Struck off for missed sepsis

Ruth Ryan ruth at RYAN-GRAHAM.COM
Wed Dec 13 20:53:58 UTC 2017


Thank you for sharing this extreme example of the interplay of cognitive and systems factors.

A Differential Diagnosis generator tool is certainly a great help-- but if you handed one to a harried physician in a situation like this, she might catch this diagnosis while missing the one in the next room.
It’s a stark demonstration of what’s wrong with the punitive, shaming approach. It results in exacerbation of burnout factors and hurts patients. In this case, there’s now one less physician in an understaffed situation.
In the US, it exacerbates the tendency for doctors to gravitate toward the lower-risk, higher-paid specialties.

There is a body of research in the US showing in detail how every patient added to a nurse’s load over the norm increases the patient death rate by 7% (Aiken et al.).  Precisely nothing has been done about this in all the years since this research has been published, replicated and replicated again.

Scary indeed.  Was Dr. Hadiza’s draconian and unconscionable 2 year jail sentence lifted?

From: Jason Maude [mailto:jason.maude at ISABELHEALTHCARE.COM]
Sent: Wednesday, December 13, 2017 12:25 PM
Subject: [IMPROVEDX] Struck off for missed sepsis

This story gives a rather chilling spin on a case of delayed diagnosis of sepsis and subsequent malpractice case in the UK. The GMC (regulates doctors in the UK) has decided the doctor should be struck off but hundreds of doctors have rallied around to her support. Is this a case of doctors closing ranks or has her treatment been unfair punishing her as an individual while there were several systemic issues?

My initial reading reminds me of Captain Sully when the air accident investigators assume that he should have made an instant decision to try and get to La Guardia….

The Daily Mail article gives the background and I have attached the actual Tribunal report.

This blog in the BMJ and article in the New Statesman give a more ‘medical’ view:

Dr Hadiza was obviously under huge pressure that day covering 3 separate units. The hospital later admitted to finding several systemic issues in their investigation. The GMC representative said that she should have had sepsis in mind as a diagnosis. Her initial diagnosis was gastroenteritis.

Is this a case where the clinician was just so busy and couldn’t be expected to do anything else or the health system, knowing that dx mistakes will happen when it’s so busy, should require the clinician to work up a differential?

I have attached 2 screen shots from a DDx tool with first showing the presenting symptoms of ‘diarrhoea, vomiting and difficulty breathing’ and then a 2nd screen shot with the presenting symptoms and the blood gas result showing high lactate. As you see, sepsis appears in 2nd position with just the presenting features and 1st with high lactate.
Does a tool like this help a clinician to be able to think more broadly and clearly while under pressure or does it hinder?

She was clearly under huge pressure so it would obviously be hard to think calmly but a DDx tool that is quick and easy to use could just possibly have triggered her to suspect sepsis which would certainly have changed how she managed the patient subsequently.

So, it’s a question of either too busy to do a DDx or so busy that must do a DDx? What are your views?


Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890<>



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