**5. Using Clinical Futile Cycles to safety proof health from the sharp end back**

If we accept the model of clinical futile cycles, it becomes immediately apparent that no amount of activity away from the sharp end of the healthcare adverse event will help, least of all the generation of more policy and procedure. Instead, we need to focus attention on the healthcare professional and the immediate socio-cultural environment in which they work [39]. Dealing first with the health care worker; the selection of these individuals to undertake their chosen vocation is invariably done by consideration of various personal attributes, in the case of medicine academic achievement and individual performance in tests [40–43]. This process and subsequent education take no account of the fact that as soon as these people graduate, they will be working in a team environment.

The clinical care we deliver (and receive) is a function of the education and capability of our students who will eventually be our doctors and ultimately clinical leaders and decision makers. What we teach and practise best is point of care medicine and clinical interventions. Therefore, it is no surprise that what we examine and, and what students focus on, is specific point of care clinical assessments and interventions [44]. This is best represented by the objective, structured, clinical, examination system (OSCE) that is now a widespread and common form of summative assessment

*Clinical Futile Cycles: Systematic Microeconomic Reform of Health Care by Reform… DOI: http://dx.doi.org/10.5772/intechopen.106034*

[45]. In the OSCE, candidates undertake clinical assessment tasks at a number of specific stations for 5–8 min. Each station has a structured "score card" that students must address to get the points. This system of examination in no way gives any indication on a student's ability and competency to comprehensively take a history, do a physical examination, synthesise these findings into a meaningful problem list and finally and actually least importantly come up with a diagnosis [46]. It has got to the point now in the undergraduate curriculum, that the clinical process of whole patient assessment is variably taught and certainly not examined, in a sufficiently stringent manner to motivate students to spend long hours doing patient histories and examinations. Having competent health care professionals spend time with and understanding our patients is the single biggest step to making health care safe.

Second, priority needs to be given to the core business of hospital care; the interaction at the bedside and clinic between the patient and the various healthcare professionals [28–30]. Clinical Futile Cycles gives a practical platform to understand this culture. We need to accept that an abnormal or inappropriate workplace culture is at the heart of every major inquiry into poor hospital care [47–52]. Every report into these enquiries recommends change. Yet 30 years on from Bristol [51] we have mid-Staffordshire [50]. So, what have we really learned from the reports and thousands of pages of recommendations? Nothing. We need a different strategy; one that puts the patient and their wellbeing first. This should be followed by the implicit understanding that our core business is that of interaction with the patient from the most basic and junior levels. The bedside healthcare team needs to be trained, credentialed and supported to deliver better healthcare, not as individual players, but as members of a team (**Table 1**).


#### **Table 1.**

*Hospital adverse events; review by root cause analysis (RCA) versus clinical futile cycles (CFC).*

## **5.1 Two typical cases**

#### **References**

https://www.abc.net.au/news/2021-05-17/aishwarya-aswath-perth-childrens-hospital-death-report-relea sed/100144052 (last viewed 22/07/2021)

On April the 3rd 2021 at 1722 a 7-year-old child girl presented to the Emergency Department at Perth Children's Hospital (PCH). Prior to death the family made multiple attempts to get help, which did not occur, despite continuing and deteriorating signs of sepsis. At 2122 after more than an hour of resuscitation she was deceased. The following morning a blood culture grew Strep A. In the ensuing days weeks and months, several of the frontline clinical staff have been referred to APHRA, in retaliation the Nurses union have referred several middle level nurse managers to APHRA. The Chairperson of the PCH resigned, the CEO offered his resignation, and there have been calls for the State Health minister to resign. An initial confidential RCA report into the death highlighted many short comings and made 11 recommendations that were tabled in Parliament. The family rejected the findings as contradictory. They have insisted that such a death should never occur again. Reportedly morale amongst staff at the hospital and in particular the Emergency department is at a "rock bottom low."

WA's Child and Adolescent Health Service (CAHS) will not endorse its own report into a 7-year-old's death at Perth Children's Hospital until an independent investigation has been completed.

#### **Key points**


The report, which was released by Aishwarya Aswath's family, detailed what happened the night Aishwarya died, including the response from staff, as she waited around 2 h to be treated before being declared dead just after 9:00 pm on Saturday, April 3.

The CAHS review was conducted by a panel that was made up of a mix of health department employees and external experts.

"The panel found there were a cascade of missed opportunities to address parental concerns and incomplete assessments, with a delay in escalation which may have contributed to the patient's outcome," the report found.

Aishwarya's parents Aswath Chavittupara and Prasitha Sasidharan released the report to the public.*(ABC News: West Matteeussen).*

Eleven recommendations were made, including improvement to the triage process policy at PCH, a clear pathway for parents to escalate concerns to staff, a review of cultural awareness for staff and development of an established sepsis recognition diagnostic tool in the emergency department.

The state government has promised there will also be an independent inquiry into the hospital's emergency department, and a coronial inquest into Aishwarya's death.

#### **More investigations needed: CAHS**

CAHS chief executive Aresh Anwar said he agreed with Aishwarya's family that she was not shown compassion and care.

Aishwarya Aswath died after waiting for treatment at Perth Children's Hospital's emergency department. *(Supplied: Family).*

But he said the report would not be endorsed until further investigations were completed.

"The CAHS Executive acknowledge the findings of the panel," Dr. Anwar said in a statement provided to the ABC.

"The report represents a significant volume of investigation," however, it is the opinion of the CAHS executive that there are a number of elements that require further exploration.

"The additional independent external review must be completed before we can, in good conscience," consider this investigation to be finalised.

"This additional targeted review will ensure" we fully understand the opportunities for systemic change. "While we await the additional independent external review," we are not in a position to endorse this root cause analysis report.

"However, we remain committed and are urgently implementing all 11 recommendations."

Health Minister Roger Cook warned against making conclusions about the circumstances surrounding Aishwarya's death before additional investigations were carried out.

"We need to make sure that as individuals we don't try to play judge and jury in relation to what happened in the ED on the night Aishwarya passed away," he said.

"We weren't there, we don't know, so it's important that we leave it up to the experts and make sure they get the opportunity to investigate this properly."

Health Minister Roger Cook says he wants to ensure nurses feel "heard and supported". *(ABC News: Eliza Laschon).*

The Minister met with doctors and nurses at PCH's emergency department this afternoon.

"This will be my opportunity to tell them that I support them in the difficult work they do," he said.

"I want them to know that we will continue to work hard to make sure they have the resources they need to do the job that they are committed to."

"I'm committed to work with them closely, to come back as often as they feel necessary to make sure they feel heard and supported."

#### **Staff 'upset' with Minister at meeting**

The meeting was also attended by the Australian Nursing Federation WA chief executive Mark Olson and Australian Medical Association WA president Andrew Miller.

Emerging from the meeting, Dr. Miller said it had become emotional, with staff taking the opportunity to "call it how it is" in front of the Health Minister.

"He was received, I would say, poorly," he said.

"I've never heard staff quite so upset with anyone in a meeting before that they would speak out in that way."

AMA WA president Andrew Miller (left) says staff took the opportunity to "call it how it is". *(ABC News: Eliza Laschon).*

Dr. Miller said staff were particularly upset by reports some of their colleagues would be referred to the medical regulator, the Australian Health Practitioner Regulation Agency (AHPRA).

In response, he said he intended to make his own referrals to the watchdog.

"It's pretty clear from the evasion that we heard from management that they are intending [to], or have, reported very junior members of the staff to AHPRA," Dr. Miller said.

"We have expressed our dismay and disgust over that."

"If that if that proceeds, [I intend to] report the registered managers, executives and the director-general involved in setting up the system within which these junior staff work, so that AHPRA has the opportunity to consider everyone's actions in this."

Mr. Olson said during the meeting, nurses again raised concerns about staffing levels in the emergency department, both on the night Aishwarya died and since.

"There is this disconnect between those who are running the hospital and those who are working in the hospital," he said.

"[The nurses] have no faith in the executive at the moment. They have no trust that the executive can rebuild the reputation and rebuild the trust that the community needs in this hospital, and it's taking a toll." Posted 20 May 2021 20 May 2021, updated 20 May 2021 20 May 2021.

#### **Box 1.**

*Death of Aishwarya Aswath at Perth Children's Hospital, Australia, April 2021.*

#### **References**

https://www.pulsetoday.co.uk/analysis/regulation/bawa-garba-timeline-of-a-case-that-has-rocked-medic ine/ (last viewed 28/07/2021)

#### **18 February 2011**

A 6 year old boy is admitted to the Children's Assessment Unit (CAU) at Leicester Royal Infirmary following a referral from his GP. Jack Adcock, who had Down's Syndrome and a known heart condition, had been suffering from diarrhoea, vomiting and had difficulty breathing.

Dr. Hadiza Bawa-Garba was a specialist registrar in year six of her postgraduate training (ST6) with an 'impeccable' record. She had recently returned from maternity leave and this was her first shift in an acute setting. She was the most senior doctor covering the CAU, the emergency department and the ward CAU that day. She saw Jack at about 10.30 am.

Jack was receiving supplementary oxygen and Dr. Bawa-Garba prescribed a fluid bolus and arranged for blood tests and a chest x-ray. At 10.44 am the first blood gas test was available and showed a worryingly high lactate reading. The x-ray became available from around 12.30 pm and showed evidence of a chest infection.

Dr. Bawa-Garba was heavily involved in treating other children between 12 and 3 pm, including a baby that needed a lumbar puncture. At 3 pm Dr. Bawa-Garba reviewed Jack's X-ray (she was not informed before then that it was available) and prescribed a dose of antibiotics immediately, which Jack received an hour later from the nurses.

A failure in the hospital's electronic computer system that day meant that although she had ordered blood tests at about 10.45 am, Dr. Bawa-Garba did not receive them until about 4.15 pm. It also meant her senior house office was unavailable.

During a handover meeting with a consultant which took place about 4.30 pm, Dr. Bawa-Garba raised the high level of CRP in Jack's blood test results and a diagnosis of pneumonia, but she did not ask the consultant to review the patient. She said Jack had been much improved and was bouncing about. At 6.30 pm, she spoke to the consultant a second time, but again did not raise any concerns.

When she wrote up the initial notes, she did not specify that Jack's enalapril (for his heart condition) should be discontinued. Jack was subsequently given his evening dose of enalapril by his mother after he was transferred to the ward around 7 pm.

At 8 pm a 'crash call' went out and Dr. Bawa-Garba was one of the doctors who responded to it. On entering the room she mistakenly confused Jack with another patient and called off the resuscitation. Her mistake was identified within 30 s to 2 min and resuscitation continued.

This hiatus did not contribute to Jack's death, as his condition was already too far advanced. At 9.20 pm, Jack died.

#### **2 November 2015**

Portuguese agency nurse, 47-year-old Isabel Amaro, of Manchester is given a 2-year suspended gaol sentence for manslaughter on the grounds of gross negligence.

#### **4 November 2015**

At Nottingham Crown Court Dr. Bawa-Garba is convicted of manslaughter on the grounds of gross negligence.

#### **14 December 2015**

Dr. Bawa-Garba is given a 24 month suspended sentence.

#### **8 December 2016**

Dr. Bawa-Garba's appeal against her sentence is quashed at the Court of Appeal.

#### **13 June 2017**

The Medical Practitioners Tribunal service says Dr. Bawa-Garba should be suspended for 12 months and rejects an application from the GMC to strike her off the register. It says: 'In the circumstances of this case, balancing the mitigating and aggravating factors, the tribunal concluded that erasure would be disproportionate.'

#### **8 December 2017**

GMC takes the MPTS to the High Court and argues its own tribunal was 'wrong' to allow Dr Bawa-Garba to continue to practise.

#### **25 January 2018**

The GMC successfully appeals at the High Court bid to have the MPTS decision overruled, leading to Dr. Bawa-Garba being struck off the medical register. Lord Justice Ouseley says: 'The Tribunal did not respect the verdict of the jury as it should have. In fact, it reached its own and less severe view of the degree of Dr Bawa-Garba's personal culpability.' Health secretary Jeremy Hunt says that he is 'deeply concerned' about its implications.

#### **26 January 2018**

Prominent GPs tell Pulse that the ruling raises serious questions about how doctor's reflections are used and recorded, and that new guidance is now needed urgently.

#### **30 January 2018**

An influential international doctors group accuses the GMC of treating black and minority ethnic doctors 'differently and harshly', following the High Court case.

In light of the Dr. Bawa-Garba case, the GMC announces a review of how gross negligence manslaughter is applied to medical practice, which was initially led by Dame Clare Marx and later taken over by Leslie Hamilton after Dame Clare was appointed the next GMC chair. Meanwhile, an influential international doctors group accuses the GMC of treating black and minority ethnic doctors 'differently and harshly', following the High Court case.

#### **31 January 2018**

Dr. Bawa-Garba's defence body releases a statement saying e-portfolio reflections were not used against her in court, despite 'wide misreporting' that they were. But Pulse uncovers that her reflections were used in court, from a document submitted as evidence by the on-call consultant on the day.

#### **6 February 2018**

Former health secretary Jeremy Hunt announces a review into the application of gross negligence manslaughter charges in medicine in light of the Dr Bawa-Garba case.

#### **7 February 2018**

Following a crowd funding campaign, which raised over £335,000, Dr. Bawa-Garba decides to appeal the ruling, and considers appealing the manslaughter conviction from 2015.

#### **12 February 2018**

The GMC refutes claims that there was discrimination in its decision to launch a High Court bid. In response to an open letter from the British Association of Physicians of Indian Origin (BAPIO), the GMC said the accusations were 'troubling and without merit'.

#### **19 February 2018**

The GMC is criticised by their regulator, the Professional Standards Authority (PSA), for striking off Dr. Bawa-Garba from the medical register. The PSA said the bid was 'without merit', according to an unpublished review of the case.

#### **13 March 2018**

GMC chair Professor Terence Stephenson says he is 'extremely sorry'for the distress caused to the medical profession by the Dr. Bawa-Garba case.

#### **19 March 2018**

University Hospitals of Leicester NHS Trust releases its serious incident report in to the death of Jack Adcock, which was completed 6 months after his death. The report says that there was no 'single root cause' behind the 6-year-old's death.

#### **29 March 2018**

Dr. Bawa-Garba is granted permission to appeal the High Court's decision to allow the GMC to strike of the junior doctor. Meanwhile, the BMA applies and is later permitted to advise the Court of Appeal in the case.

#### **23 April 2018**

The GMC announces the launch of its review into why black and minority ethnic doctors are more likely to face complaints from employers than their white colleagues, which is to be co-led by researcher Roger Kline and Dr. Doyin Atewologun.

#### **11 June 2018**

Department of Health and Social Care's 'rapid review' into medical gross negligence manslaughter concludes that the GMC should longer be able to appeal decisions made by its own tribunal regarding fitnessto-practise decisions.

#### **27 June 2018**

The BMA supports a vote of no confidence in the GMC in light of the Bawa-Garba case at its Annual Representative Meeting.

#### **3 July 2018**

Despite the conclusions of the DHSC's 'rapid review' in gross negligence manslaughter, the GMC tells Pulse it is not intending to halt appeals against its own fitness-to-practise tribunal until the law is changed.

#### **25–26 July 2018**

Dr. Bawa-Garba's appeal of the High Court decision that saw her struck off the medical register is heard in the High Court over one and a half days. Dr. Bawa-Garba said after the hearing that she is 'whole-heartedly sorry' for her mistakes, while Jack's mother Nicola Adcock says she 'will cause a public uproar' if Dr Bawa-Garba is reinstated.

#### **13 August 2018**

The Court of Appeal judges rule in favour of Dr Bawa-Garba, restoring the MPTS decision that she should be suspended from the medical register rather than erased. The judges said the matter has been passed to the MPTS 'for review of Dr Bawa-Garba's suspension'.

#### **20 December 2018**

The Medical Practitioner Tribunal Service (MPTS) decides to extend the suspension of Dr. Hadiza Bawa-Garba by a further 6 months, saying the measure is 'appropriate' to 'protect the public'.

#### **13 March 2019**

The MPTS announces a two-day review hearing for Dr. Bawa-Garba set for 8 and 9 April 2019. The hearing will decide whether her fitness to practise remains impaired and whether she is deemed fit to return to work.

#### **8 April 2019**

The MPTS rules that Dr. Bawa-Garba' the fitness to practise remains impaired, due to her lack of face-toface patient contact while she was under suspension, agreeing that the risk of her putting another patient at an unwarranted risk of harm is low.

#### **9 April 2019**

The MPTS decides that Dr. Bawa-Garba will be able to return to practice from July 2019—under certain conditions—but she does not intend to return to work until February 2020, when her maternity leave finishes. The MPTS argues that the public interest has been served already by her cumulative suspension and that any higher sanction would be 'disproportionate and punitive'.

*Sources*

Mr Justice Nicol, Court of Appeal (Criminal Division), 8 December 2016 Medical Practitioner Tribunal Service Decision Dr Bawa-Garba. MPTS. 13 June 2017 High Court, December 2017—Reports from court reporter MPTS press releases, 8–9 April 2019 For more on the Bawa-Garba case—click here

#### **Box 2.**

*Death of Jack Adcock at Leicester Royal Infirmary, UK, February 2011.*
