Opinion: A career destroyed in one 'exceptionally bad' day

Dr Justin Coleman reflects on a tragic case that has reverberated around the world.


The disheartening case of UK paediatric registrar Dr Hadiza Bawa-Garba sends shivers down my spine.

Bad day

The tragic death from sepsis of a six-year-old boy with trisomy 21 has had reverberations around the world.

His doctor’s erasure from the medical register has made headlines in the UK, where her colleagues are highlighting the contribution of hospital system failures and overworked medical staff.

Meanwhile, in Australia and New Zealand, 1500 doctors co-signed a letter of support for Dr Bawa-Garba, saying they felt sickened at the “gross injustice” and “individual scapegoating” she has suffered.  

In my view, the latest trigger for the outrage — the UK High Court’s decision to strike Dr Bawa-Garba’s name off the medical register — is not the crux of the injustice.

Explained: Precisely what were Dr Bawa-Garba's clinical failings?

The court’s view was that, given a jury had already determined that “Dr Bawa-Garba’s failures that day were not simply honest errors or mere negligence, but were truly exceptionally bad”, then the manslaughter conviction that followed provided grounds for her being struck off.

That isn’t too remarkable a legal opinion. B follows A.

The injustice, in my view, lies in the original finding that the registrar’s actions that day were truly, exceptionally bad.

No one, including the doctor herself, doubts they were bad. She stuffed up. Print out the blood gas numbers in a court of law and stare at the ones in red, and it is clear that more should have been done and faster. But truly, exceptionally bad? To the point where none of the rest of us would ever do the same?

Everyone agrees the registrar was a good, competent doctor, before and since. There was no suggestion that her actions bore any hint of selfishness, laziness or callousness.

It was Dr Bawa-Garba’s first full-shift in an acute setting since going on maternity leave, covering the ward and ED.

The court heard evidence she was heavily involved in treating other children, including a baby that needed a lumbar puncture. 

The boy’s blood gas results were delayed by some hours due to a lab system error, and he had been “sitting up and laughing” when she last examined him.

In the end, it was a conviction by numbers. The wayward blood gases accurately reflected the boy’s deteriorating sepsis, but the busy doctor on her first shift back failed to recognise their gravity.

I would hope— desperately hope — that I wouldn’t make the same mistake. Not ever.

Not even on a truly, exceptionally bad day, while running around wards looking after sick children, with nurses I didn’t know and without a supervisor.

I’d have just completed my first lumbar puncture since I returned from parenting leave, and I finally get the chance to look at those numbers.

On a better afternoon, pattern recognition clicks in, or I sit down and think about them in detail, or look up a reference guide, or phone my supervisor at home, or ask a friend.

But I don’t. And that afternoon destroys my career forever.

Being permanently struck off and copping a two-year suspended jail term certainly meets the description of a truly, exceptionally bad punishment, the sort of punishment that might serve as justice for that rare, odious doctor who deliberately and knowingly does awful things to patients.

For the rest of us, as we arrive at work tomorrow we can only hope that our afternoon won’t turn out to be an afternoon anything like Dr Bawa-Garba’s.

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