompted widespread outrage amongst doctors. This serious error of judgement on the part of Mr Charlie Massey, which was also criticised by the Professional Standards Authority, has led to an unprecedented loss of confidence in the regulator by the medical profession. (1)

The GMC has shown it cannot be trusted to take a balanced and non-punitive approach in the context of system failures, and the recent Williams review recently agreed it should be stripped of the right to appeal decisions of the MPTS. (2)

Dr Samantha Batt-Rawden, Chair of The Doctors’ Association UK, said: “The GMC has a remit to protect, promote and maintain safety and well-being of the public. But this concerted action by the GMC against Dr Bawa-Garba has not only halted progress on the safety agenda, but set it back decades. There are no winners in a culture that seeks to persecute and blame dedicated clinicians working within a system under unspeakable pressure.”

Dr Cicely Cunningham, The Doctors’ Association UK Learn Not Blame (3) Campaign Lead, said: “The NHS desperately needs an open, transparent, learning culture, where harm is minimised by learning from error and failings. Scandals such as Mid-Staffs, Gosport, and Morecambe Bay repeatedly demonstrate how a culture of defensiveness and denial can escalate into widespread cover-up leaving families fighting for answers. The climate of fear amongst the medical profession created by the GMC’s actions over Dr Bawa-Garba only makes it more likely that this will happen again. If the High Court ruling is overturned, this will be one small step in the right direction towards a just culture.”

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NOTES TO EDITORS

1. On 28th February The Doctors’ Association UK (DAUK) wrote a letter to Mr Charlie Massey, Chief Executive of the GMC expressing overwhelming concern regarding the handling of the Bawa-Garba case. This letter was signed by over 4500 doctors and several MPs.

2. In April DAUK submitted evidence to the Williams Review on gross negligence manslaughter, in which we recommended that the GMC be stripped of the right to appeal decisions of the MPTS. This review concluded that the GMC’s right to appeal had had “significant unwelcome and unintended consequences” and upheld our recommendation that the GMC should lose this power.

3. Following the case of Dr Hadiza Bawa-Garba DAUK launched our campaign Learn Not Blame, seeking to change the way medical error is approached in the UK. Our aim is to transform the current culture of blame and fear, into one of learning. We believe this is vital for patient safety, and have received cross-party support for the campaign, as well as backing from our peers. More information on the campaign can be found here:

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