This contained one section for Dr O’Riordan to write on and one for Dr Bawa-Garba to document her learning points and reflections. Instead, Dr O’Riordan insisted on seeing Jack’s parents without her. But some local GPs were frustrated and thought there was a resistance to change and a reluctance to talk openly about the problems. The night Jack died, Mr and Mrs Adcock were taken into a room off the ward, where they were met by doctors they’d never seen before. Then she asked for a pen to write. “I was just saying, ‘Come on sweetheart go to sleep,’ and I was rubbing his face. But she says Dr O’Riordan told her that she had to get on with her clinical duties. She went along thinking it would be a similar process to the hospital investigation. “It just didn’t sink in.” She remembers them saying he had had pneumonia and an internal bleed. “We said if there’s fear in the system people are frightened about identifying hazards, about speaking up when they make a mistake about speaking up when something goes wrong then how could it ever get safer?” he says. We do not capture any email address. There was a catalogue of errors in this case, and patient safety will never be improved unless everyone promotes an open learning culture.”. The problems ran across all health care in Leicestershire and Rutland, but the “vast majority” of lessons came from the hospital. Another consultant based elsewhere in the hospital had said she was available to help and cover him if needed – although she had her own duties. Professor Riordan is Professor of Medicine (Conjoint) at the Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales and Head of the Gastrointestinal and Liver Unit at the Prince of Wales Hospital, a University Teaching Hospital, in Sydney, Australia. She knew the hospital was meeting the Adcocks and asked if she could attend. “It is the duty of senior members of the healthcare team to critically evaluate information provided by less experienced colleagues, identify incongruences, and reassess patients to better understand the clinical state of the patient,” he said. She told medical staff he had been up all night with diarrhoea and sickness. But suddenly she found herself under arrest and being read her rights. It suggests that factors that let her down were her interpretation of biochemistry and venous blood gas results and her “lack of clear communication.”. On 4 November 2015, the jury found Dr Bawa-Garba guilty. The following day, she says, she was admonished by Dr O’Riordan for making that call and told not to have any more contact with the family because an investigation was to be launched. Jack died from sepsis. A terrible confusion was about to follow. Mrs Adcock says she feels that these doctors are blaming her for her son’s death. Attached to his witness statement was the training encounter form containing details of his discussion with Dr Bawa-Garba in the canteen eight days after Jack’s death - the form Dr Bawa-Garba refused to sign. During the six-hour interview, all she could think about was her two-week-old daughter who would need breastfeeding. There she would see lots of children with sepsis, some of whom would get better then get worse – like Jack, she says. “It was shocking. “I remember on the morning of the sentencing telling my parents that I didn’t want them there in the court in Nottingham,” she says. “I wish that I had been clearer in my communication with the consultant,” she said. Professor of Medicine (Conjoint, UNSW)Head, Gastrointestinal and Liver Unit, Prince of Wales HospitalSenior Staff Specialist in Gastroenterology and HepatologyPrince of Wales Hospital, Sydney Children’s Hospital, Royal Hospital for WomenConsultant Physician, Gastroenterologist and … The next day was spent exploring all the points in detail. View Stephen O'Riordan’s profile on LinkedIn, the world's largest professional community. That isn’t the case. This is where you learn the most, Dr Hsu says. In the morning, Dr Bawa-Garba had had to intervene to stop doctors from trying to resuscitate a terminally ill boy who had a “do not resuscitate” order. “I hadn’t worked with him before, so I introduced myself,” Dr Bawa-Garba says. Irish News; Barry Roche; January 17, 2016, 20:33; A 51 … None felt able to go on the record. "The court heard that O’Riordan was aware before Jack died that he had a serum pH of 7.084 and a blood lactate concentration of 11.4 mmol/L, which he wrote down in his notebook at evening handover. But five months after Jack’s death, Dr O’Riordan left the Leicester Royal Infirmary and moved to Ireland. Get up to date with the latest news and stories about the person Steven O Riordan at The Irish Times. Using what she had learned from Jack Adcock’s death, Dr Bawa-Garba says, she helped carry out a sepsis study and formed a junior doctor weekly teaching programme where doctors would discuss “near misses” or incidents when patients had died so they could learn from them. The point of a handover, he said, was the passing of information from one junior doctor to another - the consultant’s role was supervisory to ensure the information was transferred. Jack had been admitted under the care of Dr Stephen O’Riordan, the consultant who was supposed to be in charge that day – but he hadn’t realised he was on call and had double-booked himself with teaching commitments in Warwick and hadn’t arrived at work. They said that while her actions fell “far below the standards expected of a competent doctor”, they had taken into account other factors. Stephen Martin O'Riordan obtained his title of Licentiates and Bachelor of Medicine and Bachelor of Surgery in RCP of Ireland and the RCS in Ireland, National University of Ireland with one thousand and one hundred and ninety fifth doctors completed education 1996. NHS England declined to comment to the BBC. Not all failings were heard, he says. He later started vomiting and had diarrhoea, which continued through the night. After initially being denied one, in case she harmed herself, she was given a pen outside the cell. Experts later said the interruption to the resuscitation had not contributed to his death – but he shouldn’t have been given enalapril and he should have been given antibiotics much earlier. Steven Oriordan is on Facebook. “I can’t face it.”. Dr Bawa-Garba did not, however, ask Dr O’Riordan to review Jack. He then pressed her further and one by one, she listed how she felt she should have done better. There were six root causes for Jack’s poor care, the report said, listing 23 recommendations for improvement and 79 actions to minimise the risk of another child dying in such unacceptable circumstances. Jack used to love dancing, swimming and going to watch Leicester City football team, says his father, even though he had been in and out of hospital during his short life. Gastroenterology and the Liver. She asked to see her son. Join Facebook to connect with Stephen O Riordan and others you may know. If you walked into a hospital and saw that doctor, would you be happy for her to treat your child?”. “I was shocked and I was like, ‘Why is Jack crashing?’” she says. “Since April 2020, the insulin pump training is now provided online,” said Dr Stephen O'Riordan, consultant endocrinologist at CUH. See the complete profile on LinkedIn and discover Stephen’s connections and jobs at similar companies. He said he would have expected her to “stress” these results to him. She told the team to continue the resuscitation. This time, “there was blood – I just couldn’t believe it was him, my baby, gone”. And Dr Bawa-Garba volunteered to step in. After deliberating with the Trust, they asked Dr Ron Hsu, then a public health consultant and now associate professor at the University of Leicester, to investigate further. “I remember being absolutely terrified, thinking, ‘I haven’t done anything, why are the police here?’” Mrs Adcock says. But the coroner, Mrs Catherine Mason, dismissed this idea. But to lose a child in the way we lost Jack – we should never have lost him,” Mrs Adcock says. He then told her that they needed to discuss Jack’s death properly because he thought she hadn’t highlighted to him how ill Jack was, she says. Dr Bawa-Garba also reviewed Jack’s X-ray, which had been ready for a few hours. “As you can imagine at that point, we felt physically sick – the anger raged. 0 Reviews. For Dr Hsu, the outcry from around the country suggested that what he had seen at Leicester was widespread across the NHS. After an hour of being on fluids to rehydrate him, Jack seemed to be responding well. Join Facebook to connect with Steven Riordan and others you may know. Far from ignoring problems, he says, the Trust went looking for them. Dr Bawa-Garba continued to work at Leicester Royal Infirmary, but one evening in December 2014, while she was on call on the neonatal unit, she was contacted by her educational supervisor, who asked to meet her. Stephen O'Riordan Senior Automation Integration Architect (IT) at AbbVie Ireland. “I've been in the UK for more than half my life,” she says. One doctor said she would pray before she went into work because she was worried something bad would happen. Stephen has 1 job listed on their profile. Jack Adcock wasn’t himself when he returned from school. By this time, Jack had been moved to ward 28 under the care of a different team. She then went to chase up Jack’s blood results, which still hadn’t come through – the doctor she had assigned to do it hadn’t managed to get them. The family are clear about who they blame for Jack’s death – Dr Bawa-Garba and one of the nurses who had treated him. At 16.30 hours Dr Bawa-Garba gave one, of two handovers, to the consultant on-call, Dr Stephen O’Riordan. He pressed Dr Bawa-Garba on the reflection she did after Jack’s death. Stephen O Riordan 6 results. “We didn’t really know anything until it went to the inquest,” says Mrs Adcock. But in fact nearly a quarter of patients in the report had received “unacceptable care” – serious errors had been made that would have increased the risk of harm. The court heard that Stephen O’Riordan, duty consultant paediatrician that day, had written them down at evening handover but chose not to review … Dr Bawa-Garba was given a two-year suspended sentence. Cusack has serious concerns about how a document intended for reflective practice and learning for personal development was used to apportion blame in the criminal justice process. Care assistant convicted of two assaults on disabled man . “They said he just wasn’t looked after; he didn’t have the right support; he wasn’t given the right care,” Mrs Adcock says. The role of a consultant is not just to review patients who are unwell but to recognise when a patient has been missed by junior members of the team. It’s a description Mr Furlong rejects. “The criminalisation of medical error when events are considered singularly rather than as a part of a highly complex system is going to seriously impede learning,” said Jonathan Cusack, the Leicester Royal Infirmary neonatologist who was Bawa-Garba’s educational supervisor after the incident. But when asked if it was a “significant factor” in Jack’s rapid deterioration, he said this was “consistent with the clinical history”. But the hospital’s report was not heard in court. He was due his second dose of the day. “I automatically thought he was perking up,” says Victor, Jack’s father. Mr Furlong says the Trust was the first to use this review method and now others are using similar techniques to look at what can be learned from patients who have died. As the police were investigating Jack Adcock’s death, other failings in patient care across Leicestershire were emerging. “We have to help them understand what happened, to be open about what happened, to apologise for what happened,” he says. Before her 13 months’ maternity leave, she had been working in community paediatrics, treating children with chronic illnesses and behavioural problems. 25 years experience in a variety of Site based & Central Finance roles in the FMCG / Food Manufacturing Industry. “Also, the result I got showed that the pH had gone from seven to 7.24. She noted it was 97, far higher than it should have been, so she circled it. David Grant, a consultant in paediatric intensive care at University Hospitals Bristol NHS Foundation Trust with a special interest in simulation and human factors, told The BMJ that the case risked setting a precedent that “will undermine all attempts to create a culture of openness and learning aimed at improving patient safety through proactive healthcare systems improvement.”, He said, “Without such a system and culture in place, organisations and healthcare systems will continue to learn the same lessons over and over again, while patients continue to come to preventable harm.”, Grant emphasised the need for people to be accountable for their errors, which can then “serve as triggers for systems analysis and organisational learning focused on preventing future occurrences.”, Indeed, the report that resulted from the serious untoward incident review after Jack’s death, seen by The BMJ, included recommendations to improve support for trainees and to enhance patients’ safety. Why did he crash? Nine months after Dr Hsu submitted his report, it was posted on the Trust website. The negligence had to be gross or severe, he said - what they did or didn’t do had to be truly, exceptionally bad. She assumed it was the same boy. Dr Bawa-Garba says she had assumed he would go to see Jack - based on the description she had given and the fact he had asked for further tests - but he didn’t. There was then a second post-mortem examination in case criminal proceedings were opened. I suspect that many would have died anyway but in some cases my errors are likely to have contributed to poor outcomes and some patient deaths,” he says. “It took ages for the conclusions to become public,” says Dr Orest Mulka, a former GP in Measham, and one of the reviewers. At the meeting she was asked to reflect on the circumstances and to sign a trainee encounter form setting out what she should have done differently. Though it criticised aspects of Bawa-Garba’s involvement, it also found fault with “many aspects of the care that child JA received, and many of these were system failings.”, Andrew Furlong, medical director at University Hospitals of Leicester NHS Trust, which runs Leicester Royal Infirmary, told The BMJ that the trust had “implemented a number of improvements to our systems and processes which have reduced the risk of such events occurring again.”, He added, “This was a tragic event, and in 2015 a jury reached its decision having had all the evidence presented to it.”. “I had two very young children - my oldest is severely autistic and goes to a special needs school. The nurse was doing his observations - including his temperature, heart rate and blood pressure - but did not record them regularly. The hospital appointed Dr Ian Sturgess to consider improvements in the emergency sector. They read out Jack’s results and she noted them down. 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