GMC considers overhaul of investigation methods after Bawa-Garba case

The GMC could overhaul its investigation process in a bid to stop doctors being blamed for NHS system failures in the wake of the Bawa-Garba case.

The regulator revealed in its submission to the independent Hamilton review into gross negligence manslaughter (GNM) and culpable homicide that it is considering changing its approach to fitness-to-practise procedures to include more ‘human factors’ rather than ‘root cause’ analysis.

The GMC says human factors refers to the 'environmental, organisational and job factors - and human and individual characteristics - which influence behaviour at work in a way that can affect health and safety', while root cause analysis is a 'systematic process for identifying "root causes" of problems or events and an approach for responding to them'.

Responding to the review, the GMC said: ‘Focusing on root cause analysis may not always be the best way of dealing with all investigations and we understand that exploration of a human factors approach is underway at several NHS Trusts in England.

Human factors

‘We too recognise the value of exploring a human factors approach and have met with leaders in the field of human factors to consider how we might ensure that our response to systemic issues is effective and reflects best practice.’

The regulator said it is ‘exploring’ human factors training possibilities for case examiners and GMC-affiliated medical experts so that they are ‘well equipped to recognise the impact of systems on human conduct’.

The Hamilton review follows the high-profile case of Dr Hadiza Bawa-Garba - a junior doctor convicted of GNM and later struck off the medical register after a High Court appeal by the GMC against a one-year suspension imposed by the Medical Practitioners Tribunal Service (MPTS).

Dr Bawa-Garba - a junior doctors just back from maternity leave - was the most senior clinician on duty at the children’s assessment unit (CAU) at Leicester Royal Infirmary due to staff absences on the day a patient, six-year-old Jack Adcock, died. An IT failure also led to delays in obtaining test results.

Bawa-Garba case

Last month, the Court of Appeal overturned the decision to remove Dr Hadiza Bawa-Garba from the medical register, stating that the MPTS 'was entitled to take account of systematic failures at the hospital, and failures by other staff who worked there, when deciding what action to take in relation to Dr Bawa-Garba'.

The GMC submission to the Hamilton review says: ‘Several high profile patient safety inquiries and our own fitness to practise data have identified major deficits in basic areas of professional practice. These underline the importance of and a need for specific training to address individual, team and organisational deficiencies, as well as addressing wider systemic failures.’

The regulator also highlighted the need for human factors training in its most recent ‘outcomes for graduates’ document, updated in June to require newly qualified doctors to be able to ‘describe basic human factors principles and practice at individual, team, organisational and system levels and recognise and respond to opportunities for improvement to manage or mitigate risks.’

Other organisations have also voiced support for a ‘human factors’ approach in GNM investigations. The BMA's Hamilton submission said: ‘The BMA believes that a human factors training programme should be developed for everyone involved in local investigations.’

The final report from the review is expected to be published in early 2019.

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