Struck off for missed sepsis

Mark Graber Mark.Graber at IMPROVEDIAGNOSIS.ORG
Sun Dec 17 15:11:35 UTC 2017

This story is indeed chilling, and adds to the sad collection of instances where medical error was addressed through legal channels.  There are similar stories of nurses and pharmacists who have been subjected to disciplinary or legal actions for unintentional safety lapses, and all of these are completely at odds with the paradigm of establishing a culture where learning about safety is maximized and blaming is minimized.  The legal system has no understanding of that concept at all.

This story brings to mind though 2 related issues that we eventually need to deal with.  If we say that unintentional error is to be expected but intentional error merits disciplinary action, where do we draw that line?  Behavior that is ‘at risk’ is a grey zone.  Secondly, we simply have no good approach to identify or deal with clinicians who lack enough competence to provide generally safe care.

Mark L Graber MD FACP
President, SIDM
Senior Fellow, RTI International
Professor Emeritus, Stony Brook University
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From: Jason Maude <jason.maude at ISABELHEALTHCARE.COM>
Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Jason Maude <jason.maude at ISABELHEALTHCARE.COM>
Date: Wednesday, December 13, 2017 at 2:02 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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