Saturday, 17 March 2018

Dr Bawa-Garba's and responsibilties of many people

Dr Hadiza Bawa-Garba, arriving at Nottingham Crown Court todayPhotograph: Daily Mail

Dr Bawa-Garba is a Paediatrician who has worked in Leicester Royal Infirmary Hospital.

The Uniform and Dress Code Policy in University Hospitals of Leicester NHS at the time clearly recognised purposes, and principles of the policy one of which is:

"Ensuring that the individual promotes a clean, smart professional appearance, building public trust, confidence and promoting a positive image for the Trust - First Impressions Count as stated in the Caring at its Best standards and UHL Values."

Many doctors, in many medical disciplines, do not wear uniforms at work because uniforms decrease trust and rapport with their patients.

In mental health setting, for example, research has shown that wearing of uniforms (including religious) is associated with with poorer compliance with medication, increased violence, unauthorised absences from the hospital and more deaths from suicides.

However, Department of Health refused, now for twenty years,  to make a national policy on workwear and left it to the local NHS trusts to create them. This led to loss of many lives.

The Uniform and Dress Code Policy in University hospitals of Leicester NHS (2010):

"7.8 Female members of staff who for religious reasons need to cover their hair and neck by the wearing of a dark coloured scarf are permitted to do so. The material must be able to withstand a 60 degree mechanical wash".

The medical regulator, the General Medical Council, condemned research by Dr Helen Bright on approachability of social worker wearing religious uniform (Christian) in mental health setting as serious professional conduct. The research has been published HERE.

Dr Bawa Garba had unblemished record until 18th February 2011 when she returned from maternity leave to her work as Registrar in Paediatrics. Her department was understaffed: short of two doctors and a nurse, IT did not work, and staff did not inform her when some of the results of investigation arrived.

A child, Jack Adcock, who had Down's Syndrome, was admitted following illness lasting two days. He had vomiting, diarrhoea, and difficulty breathing. His GP prescribed only one medication Enalapril following cardiac surgery in the past. Dr Bawa-Garba wisely stopped it. Enalapril has serious potential side effect i.e. cardiac arrest. This fatal side effect is more likely to occur when patient is already hypotensive and/or having abnormal levels of electrolytes in his blood.

Down's syndrome causes many impairments in the immune system, and has much higher susceptibility to death from sepsis. The most common infections in this syndrome are those of the lower respiratory tract. These are more severe and frequent than in normal population.

Additionally, there is evidence of greater sensitivity to some drugs leading to increased mortality rate.

In the case of Jack Adcock, it was claimed by experts, there was evidence of sepsis and changes in blood biochemistry that demanded faster response.

Enalapril can cause electrolyte abnormalities such as raised potassium which can be fatal causing heart attack. This means that even if there are staff shortages the chances of successful resuscitation are very much diminished unless it is recognised.

There is description of one successful resuscitation hyperkalaemia case in scientific literature which involved haemodialysis, but patient was not on Enalapril and did not have Down syndrome. There is no public information of the details of what "crash team" decided to do when cardiac arrest occurred. Because Enalapril was given by mother without Dr Bawa-Garba prescription there would be no medical record of it on the prescription chart when resuscitation team arrived. In other words, there was no record and it was not because Dr Bawa-Garba had poor record keeping skills..

In review of this case hospital found numerous failings in the system and some in Dr Bawa-Garba. About 90 recommendations were made.

After criminal proceedings, GMC's tribunal imposed on Dr Bawa-Garba a suspension of her registration for a period of one year. This sanction was overturned by the High Court on GMC's application for the sanction of erasure.

Crown Prosecution Service was reluctant to prosecute initially. But experts at coroner's inquest claimed there was a case of manslaughter by Dr Bawa-Garba. Coroner stated that Enalapril played part in the death of Jack adcock. A two year prison sentence was imposed on Dr Bawa-Garba and suspended for one year. Her appeal was unsuccessful.

During the sentencing process it was stated that Dr Bawa-Garba had a child with autism, a condition of high heritability.

  It has been suggested in one theory that autism may stem from problems with prediction.

" In Ayaya’s telling, her autism involves a host of perceptual disconnects. For example, she feels in exquisite detail all the sensations that typical people readily identify as hunger, but she can’t piece them together. “It’s very hard for me to conclude I’m hungry,” she says. “I feel irritated, or I feel sad, or I feel something [is] wrong.  Information is separated, not connected.” It takes her so long to realise she is hungry that she often feels faint and gets something to eat only after someone suggests it to her."

In the same article later on an experiment is described on how autistic person reacts to change:

"Last year, for example, Lawson and her colleagues brought two dozen people with autism and 25 controls into the lab. They played a high or low beep, showed a picture of a face or house, and asked participants to press a button for ‘face’ or ‘house.’ At first, a high tone presaged a house 84 percent of the time, then a low tone did, then tones had only a 50-50 relation to image type, and so on. The controls slowed down whenever a run of violated expectations convinced them that the rule must have changed, but the participants with autism responded at a more consistent rate, which was slightly slower overall. The researchers concluded that the participants with autism responded as if each deviation — a house when the tone augured a face, say — signalled a change of rule, whereas typical people were inclined to write off the first few deviations as probabilistic happenstance".

In her evidence Dr Bawa-Garba said that normally blood results are on computer screen and abnormal results show in red. The day Jack Adcock was admitted IT system failed and she eventually got results over the telephone and although she wrote them down she did not quite realise their significance. The rule what is normal and what is not in blood results does not change based on the system of delivery. Of course, it is possible to mishear but that was not the claim. The reference range for each result has to be checked if not known by heart. Dr Bawa-Garba with two other doctors looked after patients on six wards and four floors. She had to keep calling the lab for all patients' lab. results.

It was alleged that she did not pay adequate attention to blood results such as raised  serum lactate. However, and more importantly, there was no scientific evidence on blood lactate levels and its correlation to  mortality in children at the time of Jack Adcock's admission. It was a contraversial and unsettled issue. It was only in April 2011 (about two months after patient's death) that Kama Ran Jat et al. study on the subject was published in Indian Journal of  Critical Care Medicine with title:
Serum lactate levels as the predictor of outcome in pediatric septic shock
They found that child's arival to the unit with a lactate level of 45mg/dl or more was actually a predictor of death.

Nonsurvivors had higher blood lactate levels at admission as well as at 12 and 24 h. A lactate value of more than 45 mg/dl (5 mmol/l) was a good predictor of death."

It is not clear from the information in the public domain on what scientific evidence Dr Bawa Garba was judged because no actual data was included in determinations or judgements, There is no mention on what evidence expert could claim with any degree of confidence how likely Jack Adcock was to survive. There was no such data at the time of patient's death according to the above paper. The coroner's inquest was in 2013 when two experts blamed her for the Jack Adcock's death despite the fact that following her initial treatment of him patient recovered enough to be fully alert and even smiling.

Corrected punctuation errors in judgement from Court of Appeal make significant difference in the meaning. Enalapril as well as Down Syndrome can cause coughs, colds and resulting breathlessness:

4. The case concerns the care and treatment received by Jack Adcock, a six year old boy (born on 15 July 2004), who was diagnosed from birth with Downs Syndrome (Trisomy 21). As a baby, he was treated for a bowel abnormality, and a "hole in the heart" which required surgery as a result of which he required long-term medication called enalapril. and He was more susceptible to coughs, colds and resulting breathlessness. In the past Jack had required antibiotics for throat and chest infections, including one hospital admission for pneumonia. However, he was well supported by a close family, local doctors and learning support assistants and he was a thriving little boy, who attended a mainstream pre-school nursery and then a local primary school. He enjoyed playing with his younger sister and was a popular and energetic child. 

Enalapril manufacturer produces Patient Information Leaflet. It was mother's duty to follow it and she did not. It states that in case of diarrhoea it should not be given without consultation with doctor. Why was there assumption by patient's mother that Dr Bawa-Garba did not prescribe medication to her son competently? Lack of trust, and/or prejudice?

The fact that Dr Bawa-Garba confused Jack Adcock at the time of his resuscitation with another child who had cardiac arrest earlier in the day is not a reflection of her incompetence but grief. Visual hallucinations are known to occur in normal people in grief situation. She quickly, within seconds, corrected herself and it had no impact on the outcome of the case.

Doctors are exposed to the high degree of psychological trauma. One of the consequences is re-experiencing of the traumatic event when reminder occurs.

Wednesday, 14 March 2018

Whistleblowing - report by Sir Anthony Hooper to General Medical Council (GMC)

Airing tonight...

One of the justifications for dishonesty in human beings arises in so called situational ethics.

Situational ethics is a concept describing human behaviour depending on the situation so that dishonesty is OK. In an experimental situation it involved monetary incentive to cheat in game against a partner.

In 2014, GMC (General Medical Council, regulator of medical profession in United Kingdom, Europe) commissioned an independent report from Sir Anthony Hooper, a retired Court of Appeal Judge, to review medical whistleblowers' treatment by GMC. In 2015, GMC published the report.

As published by GMC the terms of reference for the report by Sir Anthony Hooper have been:

 "To conduct a review of how the General Medical Council handles cases involving individuals who regard themselves as whistleblowers and who have appropriately raised concerns in the public interest. These are individuals: 

• whose fitness to practise is being investigated or determined under the General Medical Council (Fitness to Practise) Rules 2004; or 
• who have reported such a concern to the GMC.” 

There is no definition in the report of what is appropriately raised concern using law to define it or anything else. 


 Instead, whistleblowing is defined:
"3. Whistleblowing is the raising of a concern, either within the workplace or externally, about a danger, risk, malpractice or wrongdoing which affects others."  
This definition is somewhat problematic as whistleblowers can raise a number of concerns in short period of time leading to their persecution. The same whistleblowers can also make a number of very successful complaints that are not public at all and well before persecution in a particular, for example, political environment that grips the state institutions. Concerns can be raised within the workplace, within the workplace and externally or just externally. Concerns can be about criminal matter(s) (such as patients dying due to institutional neglect- corporate manslaughter). Of course, this is not convenient for some medical directors and they report whistleblowers to GMC when they sense danger for themselves. Labelling whistleblowers as inappropriately raising concerns is great escape for some doctors who even managed to get employed by GMC for many years for their services to the faulty political party. One managed to get three terms as GMC's Fitness to Practice panellist.

Image result for cartoon criminals working for justice
In point 6 of the report:

"6. It is sometimes said that a whistleblower is a person who raises concerns externally, that is with persons other than his or her employer. That is not right". As in his point 3 it could be.

The law recognises that there are whistleblowers who raise concerns in different ways including externally only because they have to do so. Various sections of Public Interest Disclosure Act 1998 deal with that aspect. 

Here are some examples:

43DDisclosure to legal adviser.

A qualifying disclosure is made in accordance with this section if it is made in the course of obtaining legal advice.

43EDisclosure to Minister of the Crown.

A qualifying disclosure is made in accordance with this section if—
(a)the worker’s employer is—
(i)an individual appointed under any enactment by a Minister of the Crown, or
(ii)a body any of whose members are so appointed, and
(b) the disclosure is made in good faith to a Minister of the Crown.

43GDisclosure in other cases.

(1)A qualifying disclosure is made in accordance with this section if—
(a)the worker makes the disclosure in good faith,
(b)he reasonably believes that the information disclosed, and any allegation contained in it, are substantially true,
(c)he does not make the disclosure for purposes of personal gain,
(d)any of the conditions in subsection (2) is met, and
(e)in all the circumstances of the case, it is reasonable for him to make the disclosure.
(2)The conditions referred to in subsection (1)(d) are—
(a)that, at the time he makes the disclosure, the worker reasonably believes that he will be subjected to a detriment by his employer if he makes a disclosure to his employer or in accordance with section 43F,
(b)that, in a case where no person is prescribed for the purposes of section 43F in relation to the relevant failure, the worker reasonably believes that it is likely that evidence relating to the relevant failure will be concealed or destroyed if he makes a disclosure to his employer, or
(c)that the worker has previously made a disclosure of substantially the same information—
(i)to his employer, or
(ii)in accordance with section 43F.
(3)In determining for the purposes of subsection (1)(e) whether it is reasonable for the worker to make the disclosure, regard shall be had, in particular, to—
(a)the identity of the person to whom the disclosure is made,
(b)the seriousness of the relevant failure,
(c)whether the relevant failure is continuing or is likely to occur in the future,
(d)whether the disclosure is made in breach of a duty of confidentiality owed by the employer to any other person,
(e)in a case falling within subsection (2)(c)(i) or (ii), any action which the employer or the person to whom the previous disclosure in accordance with section 43F was made has taken or might reasonably be expected to have taken as a result of the previous disclosure, and
(f)in a case falling within subsection (2)(c)(i), whether in making the disclosure to the employer the worker complied with any procedure whose use by him was authorised by the employer.
(4)For the purposes of this section a subsequent disclosure may be regarded as a disclosure of substantially the same information as that disclosed by a previous disclosure as mentioned in subsection (2)(c) even though the subsequent disclosure extends to information about action taken or not taken by any person as a result of the previous disclosure.

43HDisclosure of exceptionally serious failure.

(1)A qualifying disclosure is made in accordance with this section if—
(a)the worker makes the disclosure in good faith,
(b)he reasonably believes that the information disclosed, and any allegation contained in it, are substantially true,
(c)he does not make the disclosure for purposes of personal gain,
(d)the relevant failure is of an exceptionally serious nature, and
(e)in all the circumstances of the case, it is reasonable for him to make the disclosure.
(2)In determining for the purposes of subsection (1)(e) whether it is reasonable for the worker to make the disclosure, regard shall be had, in particular, to the identity of the person to whom the disclosure is made.
Although, Hooper whistleblowing report does not state exactly that state bureaucracy hates media spotlight on them he does acknowledge that there could be reprisals against whistleblowers of serious nature and would agree probably, that media attention is hated. 
The Hooper report does not state what scientific methodology he used in sampling of whistleblowers. We presume it was enough for whistleblower to be struck down by prejudiced, biased, and even fixed tribunal of some sort in order to be excluded by GMC and therefore by him as inappropriate. Tribunals label whistleblowers as non-whistleblowers or in the case of GMC. whistleblowing doctor is labelled as mad when not mad, or as cases of serious professional misconduct when there is no misconduct at all. The same psychiatric experts that GMC employed to defend paedophile doctors were used to attack whistleblowing doctor(s). Sir Anthony Hooper will be aware of them as he also wrote a report for GMC on Dr Morris Fraser, a paedophile and criticised those expert witnesses. Why is there no recommendation that these experts are checked over by GMC or referred to the courts? It would be novel, perhaps. There were complaints to GMC about these experts even before Sir Anthony Hooper ever got the job to write any reviews for GMC. We wonder if he ever got this information. Our guess is that he did not, but we could be wrong. Sir Anthony Hooper although respected for his expertise in court does not write in the style of an expert witness by listing all the documents provided to him. He is not in court and no court rules apply to him as an expert witness at GMC. He can have secret conversations with whistleblowers as well.
Image result for cartoon reformed character
Sir Robert Francis report "Freedom to speak up" recognises ethnic minorities and injustice done to other groups of doctors, on page 10, paragraph 19:"It was also clear from the evidence that there are some groups who, for different reasons, are particularly vulnerable including locums and agency staff, students and trainees, BME groups and staff working in primary care". Discrimination cartoons, Discrimination cartoon, funny, Discrimination picture, Discrimination pictures, Discrimination image, Discrimination images, Discrimination illustration, Discrimination illustrations
We tried the search tool for word "women" and found no results in Francis report. Scientific evidence is that women whistleblowers have worse outcomes in courts. In Hooper report on whistleblowing for GMC, again search tool for words women and female get zero results although he acknowledges that there are women whistleblowers as would Sir Robert Francis.

Hooper report does try to help GMC investigator by suggesting a bit of comparative methodology in investigative stages. This may help some cases of discrimination to be uncovered. We can only say that GMC sometimes does it and sometimes not. They have certainly done that in the cases won by some of their ex council members who had allegations against them brought to GMC. The case of Professor Wendy Savage is one. She and her private solicitors did take on the issue of discrimination against women and won. However, medical defence unions do not care about women and ethnic minorities to the same extent as others so they do not ask the right questions when they should. Women's rights would be pushed back during authoritarian regimes when religions of patriarchal nature are promoted as was the case with GMC during the last Labour Party governments. The right to speak up for women? Certainly, not. Employment Law cartoons, Employment Law cartoon, funny, Employment Law picture, Employment Law pictures, Employment Law image, Employment Law images, Employment Law illustration, Employment Law illustrationsGMC website page link on Sir Francis report is there on GMC website (not on Hooper's report page). Some links in the Hooper report references have not been found. For example, reference 4 link. We recommend GMC IT department use different method for linking of website pages so they do not go missing. They need a permanent bank of documents which are linked to the articles on their website.
Image result for cartoon it problemsAlthough Sir Anthony Hooper recommends to GMC investigators to  ask questions of organisations when they refer doctor to GMC if they raised concerns about patient safety or integrity of the system, we do know that some medical directors would lie endlessly and that GMC is partial to them whatever facts are documented at the hearings later on. This brings us to the start of this article: money talks. In English culture complaining is something some people even apologise for. For example: " I am not complaining, but..." Yes, English apologise from breakfast to dinner and beyond in their dreams, probably. For some people complaining has negative connotations. So, according to GMC patients and relatives complain but institutions make referrals to them.
In his report Sir Anthony Hooper refers to complaints from patients but referrals from organisations. Similar to organisations some patients can be malicious if they sense they have been caught by doctor in some wrongdoing such as criminal, fraudulent or manipulative behaviour for the purposes of housing, for example. They can also join forces with medical staff in mega mobbing attacks on whistleblowers. We do not think GMC provided Sir Anthony Hooper with the data they have on mobbing attacks. Mobbing attacks can go on for decade or longer.
Image result for cartoon complaining

Sir Hooper still has confidence in the system when he writes that good record keeping could save whistleblowers. Well, when there is excellent record courts ignore it, in our experience. Truth and evidence of truth do not necessarily conquer prejudice, hate or monetary inducements such as promotions for tribunal members. See situational ethics above. That is why Doctors4Justice warmly recommends financial penalties for those who beat up whistleblowers. Science is on our side not faith. Because human beings have different capacity for empathy we realise some are never going to be moved by evidence. Please, see again
Somewhat usefully, Sir Anthony  Hooper suggests that investigators at GMC should consider if referring organisations have procedures in place to deal with complaints. Well, they do not care about those doctors who have little power (eg locums) and do not bother making procedures when Department of Health themselves have led the way of lawlessness, for example, recommending different justice for locum doctors such as lack of job reference and the absolute requirement for the reference from the last job. Ha, ha, ha. Political masters are wilfully, blindly followed by agitated and incompetent NHS medical directors who refer whistleblowers with false allegations to GMC. Had Sir Anthony Hooper had the courage to speak to Doctors4Justice his report would have been more interesting from legal perspective and the number of laws that actually apply to GMC. There is more to life than Medical Act 1983 and GMC Fitness to Practice Rules 2004 which themselves have not been compliant with law for example Article 6 of Human Rights Act.. Sir Anthony Hooper is silent on the deficiencies of GMC 2004 rules with respect to European Convention on Human Rights, the period his whistleblowing cases cover, and which Good Medical Practice Rules he is referring to because over the many years there have been different rules. He appears to be quoting  the more recent Good Medical Practice rules which again are not compatible with law. It would have been helpful to the mere mortals if he stated the relationship between the rules and the law and where the discrepancies exist. Law trumps GMC rules, is that not good to know? For example, GMC guidance states what one must do but does not recognise that it may be unnecessary to ask others for advise if one knows the law:
 "If you have concerns that a colleague may not be fit to practise and may be putting patients at risk, you must ask for advice from a colleague, your defence body or us. If you are still concerned you must report this, in line with our guidance and your workplace policy, and make a record of the steps you have taken.14,16" 
Reporting to GMC their Fitness to Practice Panellists is a complete waste of time in our experience. Evidence does not matter. It does not matter how clever you are or how many other professionals (for example, lawyer, brilliant mathematician) have made complaints about the same doctor lacking integrity. Spitefully, GMC will stick to their guns defending their own because they know they have easy, very easy time in High Court.
Kangaroo Court cartoons, Kangaroo Court cartoon, funny, Kangaroo Court picture, Kangaroo Court pictures, Kangaroo Court image, Kangaroo Court images, Kangaroo Court illustration, Kangaroo Court illustrations
Hooper report correctly identifies some of the risks for the whistleblowers such as:
56. Although the risk of taking retaliatory action against a doctor who has raised concerns may arise in the context of a complaint, it is much more likely that it will arise in the context of a referral from an organisation. I shall therefore concentrate on referrals from an organisation. Complaint is what patients write and referrals is what organisations write.  These are all complaints or all referral, we think. Doctors are also members of the public so one can presume that whistleblowing is in their interest too. We mentioned this because some guidance issued to doctors states that when patients complain it is about wrong inflicted to them while whistleblowing doctors are concerned about others. The reality is that whistleblowing doctors are also afected if working with bad doctors or other professionals involved in wrongdoing.
While we would like justice to be swift NHS organisations take years to disclose essential information to GMC because they are hiding what they did wrong in the case of whistleblowers. GMC allowed that. Hooper quite rightly recommends more speed and he would know what law is there to assist GMC.
Hooper tries to advocate resolution through mediation and suggests it even though government rejected it. Well, we find nothing wrong there.  Mediation could save many lives, money and many reputations. There are some good legal points made on refusal of mediation and this not being used for further retaliation.
Of course, as a legally trained person Sir Anthony Hooper is somewhat reluctant to recommend family therapy for dysfunctional management and dysfunctional doctors. At least 30% have significant issues with mental health. Contrary to GMC allegations of madness in whistlblowers reserch has shown them to be healthier people. GMC hate swearing in whistleblowers but it is healthy. It is not serious professional misconduct. All that offends is not professional misconduct. And on this healthy note this article ends.

Monday, 12 March 2018

Nerve gas in fruit, vegetables and water

Recently, in UK, there has been alleged poisoning of a Russian double agent and his daughter which sparked interest in nerve agent they were poisoned with.

Thursday, 8 March 2018

Wash your own pants, I don't want a rose I want revolution - International Women's Day - Many demonstrations and celebrations around the world

  "Casher wishes to go to the seaside" from demonstrations in Croatia stressing low wages for women, a recurrent problem all over the world

                       Spanish women stopped most of the trains countrywide and 5 million people joined the strike. Probably the biggest protest in the world

Women march in central London, following in the footsteps of the suffragettes. Photograph: Ray Tang/Rex/Shutterstock in Guardian newspaper
New York, USA

Colombia photo Reuters
Liberian demonstration with dance ENA
nImage may contain: 1 person, smiling, outdoor and nature Ice maidens who crossed Antarctica last year elebrated today in UK 8th March 2018 and encouraged other women not to give up and to support each other

Istanbul Reuters
Pakistan Reuters highlight on acid attacks on women 

Nepal women's police officers band celebrating International Women's Day Photo Navesh Chitrakar/Reuters

Belgrade demonstrations

Many companies have offered large discounts to women in China, and  France. McDonalds inverted its trade marke to W.
In some countries women have either whole or part of the day off. In Belgrade, Serbia, a bus driver decided to change bus destination to: Happy 8th March. Some women wanted his phone number, men to photograph the bus.

Iranian women could not have their demonstrations today as police were waiting for them ready to prevent expressions of protest. It is not known yet how many were arrested. Regime invented a date of birth of Fatima on 9th March as something they could be allowed to celebrate. May the ghost of Clara Zetkin visit them if they believe in such things.

 More Here from The New York Times