Struck off for missed sepsis

Tom Benzoni benzonit at GMAIL.COM
Sun Dec 17 16:37:47 UTC 2017


As a practicing EM doc, the coverage of this case leaves a lot to be
desired.
Or, to put it more simply, from the information I'm given, I know
absolutely nothing about the case.
And, no, I don't trust the summaries I've read; they come nowhere near to
telling me what I'd need to know to be certain about the care rendered.
That lack of pertinent detail raises huge red flags for me.

To take the outcome and say that the preceding care was negligent amounts
to fiction of the worst type, one that seeks to confuse and cover up.
This is a classic cognitive bias that we should call out on initially
viewing it, challenging those who want the case heard to present facts.

So I'd deep-6 the conversation except to say this forum should stick with
discussing facts, discarding fantasy as unworthy of the minds hereon.

tom benzoni

On Sun, Dec 17, 2017 at 9:11 AM, Mark Graber <
Mark.Graber at improvediagnosis.org> wrote:

> 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
>
>
>
>
>
>
>
> *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
> *To: *Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> *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 http://www.dailymail.co.uk/
> news/article-5146713/Doctors-rally-against-efforts-strike-Bawa-Garba.html
> and I have attached the actual Tribunal report.
>
>
>
> This blog in the BMJ and article in the New Statesman give a more
> ‘medical’ view:
>
>
>
> http://blogs.bmj.com/bmj/2017/12/08/rachel-clarke-hadiza-
> bawa-garba-could-have-been-any-member-of-frontline-staff-
> working-in-todays-overstretched-nhs/
>
>
>
> https://www.newstatesman.com/politics/health/2017/11/case-
> hadiza-bawa-garba-should-worry-every-doctor
>
>
>
>
>
> 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?
>
>
>
> Regards
>
> Jason
>
>
>
>
>
> Jason Maude
>
> Founder and CEO Isabel Healthcare
> Tel: +44 1428 644886 <+44%201428%20644886>
> Tel: +1 703 879 1890 <(703)%20879-1890>
> www.isabelhealthcare.com
>
>
>
>
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>
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
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>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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