Some sick patients died. Why did he crash? “It’s terribly tragic that a child has died, but there are no winners in a system which blames tragic outcomes on a trainee. He gave evidence in support of her in her criminal trial and at the medical practitioners tribunal. According to Mrs Adcock, the expert witness at the inquest, Dr Gale Pearson, a paediatric intensive care consultant, stated that if Jack “had been given the right treatment, antibiotics, correct bolus, intensive care, consultant treatment, he would have not died when he died, how he died, the way he died – he may have still been here”. Later that month, he says he received a list of 50 changes – mostly relating to the colour and presentation of the report and the size of the charts. The tests revealed his blood was too acidic. She recalls the nurse telling her she’d checked with another doctor on duty. “I’ve made clinical mistakes including delayed diagnosis and errors in treatment. She told medical staff he had been up all night with diarrhoea and sickness. Dr Liz O'Riordan with a rescued hedgehog The centre is run by an amazing couple in their 70s who look after more than 100 orphaned and poorly hedgehogs. Cusack has serious concerns about how a document intended for reflective practice and learning for personal development was used to apportion blame in the criminal justice process. “How can somebody make that many mistakes, be found guilty by a jury and be able to practise again? Professor of Medicine (Conjoint, UNSW)Head, Gastrointestinal and Liver Unit, Prince of Wales HospitalSenior Staff Specialist in Gastroenterology and HepatologyPrince of Wales Hospital, Sydney Children’s Hospital, Royal Hospital for WomenConsultant Physician, Gastroenterologist and … She went home at 23:00 – some 15 hours after she had started her 12-hour shift – and updated Jack’s notes with what had happened at the resuscitation. “It’s my way of coping,” says Mrs Adcock. See the complete profile on LinkedIn and discover Stephen’s connections and jobs at similar companies. Teams of doctors and nurses were tasked with going through the records of patients who had either unexpectedly died in hospital or died within 30 days of leaving between 1 April 2012 and 31 March 2013. It doesn’t give the public any faith in the NHS,” she says. A social media storm ensued, accompanied by the hashtag “#IamHadiza”, with doctors wearing T-shirts and badges in her support. The doctor came over to express her condolences and Mrs Adcock thanked her for looking after Jack. Irish News; Barry Roche; January 17, 2016, 20:33; A 51 … Instead, Dr O’Riordan insisted on seeing Jack’s parents without her. The nurse later said she had also asked for a doctor to come to see Jack. During phone calls home, she could hear the hungry baby crying. “If they found these kinds of issues when the Trust’s SHMI was high but not that high, what would they find with other hospitals that had higher ones?" Though it criticised aspects of Bawa-Garba’s involvement, it also found fault with “many aspects of the care that child JA received, and many of these were system failings.”, Andrew Furlong, medical director at University Hospitals of Leicester NHS Trust, which runs Leicester Royal Infirmary, told The BMJ that the trust had “implemented a number of improvements to our systems and processes which have reduced the risk of such events occurring again.”, He added, “This was a tragic event, and in 2015 a jury reached its decision having had all the evidence presented to it.”. After her first degree at Southampton University, she studied medicine at Leicester and set her sights on becoming a paediatrician. “I therefore feel obliged to ask the GMC to investigate my clinical practice over the last 40 years to see whether I should be struck off the medical register.”. “All doctors are expect to regularly reflect honestly and openly on their practice to improve patient care,” he says. He later started vomiting and had diarrhoea, which continued through the night. “It took three months to get my little boy back, to be able to lay him to rest,” Mrs Adcock says. When Dr Hsu came to tally the results, he did not believe what he saw. Later that night, Dr Bawa-Garba called Dr O’Riordan – the consultant who had arrived in the afternoon, after double-booking himself that day – to tell him about Jack’s death. She was led away in handcuffs to a cell while her team worked out her bail conditions. “After I realised that we were actually resuscitating Jack, I just couldn’t understand why he had crashed. “Doctors became particularly concerned when they heard about all of the systems failings at the hospital and felt these weren’t heard fully in court,” says Dr Cusack, Dr Bawa-Garba’s educational supervisor, who attended parts of the trial. “I said to her, ‘I'm really sorry about the outcome – I don't know how this happened,’” she says. The judges ruled that Dr Bawa-Garba's actions had been neither deliberate or reckless and she should not have been struck off. By this time, Jack had been moved to ward 28 under the care of a different team. The role of a consultant is not just to review patients who are unwell but to recognise when a patient has been missed by junior members of the team. At 21:21 the decision was made to stop resuscitation. A normal is about two and his was 11, so I knew then he was very unwell,” Dr Bawa-Garba says. She asked to see her son. What went wrong?’”. he asks. Written by a team of experts from around the world, each chapter in Coaching Psychology will help you to understand the key concepts, providing you with the essential theory, research and applications for practice. Stephen O'Riordan Senior Automation Integration Architect (IT) at AbbVie Ireland. Experts later said the interruption to the resuscitation had not contributed to his death – but he shouldn’t have been given enalapril and he should have been given antibiotics much earlier. He wasn’t really very with it,” says Mrs Adcock. Professor Stephen Riordan. The hospital’s own investigation, which flagged up all the contributory factors and failings that had led to Jack’s death, wasn’t put before the jury, he says. “Trainees felt that their colleague was being scapegoated and taking the blame for a series of system failings,” he said. A terrible confusion was about to follow. Dr Bawa Garba applied for leave to appeal against her conviction, but this was denied in November 2016. The boy’s hands and feet were cold and had a blue-grey tinge. The police investigation came to nothing. “When I reassessed Jack, I was falsely reassured because he was alert, drinking from a beaker, responding to voice, pushing his mask away because he didn't want it on his face,” she replied. As soon as the meeting finished, Dr Bawa-Garba says she was sent home by Dr O’Riordan. “That isn’t unique to this trust, nor was the difficulty in recruiting doctors and nurses, too few were coming out of training nationally, a fact which the NHS locally and nationally is still struggling with. On 4 November 2015, the jury found Dr Bawa-Garba guilty. It’s a description Mr Furlong rejects. Find out contact details, practice location and patient reviews about the doctor. There was nothing in the report by Dr David O’Neill, the pathologist, or from toxicology, that suggested it played a role, she said. The three pleaded not guilty to the charge of manslaughter by gross negligence at the start of what was to be a four-week trial. “We have to help them understand what happened, to be open about what happened, to apologise for what happened,” he says. “Huge solidarity with this doctor who could be any one of us NHS doctors working in an overstretched, purposefully underfunded and dangerously understaffed service,” added another. They had tried but couldn’t get blood, so Dr Bawa-Garba went to do it herself. But she says Dr O’Riordan told her that she had to get on with her clinical duties. They said doctors and nurses at the hospital had been raising concerns about staffing before Jack’s death. Charlie Massey, chief executive of the GMC, says that after receiving legal advice the GMC applied to the High Court to overturn the decision made by its own tribunal. She added: “I should not have relied on the nurses to get back to me with the clinical deterioration as I normally do.” She should have looked at the nursing chart, she said. Doctors, medical errors, and the justice system doi:10.1136/bmj.i6274; Editorial Shadow of the law in cases of avoidable harm doi:10.1136/bmj.i6268. But Dr Bawa-Garba says she didn’t want him to have the enalapril, because he was dehydrated and it might have made his blood pressure drop too much. “The last picture I have of Jack is him sitting up drinking from a beaker, nothing prepared me to see him crash,” she says. Genealogy profile for Stephen John O'Riordan Stephen John O'Riordan (1958 - 1993) - Genealogy Genealogy for Stephen John O'Riordan (1958 - 1993) family tree on Geni, with over 200 million profiles of ancestors and living relatives. They didn’t agree on how much it had affected him, though. Stephen Paul O'Riordan was born on month day 1963, at birth place, to O'Riordan and Clare Eithne O'Riordan (born Gunn). Dr Stephen O'Riordan Consultant in Paediatric Endocrinology, University College Cork, Ireland Ireland 323 connections Stephen passed … Dr Nadel said the little boy was “well on down the slippery slope by then” and had a “barn door” case of sepsis. Based on what I read I was expecting around 10% of patients to have received unacceptable care,” he says. . When a junior doctor was convicted of manslaughter and struck off the medical register for her role in the death of six-year-old Jack Adcock, shockwaves reverberated through the medical profession. The Summary Hospital-Level Mortality Indicator (SHMI) uses adjusted data from individual trusts to flag up a higher-than-expected number of deaths. “I remember being absolutely terrified, thinking, ‘I haven’t done anything, why are the police here?’” Mrs Adcock says. All doctors make mistakes and that is understandably scary for patients, he says. Some doctors have expressed concern that its role in Jack’s cardiac arrest has been underplayed. Jenny Vaughan, a neurologist who runs Manslaughter and Healthcare (www.manslaughterandhealthcare.org.uk), an online resource that follows prosecutions of healthcare staff in the criminal courts, has been watching Bawa-Garba’s case. She is a Chartered Psychologist, International Society for Coaching Psychology Accredited Coaching Psychologist and Supervisor, and a CABA Chartered Certified Coach. But when she went to view them on the computer system, it had gone down. This we believe would have a detrimental effect on the overall quality and safety of healthcare.”. The hospital appointed Dr Ian Sturgess to consider improvements in the emergency sector. The recommendations were wide-ranging but included: - Robust processes for helping staff return to work after periods of protracted leave or maternity leave, - A dedicated presence of consultants on the children’s assessment unit, - New guidelines on the use of agency nurses, - Better visual prompts for staff about abnormal blood results. She set up an online petition, with thousands of people pledging support. “Drs working flat out in a broken and unsafe system,” said another. It suggests that factors that let her down were her interpretation of biochemistry and venous blood gas results and her “lack of clear communication.”. But Dr Bawa-Garba says she wishes she had given him antibiotics sooner. He was due his second dose of the day. The University Hospitals of Leicester NHS Trust was not the worst, neither was it the best, he adds. The BMJ understands that these were fed into the hospital’s investigation. “I had two very young children - my oldest is severely autistic and goes to a special needs school. She told the team to continue the resuscitation. But in fact nearly a quarter of patients in the report had received “unacceptable care” – serious errors had been made that would have increased the risk of harm. The court heard that Stephen O’Riordan, duty consultant paediatrician that day, had written them down at evening handover but chose not to review … View Stephen O'Riordan’s profile on LinkedIn, the world's largest professional community. 0 Reviews. But she says she was concentrating so much on the CRP that she failed to register that his creatinine and urea were also high – signalling possible kidney failure. “I sat in that small room and prayed,” she says. They said consultant cover had been patchy and that factional infighting between consultants had caused problems for trainee doctors - it wasn’t something they could speak out about, they had had to keep their head down. Dr Bawa-Garba has been on a long journey. In 2013, Leicester GPs had started to become concerned about the University Hospitals of Leicester Trust’s SHMI. Then, the following February, he received another raft of changes. The following day, she was back at work at the assessment unit. because of his duty of patient confidentiality.”. They read out Jack’s results and she noted them down. In that moment, Dr Bawa-Garba didn’t recognise her. This is a mistake,’” she says. “Families can … And Dr Bawa-Garba volunteered to step in. “I’m a very private person, but I had my face in the newspaper.”. “Jack was really lethargic, very sleepy. Mrs Adcock says she feels that these doctors are blaming her for her son’s death. Consultant Dr Stephen O’Riordan arrived at the hospital. The GPs went on to say that in their view the hospital was “potentially on a par with Mid Staffordshire Hospital”. On the fifth day of the trial, Dr Stephen O’Riordan, the consultant who was meant to be on duty the day Jack died, took the stand. They had to consider the circumstances within which the defendants were working when considering if they were guilty. But some local GPs were frustrated and thought there was a resistance to change and a reluctance to talk openly about the problems. She says she was looking out for one particular test result called CRP, which would confirm whether Jack’s illness had been caused by bacteria or a virus. So Mrs Adcock gave it to him. Diabetes Care 32 1020–1022. “He was a little more alert and we thought he was getting better,” Mrs Adcock says. “I think that we let Jack Adcock down - there’s no doubt about that in my mind,” says Andrew Furlong, medical director since 2016 of University Hospitals Leicester, which includes the Leicester Royal Infirmary. “I was beating myself up about every single detail and obviously wishing that I had recognised sepsis, so we spoke about that and I was very open and explained everything,” she says. “We said if there’s fear in the system people are frightened about identifying hazards, about speaking up when they make a mistake about speaking up when something goes wrong then how could it ever get safer?” he says. Dr Bawa-Garba looked for Jack’s blood results from the lab. Following the Mid Staffs scandal – where hundreds of patients were exposed to “appalling” levels of care at Stafford Hospital – a new measure to help hospitals spot problems was introduced. “We couldn’t speak to anyone – we weren’t really told anything.”. In October 2014 they sent a letter sent to former Health Secretary Jeremy Hunt and Simon Stevens, chief executive of NHS England, warning of “broken systems serving patients and carers in our area”. He then told her that they needed to discuss Jack’s death properly because he thought she hadn’t highlighted to him how ill Jack was, she says. She noted a raised CRP level, the serum pH of 7.084 and the lactate concentration of 11.4mmol/L. She was sent home immediately afterwards and told not to come back until she was asked to. Other aspects of the investigation into Jack’s death have also led to disquiet and anger among doctors in Leicester. She had only recently returned to work after having her first baby. The cells below were a constant reminder of what might happen to her. She gave him a large boost of fluid – a bolus – to resuscitate him. While doctors are responsible for their actions, many feel Dr Bawa-Garba was let down by the consultant on call both on the day that Jack died and subsequently,” Dr Cusack says. The inquest was adjourned shortly after Dr Pearson’s expert testimony and the case was referred back to the Crown Prosecution Service, which reviewed its decision to prosecute. There she would see lots of children with sepsis, some of whom would get better then get worse – like Jack, she says. “The officer said, ‘We’re investigating Jack’s death as a possible manslaughter case and we need you to come down to the station,’” she says. So Mrs Adcock approached the GMC to see if she could appeal. “I don’t think I registered because I said, ‘Er, OK – but I need to finish my shift and I have teaching tomorrow.’ I was supposed to be teaching some medical students the next day. The whole hospital was affected. View Stephen O'Riordan’s profile on LinkedIn, the world's largest professional community. Jack died from sepsis. View the profiles of professionals named "Steven O'riordan" on LinkedIn. In my mind I’m thinking this is going the right way.”. Get up to date with the latest news and stories about the person Steven O Riordan at The Irish Times. In 2013, Professor Don Berwick MD, president of the Institute for Healthcare Improvement in the US, was asked by the then prime minister, David Cameron, to advise about how to improve patient safety in the NHS following the Mid Staffs scandal. One of the less experienced doctors in the unit had been unable to do Jack’s next blood tests. She says Dr O’Riordan noted down what she said and ordered repeat blood tests. Before her 13 months’ maternity leave, she had been working in community paediatrics, treating children with chronic illnesses and behavioural problems. “The best way to protect patients is by supporting doctors. “Doctors work in teams and the consultant is in charge of that team. NHS England declined to comment to the BBC. 6. The X-ray showed that Jack had a chest infection so she prescribed antibiotics. In February 2012 – a year after Jack’s death, and just after Dr Bawa-Garba had given birth to her second child – she received a phone call from the police. David Grant, a consultant in paediatric intensive care at University Hospitals Bristol NHS Foundation Trust with a special interest in simulation and human factors, told The BMJ that the case risked setting a precedent that “will undermine all attempts to create a culture of openness and learning aimed at improving patient safety through proactive healthcare systems improvement.”, He said, “Without such a system and culture in place, organisations and healthcare systems will continue to learn the same lessons over and over again, while patients continue to come to preventable harm.”, Grant emphasised the need for people to be accountable for their errors, which can then “serve as triggers for systems analysis and organisational learning focused on preventing future occurrences.”, Indeed, the report that resulted from the serious untoward incident review after Jack’s death, seen by The BMJ, included recommendations to improve support for trainees and to enhance patients’ safety. The case of Hadiza Bawa-Garba has left the UK medical profession rattled. This is where you learn the most, Dr Hsu says. Dr Bawa-Garba tried a number of extensions before managing to speak to someone. The BMJ has learnt that, five days after Jack’s death, Bawa-Garba was asked to meet Stephen O’Riordan, the duty consultant at the time of the incident, in the hospital canteen. Nor did the hospital comment, when asked by The BMJ, on the appropriateness of how Bawa-Garba was asked to reflect on the incident by O’Riordan. Mr Andrew Thomas QC, for the prosecution, told Dr Bawa-Garba that no-one was suggesting that she deliberately set out to harm Jack Adcock. Sepsis is when the immune system overreacts to an infection and attacks the body’s own organs and tissues. “That's two. After Jack’s death, the police started their own investigation and the Adcocks praise them for the support they have given the family. It was the same for CAU ward sister Theresa Taylor. “I remember on the morning of the sentencing telling my parents that I didn’t want them there in the court in Nottingham,” she says. Dr Bawa-Garba had already started to write down her reflections. A number of other aspects of the case have also given rise to controversy. “However, we would be concerned if the duty of candour and educational reflection was wrongly influenced by court cases and convictions of medical professionals for gross negligence manslaughter. I understand that because they’re thinking if we make an honest mistake we’re going to be charged. When she reached the fourth floor, at least 11 people were already in the side room, she says. Not all failings were heard, he says. “I have no evidence of that at all,” she said. An overworked and under-supported doctor was thrown under the bus by the GMC.”. “My hope is that lessons learnt from this case will translate into better working conditions for junior doctors, better recognition of sepsis, and factors in place that will improve patient safety.”. The nurse was doing his observations - including his temperature, heart rate and blood pressure - but did not record them regularly. They were sent a copy of the Leicester Royal Infirmary investigation and invited to discuss it, but they didn’t want to. He wanted to talk about how things could have been done differently to stop it happening again, she adds. Stephen has 1 job listed on their profile. Cusack, who was asked by trainees and the hospital trust to lead a debriefing for staff affected by Jack’s death, said that trainee doctors working in Leicester were concerned and angry about the conclusions of the trust’s investigation and the subsequent legal process. Grant said that although he did not want to comment on the specific details of the case, the Royal College of Paediatrics and Child Health’s training standards required clinical supervision to ensure patients’ safety. Dr O’Neill said whether or not enalapril played a role was beyond his expertise. Not a day goes past, Dr Bawa-Garba says, when she doesn’t think about the day Jack died. “It just didn’t sink in.” She remembers them saying he had had pneumonia and an internal bleed. Measurements of the levels of enalapril in Jack’s blood were not taken as they were thought not to be useful. Meanwhile, Nicola Adcock was waiting outside the room. He said, ‘No, you need to go home, you have been charged with manslaughter.’”. I ran out of the room, saying, ‘Can someone come and look at Jack?’”. For the Adcocks it was the day they had been waiting for. Back in the CAU, Dr Bawa-Garba was asked to see Jack Adcock by the nurse in charge, Sister Theresa Taylor, who was worried he had looked very sick when he had been admitted. The night Jack died, Mr and Mrs Adcock were taken into a room off the ward, where they were met by doctors they’d never seen before. Stephen Martin O'Riordan obtained his title of Licentiates and Bachelor of Medicine and Bachelor of Surgery in RCP of Ireland and the RCS in Ireland, National University of Ireland with one thousand and one hundred and ninety fifth doctors completed education 1996. In his evidence to the practitioners tribunal Cusack said that although a trainee might not realise the full significance of this abnormal blood gas result, a consultant should. Aspects of the trial have caused consternation among the medical profession. Then she asked for a pen to write. On 5 October 2015, Dr Bawa-Garba found herself in the dock in Nottingham Crown Court, along with two other defendants - nurses Theresa Taylor and Isabel Amaro. Dr Bawa-Garba was struck off in January 2018, meaning that she could no longer practise medicine in the UK. The hospital representatives apologised for the boy’s death and said they would investigate. Join Facebook to connect with Stephen O Riordan and others you may know. “On the reflection I did following this incident, those were the points that I looked at,” she said. Congress Theme – 2020 Vision: Navigating adversity with coaching psychology and positive psychology Welcoming video to the Congress with Dr Siobhain O’Riordan & Prof Stephen Palmer This Four-Day Virtual Congress offers four Masterclasses on Day 1, 2 and 3 and on Day 4, Keynote and Invited Speakers, Skills-based Sessions and Poster Presentations. technical support for your product directly (links go to external sites): Thank you for your interest in spreading the word about The BMJ. Dr Bawa-Garba did not, however, ask Dr O’Riordan to review Jack. But when asked if it was a “significant factor” in Jack’s rapid deterioration, he said this was “consistent with the clinical history”. But he says he has sympathy for Dr Bawa-Garba. The negligence had to be gross or severe, he said - what they did or didn’t do had to be truly, exceptionally bad. His practice focuses primarily on investment (both institutional and private equity) and on development (acting for developers and investors), with a particular emphasis on transactions requiring solutions to issues arising on structuring and financing. The decision has certainly been unpopular among the medical profession. She then asked for an X-ray to check Jack’s chest. What she didn’t know was that Jack had subsequently been moved to the same ward as the boy who had crashed in the morning – ward 28. The police then arrived – there was to be an investigation after the unexpected death of the child. “For a split second you think, ‘Yes, we’ve got justice for our son’s death,’” says Mrs Adcock. On 25 February, a week after Jack’s death, Dr O’Riordan asked Dr Bawa-Garba to meet him in the hospital canteen, rather than the office he shared with other consultants. She wanted to know about the interrupted resuscitation and so they talked about that too. 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