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Bawa-Garba Case

During your time at medical school, you will learn and s many controversial medical ethicas using cases, particularly those which attracted a lot of publicity. One of the most important of these is the case of Dr Bawa-Garba. We will discus the events which lead to Bawa-Garba's conviction and removal form the medical register, what we can learn from this case, and the eventual outcomes.


  • Dr Bawa-Garba was a paediatric registrar working at Leicester Royal Infirmary. She had recently returned from maternity leave at the time of the incident.

  • On 18th January 2011, a 6 year old boy called Jack Adcock was admitted to Leicester Royal Infirmary with breathing difficulties, diarrhoea and vomiting. He also had a diagnosis of Down's syndrome. He was placed under Dr Bawa-Garba's care.

  • jack's condition deteriorated over the course of the day and he passed away from sepsis. Dr Bawa-Garba was take to the high court due to several mistakes she made during his care, and on 4th November 2015 was found guilty of manslaughter on the basis of gross negligence.

What mistakes did Dr Bawa-Garba and the NHS make?

  • When handing over to the consultant on the next shift, she did not ask him to review the patient's results.

  • She did not tell the patient's mother not to administer his usual medication (though she did omit it from the prescription chart).

  • When the patient went into cardiac arrest from sepsis, she confused him with another patient who had a Do Not Resuscitate Order. This caused his CPR to be stopped for 2 minutes. Upon realising her mistake, she resumed CPR but by this time the boy had died.

  • There was a computer systems failing which meant that the blood tests were delivered 5 hours late.

  • Chest x-ray that showed an infection was seen 2.5 hours after it was available, leading to a delay in the prescription of antibiotics. Bawa-Garba was busy and not informed of the x-ray.

What happened afterwards?

  • Dr Bawa-Garba was struck off by the GMC.

  • Many doctors' organisations attempted to raise awareness about the stress that doctors face, to place Dr Bawa-Garba's actions in context.

  • Eventually, the decision to strike Dr Bawa-Garba off the GMC register was overturned.

  • The UK government released a set of reforms in response to the case.


What lessons were learned?

  • Changes in hospital protocol including better registration of safety concerns.

  • Investment in tech infrastructure to prevent tech failings or delays in accessing results in the future.

  • Discussion about the stress and workload that doctors face and how to reduce it.

  • Some doctors suggested they should not admit to making mistakes to avoid facing blame!


  1. Dr Bawa-Garba made mistakes, but remember that her actions must be considered in context.

  2. Don't forget to mention that the NHS has systematic failures, not just individual failures.

  3. Consider the positive outcomes of this situation (e.g. reforms) as well as the clear negative outcomes.

  4. Be as objective as you can and avoid judging Dr Bawa-Garba.



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