The General Medical Council has, this month, published its Independent Review of Gross Negligence Manslaughter and Culpable Homicide.

The review was commissioned following widespread criticism of the GMC’s response to the death of Jack Adcock and the involvement of Dr Hadiza Bawa-Garba. Dr Bawa-Garba, who was responsible for the child’s treatment, was found guilty of gross negligence manslaughter and struck off the medical register by the GMC in 2018.

There was widespread condemnation of the GMC by medical professionals following this outcome.

As observed in the GMC report, ‘many questioned why an individual trainee working under pressure should carry the blame for what they considered to be wider systemic failings within her working environment.’

It continues, ‘the actions of the GMC provided the immediate focus for doctors’ fears and sense of injustice…..the fear begins when things go wrong in the workplace and with the belief that the ‘system’ is structured to apportion individual blame rather than to learn from events and prevent future harm.’

The independent review aimed to assess the workings of the current system and ‘make recommendations aimed at the better application of a just and fair system when things go wrong.’

The report makes 29 recommendations covering a wide range of aspects emanating from the incident. These include recommendations relating to GMC policies and processes, equality and diversity, local investigations into patient safety incidents, and families and healthcare staff.

The BMA (British Medical Association) has responded by saying, ‘We welcome this review, which takes on board many of the points the BMA raised in its own submission – not least on the need for a just culture based on learning rather than blame….This culture shift is vital to help avert such tragedies and give the public confidence in the health service while reassuring doctors and other staff that they will not be unfairly blamed when things went wrong.’

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