Independent review into gross negligence manslaughter and culpable homicide

The Intensive Care Society welcomes the publication of the independent review into gross negligence manslaughter and culpable homicide-commissioned after the tragic death of a young patient, the subsequent conviction of Dr Bawa–Garba in 2018, and the subsequent decisions and actions of the General Medical Council (GMC). 

Following these events there were serious questions and concerns raised over the future impact on critical care professions, where the nature of care means that timely and complex decisions must be made 24 hours a day, in often very difficult clinical situations with mixed outcomes.  In this setting, the ICS strongly believes that fear, defensive behaviour, and distrust in potential investigative processes are all detrimental to safe patient care.  

Whether in correctly laying accountability and learning from mistakes, or in the difficult ethical issues that will arise now and in future, continuing trust between the health professions and their regulators is essential as healthcare evolves. The society makes note of all the recommendations outlined in the report, including:

1. The critical importance of effective local investigations. 
2. The recognition that scrutiny should include the department and systems where an incident happened, including educational and training environments.
3. The need for absolute candour and support for families and carers. 
4. Equally, the recognition of the 'second victim' and the need to provide support for practitioners involved in investigations.
5. The importance of reflective practice, and the recommendations for legal protection in this area.

Importantly, the review took into account the views of patient families and carers.

ICS President, Dr Ganesh Suntharalingam said  “We are pleased to see the independent Hamilton review has identified appropriate action to repair the damage between health care practitioners and one of their key regulatory bodies. The review makes clear that in this instance the GMC fell short of its own professional standards in its decisions and actions. 

There are also important future lessons for all regulators and professional bodies. The ICS hopes that the review will bring about positive change and improved safety for all our patients, who should always be able to receive safe, reflective care in well-scrutinised systems, delivered by a multidisciplinary team able to share and learn without fear.

The Society is ready to support the GMC to ensure that these changes are put in place.