The heartbroken mum of a 6-years-old Down’s Syndrome boy killed by the “appalling”
blunders of a hospital doctor who escaped jail yesterday said: “She’s
never even said sorry.”
Tragic Jack Adcock was admitted on to a ward with sickness and diarrhoea and
placed in the care of blundering Dr Hadiza Bawa-Garba.
But he died hours after being misdiagnosed by the ‘incompetent’ medic who
failed to spot he was already suffering from the deadly condition septic
shock.
It was the first in a series of ‘exceptionally bad’ errors at the hospital
that prosecutors said ‘robbed’ Jack of his chance of survival and ‘led to
his death in avoidable circumstances’.
In one of the most shocking, Nigerian-born Bawa-Garba ‘inexplicably’ mixed
Jack up with a different child – who was under a ‘do not resuscitate’ order
– and ordered colleagues to stop life-saving attempts when his heart
eventually stopped.
They only restarted when a junior doctor spotted the mistake.
She also missed ‘seriously abnormal’ blood test results that showed Jack’s
organs were shutting down.
And other blunders included waiting four hours to act on the results of a
chest X-ray, and failing to reassess the youngster or mention any concerns
to a senior consultant when she handed his care over.
Bawa-Garba, of Leicester, denied manslaughter by gross negligence but was
found guilty of the charge at Nottingham Crown Court last month following a
three-week trial.
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Doctor
guilty of causing lad’s death
Family
fury over ‘do not resuscitate’ order on Down’s syndrome son
An agency nurse, Portuguese-born Isabel Amaro, 47, who was responsible for
Jack’s hands-on care and was accused of ‘woefully inaccurate’ record keeping
of his vital signs, was also convicted of the offence.
A third medic, 55-year-old ward sister Theresa Taylor, was cleared.
Bawa-Garba and Amaro, of Manchester, who had worked in nursing for 19 years,
returned to the court for sentencing yesterday but were spared custody.
Instead, they were each handed two-year jail terms, suspended for two years.
Bawa-Garba was also ordered to pay £25,000 in prosecution costs.
But Jack’s mum, Nicola Adcock slammed the 38-year-old medic for failing to
show any remorse in the four-and-half years since her son’s death.
She now wants her struck off by the General Medical Council.
Nicola had shouted angrily: “What about my son?” from the public
gallery as Bawa-Garba’s lawyer told how the lawyer’s career and reputation
were in tatters.
Nicola said outside the court: “She has never said sorry and never shown
any emotion.
“She was given a chance to apologise, but has never shown any remorse.
She has never even said sorry for what happened to Jack.
“Our main aim was to get a conviction. It is a little bit of justice for
Jack.
“Obviously we will never get him back. She should never be allowed to
work again to do it to anyone again.”
She added:”I am glad she has to pay back some money because we had to
remortgage our house to pay for legal fees for the inquest.”
Judge Mr Justice Nicol told Bawa-Garba and Amaro: “The problem was
neither of you gave Jack the priority which this very sick boy deserved.
“Jack’s life was cut short prematurely. That was a tragedy. No sentence
that I pass on you will alter it.
“I have to take into account the harm caused by the offence. Any person’s
death will cause suffering for family and friends, but the death of a child
with his whole life ahead of him is particularly painful.”
Turning to Bawa-Garba, the judge said that after her initial assessment, she
‘did not pursue the investigation and treatment of Jack’s condition with the
urgency, priority and attention it deserved.’
He added her error in calling off Jack’s resuscitation was ‘extraordinary’ and
showed her ‘departure from the proper standard of care towards Jack that
day.’
Earlier, in a heart-rending victim impact statement read to the court by
Andrew Thomas QC, prosecuting, before the pair were sentenced, Mrs Adcock,
said: “Never in a million years did we expect our son to die.
“He went into hospital with sickness and diarrhoea and never came home.
“If I knew then what I know now, I would never have let that doctor and
those nurses near our son.
“I thought I was doing the right thing but they let him down.
“Jack was neglected from the minute he entered the unit to the moment he
died.
“I will never forgive myself for taking him home. I could have looked
after him better than they ever did.
“It makes me so angry to think he would still be here today if they had
done their jobs right.”
In his statement Jack’s father, Victor Adcock, said: “I wish I could
forgive them but I do not know if I ever will.
“I had to watch my little man get laid to rest. I miss him every day and
will for the rest of my life.”
During Bawa-Garba and Amaro’s trial, Andrew Thomas QC had told jurors: “If
the defendants had recognised the severity of Jack’s illness, and the fact
that he was in shock, if they had reassessed him and acted on the findings,
the risk death would have been very greatly reduced. He would probably have
survived. As it was, he was allowed to deteriorate without necessary
treatment.
“They failed to recognise his condition; they took no account of the
important fact that he was struggling for oxygen; they did not recognise
that he was already in shock; they failed to monitor his condition; and
because of that they delayed the start of effective treatment.
“Under their care, Jack’s condition needlessly declined to a point where,
before he had been transferred to the next ward, he was effectively beyond
the point of no return.”
He added: “The prosecution say their conduct was grossly negligent:
truly, exceptionally bad; amounting to a criminal offence.”
Jack, who suffered from Down’s Syndrome, died on February 18, 2011, around 11
hours after he was admitted to hospital.
After arriving at around 10.30am that morning, he was sent to the Children’s
Assessment Unit (CAU) and initially assessed by Taylor, the ward sister, and
Amaro, of Manchester.
The pair carried out a set of basic assessments but failed to flag Jack up as
a high-risk patient – although Taylor did immediately ask Bawa-Garba to see
him.
The doctor, who qualified as a paediatrician in 2006, conducted a couple of
tests and ‘hastily’ diagnosed Jack as suffering from gastroenteritis – even
though he was turning blue around the lips and suffering from ‘very low’
oxygen levels that Mr Thomas said ‘should have rung alarm bells’.
He added: “By the time he was admitted to the CAU, Jack was already
suffering from a condition known as sepsis, affecting his whole body. Put
simply, his body was shutting down because of the spread of the infection
and had gone into shock.
“The defendants failed to recognise that condition and act on it.
“The prosecution say that the signs had been there from the outset, and
should have been perfectly obvious to a competent doctor working on a
paediatric emergency ward. The doctor did not need formal tests to
appreciate that.”
In the hours that followed, further mistakes took place – in particular
Bawa-Garba failing to reassess Jack or reconsider her diagnosis.
And the court heard that between his admission on the CAU at 10:30am and the
time he was moved to another ward at 7pm, Jack’s vital signs were only
recorded twice – and even then, the record was ‘woefully incomplete’.
Between 4pm and 7pm, Dr Bawa-Garba didn’t check on Jack, who was suffering
constant diarrhoea, at all, or flag up his condition to a more senior
colleague when he came on the ward at 4.30pm.
At 7pm, Jack was transferred to a children’s ward – but went into cardiac
arrest around 45 minutes later.
A nurse put out a ‘crash call’ and a large team of doctors and nurses
assembled in a bid to revive Jack – but Bawa-Garba arrived and ‘almost
immediately’ told them to stop after mistaking him for a child who had
already been discharged.
But, a junior doctor spotted there was no ‘do not resuscitate’ order in Jack’s
notes and raised it with Bawa-Garba – who instantly ordered the life-saving
bid to recommence.
Medics battled to revive Jack for another 90 minutes, but he died at 9.21pm.
The court heard the break in resuscitation lasted up to two minutes, and that
Jack was so poorly he would have died even if Bawa-Garba hadn’t called a
halt.
But Mr Thomas said it demonstrated the ‘astonishing degree of the lack of care
and attention’ Bawa-Garba had shown Jack that day.