Reflective learning: What the Dr Bawa-Garba case means for GPs in Australia

Neelima Choahan

20/08/2018 12:27:35 PM

Following Dr Hadiza Bawa-Garba’s successful appeal of a lifetime ban from the UK medical register, many practitioners remain concerned about their own learning processes. But medico-legal experts told newsGP that Australian practitioners are on safer ground.

Dr Bawa-Garba successfully appealed a lifetime ban from the UK medical register. (Image: Nick Ansell)
Dr Bawa-Garba successfully appealed a lifetime ban from the UK medical register. (Image: Nick Ansell)

It was 2011 and the UK’s Dr Hadiza Bawa-Garba, a junior doctor specialising in paediatrics, had just returned to work after 14 months of maternity leave.
The registrar was on her first full day at the Leicester Royal Infirmary Hospital when she was called to treat Jack, a six-year-old boy with Down’s syndrome. He also had a hole in his heart.
Jack was brought into the hospital with dehydration caused by vomiting and diarrhoea, his breathing was shallow and his lips were slightly blue.
In fact, when Jack was admitted to hospital he was experiencing pneumonia (a Group A streptococcal infection, also referred to as a ‘GAS’ infection), which caused his body to go into septic shock. The sepsis resulted in organ failure and caused his heart to fail. Despite efforts to resuscitate him, Jack died.
In 2015, Dr Bawa-Garba, was convicted of manslaughter by gross negligence and sentenced to two-year imprisonment, which was wholly suspended. An independent tribunal also suspended her from the medical register for 12 months.
But, last year, the UK’s regulator General Medical Council appealed to the High Court and succeeded in having Dr Bawa-Garba permanently struck off the medical register.
Dr Bawa-Garba, in turn, appealed that decision. She was ultimately successful, with the UK Court of Appeal last week restoring the original order that she be suspended for 12 months.
Safe reflection
It is widely believed the self-reflections that formed part of Dr Bawa-Garba’s continuing professional development were used against her in court. But Dr Penny Browne, a GP and the Chief Medical Officer at AVANT medical defence organisation, said that is a misconception. Dr Bawa-Garba’s professional reflections, written in her educational portfolio, were not submitted into court evidence.
However, Dr Browne told newsGP, the case has raised a lot of anxiety among health practitioners in Australia.
‘This case has had a significant media storm and we have had a lot of enquiries,’ Dr Browne said.
‘Doctors feel, “There, but for the grace of God, go I. That this could happen to any one of us. We could go to work one day do our best, make an error and this terrible outcome that has happened to Dr Bawa-Garba could happen to any of us”.’
Online reflection is part of the RACGP’s Quality Improvement and Continuing Professional Development (QI&CPD) planning learning and need activity, PLAN. The aim is for GPs to review their current knowledge and skills, and identify areas of focus for their general practice learning necessary to meet the evolving needs of their patients, their community and themselves.
Unlike the reflective diaries used in the UK, PLAN is not a tool used to measure competence or reflect on clinical cases and performance.

Helen_Penny-hero.jpgL–R: Dr Penny Browne said she encourages reflective learning, but GPs should take some measures to protect themselves; AVANT lawyer Helen Turnbull believes reflective learning should have legal privilege.
Dr Browne said she encourages reflective learning; however, GPs can take some measures to protect themselves.
‘We should be encouraging doctors to be able to reflect and learn from their errors,’ she said.
‘But we would recommend that they do it in a fashion that it is not identifiable either in relation to a particular patient or particular circumstances, and maybe even should change some of the facts in order to make sure that that was not even in retrospect identifiable.’

Dr Browne said AVANT is also working with the Medical Board of Australia to develop safeguards to offer a degree of protection to the author for that document to not be used for a range of legal proceedings.  
‘We will be seeking for there be legal privilege attached to the self-reflection,’ Helen Turnbull, AVANT’s Special Council Professional Conduct, told newsGP.
But Ms Turnbull said the major difference between Australia and the UK is that to be charged for manslaughter in Australia, there must be a close correlation between moral culpability and legal responsibility.
‘To meet the elements of manslaughter by criminal negligence, you have to have a duty of care between the doctor and the patient,’ she said.
‘You need to have breached that duty, and that can be by an act or by omission and, importantly, the breach of duty must have caused the death, that the act amounts to gross criminal negligence – and this is the essential part – merits criminal punishment.’
Ms Turnbull said gross criminal negligence in the UK does not have test that it ‘merits criminal punishment’.
Dr Browne said personal reflection ultimately helps GPs become better doctors.
‘If doctors were made to write personal reflection statements and they weren’t protected … there is a sense it will lead to less honesty and openness in those statements by doctors,’ she said.
‘[Then] there is a fear that doctors would not actually get that genuine learning from doing that reflection, which kind of is against the purpose of the reflection.’
Ms Turnbull said the process is fundamentally about patient safety.
‘Self-reflection [is] a good way of learning,’ she said. ‘It is critical to protect that type of reflection,’ she said.

Hadiza Bawa-Garba medical register reflective learning

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Dr Muhammad Umer   21/08/2018 7:03:46 AM

Let us not kid ourselves- words and reassurances mean nothing.
A court can subpoena records - and that's that!
Even a legislation to protect the reflective learning may not protect the doctors(s) because there are exceptions to such legislation - for instance, "public interest" and above all "patient safety".

And once that option is there, there is no stopping it.

Rodney Jones   21/08/2018 7:12:22 AM

I have yet to see the historical and medical facts of this case against Dr Bawa Garba laid out . It still beggars belief that she could have been treated in this way if as appears she was desperately trying to do her duty against enormous odds.

Could all the relevant facts be put out in summary form. If as is claimed the reflective learning was never submitted to the court it seems to have become public knowledge, and would thus have had an overwhelming influence on decision makers.

And what steps have been taken against those who set her up to "fail"

Rosalie Schultz   21/08/2018 2:25:51 PM

Here's a summary of the event as described by a team of concerned UK paediatricians.

Jeet Patel   21/08/2018 9:41:38 PM

It has become evident following an excellent article from the BBC recently
( )
that Dr BG was made to read out in court her personal reflections line by line during the trial... I’m not sure how Dr Browne has concluded that it is a myth that her reflections were used in court against her ? They might not have been submitted as evidence but they certainly influenced the trial.

Dr Norman brown   22/08/2018 8:19:27 AM

If jack was admitted the responsibility for his management would have been vested in the specialist he was admitted under. Why is there no mention of the specialists culpability in this story? Why does the pneumonia diagnosis sometimes take more than 24 hours in the best of hospitals? It appears that all the facts of this case are not given.

Dr Molony   22/08/2018 6:22:26 PM

I think to say that her notes were not presented as evidence is disingenuous.
Her reflection was done with the consultant who was not supporting her on the unit on that day, having booked a teaching session outside the hospital.
This was done at a time when she was distraught about being involved in the death of a child.
There is a feeling that he pushed her into a reflection of her failings rather than comment on systematic failings.
Apparently she would not sign the notes that were made.
The reflections were made available to expert witnesses and counsel.
She was cross examined on the contents of her reflection.
I suspect that in retrospect, ie reflection on the reflection, she would reflect on the impact on her of working in a dysfunctional department wnich was understaffed medically and with nurses.
I know a lot of doctors here feel she has been the fall guy, unfairly taking one for the system and her colleagues.

Dr Susan Britton   26/09/2018 11:05:40 AM

I would be interested to see Dr Penny Browne's response to these comments. To what extent do the systemic problems such as excessive patient load due to understaffing and IT problems mitigate against error such as DR BG made? What happened to no blame reporting in the hospital system? I am teaching medical error to medical students and it appears this case changed the game for us as practitioners? We have been taught about Root Cause Analysis of error but to what extent are these many root causes weighted in cases such as this?

Dr Vuchuru Anila Prem Reddy   20/04/2023 7:54:35 AM

What a disgrace the GMC is….time and time again it acts in the most extraordinary way……Is racism part of the story?AHPRA is not far behind.Dysfunsionality,poor management,understaffing,poor supervision,scapegoating…..Where have I heard that before…..There is unacceptable practice being accepted all over the UK and Australia….Nothing scientific ever gets done by the regulators or ombudsmen about this and frankly I suspect the gong hunting takes precedence