During the last few days I have been reminded, more than once, of the potential significance of a gross negligence manslaughter conviction of a medical practitioner in England and the later disciplinary outcome for her. Unfortunately I have not yet had time to carefully read all the (sometimes conflicting) commentary.
In the meantime however, Dr Cristina Pelkas from Flinders University has kindly provided links to the refusal of leave to appeal the conviction and to the General Medical Council appeal which saw the doctor’s one year suspension from practice replaced by an order that she be erased from the register.
That court does not appear to have overlooked the contribution of ‘system errors’. Lord Justice Gross said “Notwithstanding the system failures and the failures of others, the jury convicted Dr. Bawa-Garba of manslaughter by gross negligence.” Justice Ouseley at  said:
Dr. Bawa-Garba, before and after the tragic events, was a competent, above average doctor. The day brought its unexpected workload, and strains and stresses caused by IT failings, consultant absences and her return from maternity leave. But there was no suggestion that her training in diagnosis of sepsis, or in testing potential diagnoses had been deficient, or that she was unaware of her obligations to assess for herself shortcomings or rustiness in her skills, and to seek assistance. There was no suggestion, unwelcome and stressful though the failings around her were, and with the workload she had that this was something she had not been trained to cope with or was something wholly out of the ordinary for a Year 6 trainee, not far off consultancy, to have to cope with, without making such serious errors. It was her failings which were truly exceptionally bad.
Clearly the matter has some complexities, which will need careful review. Fortunately Michael Eburn from ANU has written a note entitled Australian commentary on the case involving Dr Hadiza Bawa-Garba.