When things go tragically and fatally wrong in a medical case how does one determine a doctor’s culpability and future, particularly when systemic problems were involved? A recent case in the UK has triggered debate on the issue within Britain’s medical community and beyond, and has also raised serious concerns about the way ethnic minority doctors are treated by the system.

In February 2011, Jack Adcock, a six-year-old boy with Down’s Syndrome, was admitted to a hospital in the English city of Leicester with diarrhoea, breathlessness and vomiting. The boy, who died hours later from sepsis, was initially diagnosed with gastroenteritis by Hadiza Bawa-Garba, a specialist registrar in paediatrics at the hospital, who was solely in charge of the emergency department on that day, and who had just returned from maternity leave.

Despite an investigation at the hospital identifying systemic failings and willingness on the part of Bawa-Garba to openly discuss what went wrong, a jury convicted her four years later for manslaughter and gave her a two-year suspended jail sentence. A tribunal of medical practitioners subsequently ruled that Bawa-Garba should be allowed to continue her training and return to practising as a doctor after a one-year suspension, but the professional body the General Medical Council (GMC) overturned that decision, and called for her to be struck off the medical register, which was backed by the High Court earlier this year.

However, her treatment caused great concern in the medical community, who felt she had been penalised for systemic failings and that her treatment raised far wider concerns for doctors up and down the country in an NHS already severely under strain for resources and medical staff.

“This ruling has also brought into sharp focus the difficult and pressurised environment in which doctors now work,” wrote Chaand Nagpaul, the chairman of the British Medical Association, to members of the organisation following the High Court ruling that stripped Bawa-Garba of her licence in January. “Like many of you, I believe that the greatest risk to patient safety is an under-resourced, understaffed NHS which is forcing doctors, nurses and all healthcare staff to work under the most challenging of conditions...” The case also attracted widespread support from the medical community, with a crowdfunding campaign for a legal challenge raising over £3,66,000, well over the targeted amount.

Ruling overturned

This week, Britain’s Court of Appeal overturned the High Court ruling, in a move widely hailed across the medical community, which will mean that Bawa-Garba will be able to return to work as a doctor. However, beyond the relief within the medical community, many are clear that the questions raised by the GMC’s handling of the case cannot be not be ignored.

“As a regulator it has lost the confidence of doctors and must now act to rectify their relationship with the profession,” said the BMA earlier this week, criticising the GMC’s “ill-judged handling of the case.” “Lessons must be learnt 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.”

“This time, it’s not Hadiza Bawa-Garba but the GMC that is in the dock,” wrote Dr Kailash Chand, a prominent NHS campaigner and honorary vice-president of the British Medical Association, on the medical community news website Pulse this week, arguing that trust between the regulatory GMC and the profession had completely broken down.

“The GMC has shown it cannot be trusted to take a neutral non-punitive approach when the fault lies in system failures.”

Others have gone further, pointing to distinct racial overtones in the handling of the case that illustrated wider and long-standing concerns of inherent biases in the system.

“We have maintained throughout this case that if Bawa-Garba had been white she would never have had to go through any of this,” says Dr Ramesh Mehta of the British Association of Physicians of Indian Origin, which has been supporting Bawa-Garba, including in the legal challenge she mounted to the GMC.

Bawa-Garba, who has a Nigerian background, is black and wears a headscarf. So concerned has BAPIO been over the treatment of BME doctors in particular that it set up a legal arm — the Medical Defence Shield in 2011, which has won many members, both within and outside the Indian-origin medical community in the UK. “I have always said that race is the elephant in the room, which they simply won’t address,” says Mehta.

Williams Review

In a submission to the Williams Review, set up by the government into the processes of pursuing gross negligence manslaughter, , BAPIO pointed to figures that showed that in a disproportionately large number of cases that the GMC had questioned tribunal rulings, and pushed instead for doctors to be taken off the medical register, the doctors involved were from BME backgrounds.

“The numbers are small but in our view they most certainly show a trend towards a bias in how the GMC deals with this group of doctors,” they wrote in a briefing note, which outlined a range of recommendations on the steps needed, including the need to formally acknowledge the issue of racial discrimination and the introduction of steps to tackle it. “On the whole things have improved they are not as bad as they were thirty years ago. The discrimination in the NHS was much more serious. However, now the discrimination is much more subtle,” says Dr Mehta.

He points out it matters greatly for the UK and beyond – around 41 per cent of doctors in England are of Black Minority Ethnic backgrounds. BAPIO’s research suggests that discrimination is prevalent no matter whether a person gained their qualifications in the UK or abroad.

The proportion of BME doctors is only set to increase as Britain leaves the EU. An exodus of European medical professionals has piled pressure on the government to take action, resulting in new Home Secretary Sajid Javid’s decision to take doctors and nurses out of the cap on Tier 2 visas, highlighting the extent of the crisis. Over the years, NHS Trusts have repeatedly turned to India and other non-EU countries for doctors, particularly to work in fields such as emergency medicine, though the appeal of jobs in the UK cannot be taken for granted.

“The perception that the NHS is the holy grail of medical training and jobs in hospital and general practice sectors is fast fading. This was certainly the attraction to many of us who arrived with many expectations for our careers and family welfare, but the perception abroad now is one of unfairness in jobs, disproportionality by the GMC and racism in the NHS which has affected recruitment very significantly,” said BAPIO in their submission to the Williams Review.

“The situation will have to get better because they need BME doctors,” says Dr Mehta.

“They need Indian doctors a lot more than ever before. The Bawa-Garba case is a big wake-up call. I am hopeful. I don’t believe in miracles but that change will happen slowly and steadily.”

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