The role of reflection in the post Bawa-Garba era

Dr David Nicholl, consultant neurologist at Sandwell and West Birmingham NHS Trust and RCP college tutor at University Hospital Birmingham, responds to Sir Terence Stephenson's recent Commentary article where he discussed the GMC's actions in the case of Dr Hadiza Bawa-Garba.

Much of the concern and outrage after the erasure of Dr Hadiza Bawa-Garba from the medical register and the GMC’s appeal to the High Court has centred around whether her reflections were used in court. I was one of the ‘sources’ for the initial story in the BMJ (and subsequently the Times and the Daily Mail) I had legally obtained a copy of the Training Encounter form and an unredacted copy of the serious untoward incident (SUI) form. I was disturbed how a trainee’s ‘reflection’ had been obtained in a completely unsuitable environment – a hospital canteen – the notes written up by a consultant (who ended up being a prosecution witness) and then fed into the hospital investigation into the tragic death of Jack Adcock.

Thus although the jury may not have seen the trainee reflection, it certainly was available to the prosecution QC to assist his cross-examination, as has been confirmed by a witness who was at the trial, Dr Jonathan Cusack. Yet the SUI was not shown to the jury, as this happened after Jack Adcock’s death, even though it concluded ‘it has not been possible to identify a single root cause due to the systemic problems identified’. Unfortunately this version differs from Commentary’s interview with Sir Terence Stephenson.

Perhaps the time is to move on from the furore over the precise role of reflection in the Bawa-Garba case, it is not the most important aspect in the whole sorry saga.

Dr David Nicholl, consultant neurologist at Sandwell and West Birmingham NHS Trust

Looking at Dr Hadiza Bawa-Garba’s original narrative of events, handover was at 8.30am. Shortly after this time she was called urgently to the Emergency Department. When she returned, she saw Jack Adcock. At that time she was not aware that [paediatric consultant] Dr Forster was covering the Children’s Assessment Unit (CAU) as she had been called away from the unit.

There is a very real difference between a consultant being allocated to an area, and a second consultant, with other clinical duties cross covering. Professor Stephenson may feel that this is the same degree of consultant cover. The trust’s Serious Untoward Incident (SUI) review recognised that consultant cover was an issue and have successfully employed a number of staff, significantly improving the level of senior cover to the admissions unit following this case.

I am not aware that the consultant was off sick – this is not something which certainly a witness (JC) at the trial recalls, nor is this in the SUI. It would be helpful to see Professor Stephenson’s source for this statement. This is not the first time that the GMC’s version of events has been highlighted. They have yet to respond.

It is vital that readers of Commentary are accurately informed of the facts in this case. Unfortunately, the GMC keep getting some of the basic facts wrong. For example, Sir Terence seems unaware of the difference between the Appeal Court and the Supreme Court – July’s hearing will be at the former, not the latter.

Moving forward what should the guidance be regarding reflection, especially since the Williams review did not recommend legal privilege for reflection? (Although this has been disappointing, it is important to stress the much more significant positive recommendations of the Williams review – such as removal of the GMCs right of appeal of MPTS decisions.

Many such as I feel that there has been a fundamental injustice, which is something only a court, not even the GMC, can undo.

Dr David Nicholl, consultant neurologist at Sandwell and West Birmingham NHS Trust

First of all, it should be clear from the above that this was a completely dysfunctional way to use reflection. The whole point of reflection is that it is personal to the individual; it is not a document written by someone else with their opinions on what you performed incorrectly.  That would be a complete abuse of the reflective process. Although this is likely to be reviewed, the advice from the Academy of Medical Royal Colleges will likely remain. Namely it is important to anonymise the reflective records and take other measures to ensure there isn’t a breach of confidentiality. Perhaps the time is to move on from the furore over the precise role of reflection in the Bawa-Garba case, it is not the most important aspect in the whole sorry saga. Many such as I feel that there has been a fundamental injustice, which is something only a court, not even the GMC, can undo.

What perhaps ought to be emphasized is that where trainees perceive that they are being bullied or coerced they should feel free to speak to others such as an associate college tutor, college tutor or director of medical education to ensure that feel supported.

Dr David Nicholl is a consultant neurologist at Sandwell and West Birmingham NHS Trust and RCP college tutor at University Hospital Birmingham. He is grateful for the comments of Dr Jonathan Cusack (JC), consultant paediatrician from Leicester in writing this blog.

The GMC's reply

Commentary reached out to Sir Terence Stephenson at the invitation of Dr David Nicholl, to allow for a balanced discussion. Published here is his reply verbatim. 

Thank you for the opportunity to clarify some of the issues highlighted by your readers following my recent interview with Commentary

I cannot agree with the suggestion of the GMC being out of touch with the realities of front-line working. We have a dedicated Regional Liaison Service and Employer Liaison Service who are daily on the front-line engaging with doctors and their employers across the whole of the UK. Those teams met with more than 26,000 doctors in 2017.

I would also like to reiterate the fact that the GMC does not ask for reflective notes from doctors in order to investigate a concern. The main purpose of collecting and reflecting on significant events is to allow doctors to review and evaluate the quality of their work and to learn from the process.

In recent months colleagues from royal colleges have raised questions about the wording of one of our standard investigation letters, which was intended to seek evidence of support for the doctor and/or concerns. Although the letter does not ask colleges to provide reflective statements, we agreed this is not as clear as it should be.

The GMC has publicly called for doctors’ reflective notes to be given legal protection and will continue to press for this.

Sir Terence Stephenson, chair of the General Medical Council (GMC)

We are reviewing all of our documentation to make sure that they are absolutely clear that we do not ask for reflective notes from third parties in order to investigate a concern.

However, all written materials, including reflections, are potentially disclosable in the context of litigation. This is something we believe should be changed. The GMC has publicly called for doctors’ reflective notes to be given legal protection and will continue to press for this.

I apologise for referring to the Court of Appeal as the Supreme Court and for referring to illness rather than presenting elsewhere. I regret any confusion caused.

I was not present in the criminal court and so I must rely on the court’s record of the criminal trial which shows that another consultant, Dr Forster, offered her support on the ward. It was accepted in that hearing that her help and advice could have been sought at any time by those working that day.