Category Archives: reflection

Thoughts on #BawaGarba




Excuse me a little, as I’ve personally been through the entire regulatory process, and I find the GMC decision in #BawaGarba very complicated. The timeline is even more complicated.

Understanding the law of gross negligence manslaughter has not been a great help to me. I studied this for my Bachelor of Law in 2009. I was restored onto the GMC register after a period of absence (2006-2014), and a protracted period of self-reflection has indeed helped me to understand the perspectives of the doctor and  the traumatised.

The phrase ‘there but the grace of God go I’ is really no solace for a relative who will never forget ‘that day’ in hospital until he or she dies. When doctors proudly boast they have luckily escaped killing one of their patients, this runs the risk of appearing to be a testosterone-driven boast, and belies a sheer callous contempt of patients, where their job or career appear more important. What Doctors mean is that they are having to make risky decisions daily, and nothing has gone seriously wrong yet, presumably?

This genuinely worries me. Also worrying is nobody will actually ‘up sticks’ or ‘speak out’ against the system, unless something actually goes wrong. No ST6 will want to phone his or her Consultant on a busy on-call for fear of not appearing autonomous or confident, even though after the event it seems ‘good to talk’.

Saying to a devastated relative that there is a team ‘learning from mistakes’ when that relative might be traumatised that he or she was waiting for hours, the clinical assessment then seemed rushed or incomplete, and a relative dies, seems inadequate.

And indeed it seems entirely appropriate that the new sentencing guidelines does allow for actions or omissions causing for death in high risk healthcare environments as a significant mitigating factor, causing low ‘culpability‘.

The principles behind gross negligence manslaughter are clearer than one might expect. By assuming the duty bleep, the buck will stop at that ST6, in ‘assuming the duty of care‘. But an issue about whether the ST6 should ‘cop the bullet’ in the face of a plethora of other issues going wrong is important, as it potentially implies an imperfect doctor singularly working in a perfect world otherwise.

I intuitively feel though that medical manslaughter is different, otherwise you’re potentially subjecting highly skilled doctors, who work in high performance teams in highly stressful environments, such as acute medical care in the country’s national referral centres, to a situation where they’re being set up to fail.

And of course you can get highly complex medical cases in busy DGHs, and any rank of doctor, including experienced Consultants, can face the #BawaGarba situation. In other words, we need to encourage the brightest of doctors to face complex medicine, not be frightened of it.

There is a perception that certain doctors are very arrogant and don’t care about making mistakes. I agree that the GMC should show extreme sanctions for those doctors on the register who show complete contempt for the code of conduct, but I don’t feel #BawaGarba falls into that category.

In innovation, you have to crack an egg to make an omelette. For that matter, as a clinician, you may have to put up with risks and uncertainties in the clinical environment, often working with incomplete information, to function. I am not in any way promoting risky medical practice, i.e. not promoting patient safety, but I am suggesting that some doctors, for example doing highly complicated surgical operations or procedures, or dealing with highly complex medical cases, have to deal with a high element of risk.

And the law of manslaughter, killing someone through an act or omission, unintended, but through recklessness, has to be dealt with in the framing of medical manslaughter. Even if #BawaGarba is successfully struck off, but then successfully returned to the medical register at least five years later, she is bound to be at risk of being a much worse doctor than when she left the medical profession? And then what has been achieved? If #BawaGarba had shown no contrition, such a period of ‘punishment’ would have been perhaps justified, but, as far as I know, #BawaGarba says she will live with that day for the rest of her life. But the patient’s relative will be permanently emotionally scared too; “life changed”.

I don’t deny this. This will be a landmark for the rest of her life, and cause her immense trauma for years to come, whatever happens.

I hope the GMC can look at this sensibly, otherwise they might accidentally promote a culture of fear where mistakes or errors are driven underground, and the NHS truly has a secretive culture where doctors are adversarial with its regulator as well as patients.

There were no winners in that case. The outcome was truly heartbreaking and nothing will ease the pain ever.





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As people are complex, it is not a surprise that the environment supporting them is complex

Chris Roberts will be the first person – and not the last – to tell you that once you’ve met a person with dementia you’ve met one person with dementia.


Everyone has unique experiences. I liken it to all of us, including academics, blindfolded trying to recognise an elephant from part of its body.

the elephant

This morning, I was struck by a new initiative entitled ‘Standing up 4 sitting down’ from Anchor Trust. It was heavily trailed on the breakfast TV and radio as I made breakfast for mum.

Standing Up 4 Sitting Down (#su4sd) is a new national initiative aiming to improve people’s access to their local shops and high street by increasing the amount of seating available to those who need it.  For this reason, Standing Up 4 Sitting Down (#su4sd) is calling on retailers and high streets to do their bit to improve the lives of people by providing adequate seating in stores and public spaces.

It’s the sort of idea which makes intuitive sense, but which some people might never think of however many hours they sit in their office.

Once in a while, you need to get out of your office.


It’s awkward, but we have to talk about it. Despite all the talk of being united in fighting against dementia, some are impressively unimpressive at working together with people. It is all too easy for certain providers to abuse a dominant position to get ‘market share’ of providing services, particularly if they secure government backing. This is of course a disaster for plurality.

This means that charities are branded in their unique line on ‘dementia’, whether it’s basic awareness or line in training. Too often I’ve seen the 1-2 manoeuvre where X sets up a campaign to ask Government for Y, a secret deal is done, then X secure publicly secures something from Y, and everyone’s a winner.

Culture is so important. Fran O’Hara and Pam Luckock don’t ‘dominate’ in the ‘meet up’ at Llandudno, but they are, whisper it, a critical part.


But real life is not at all like that. You can only understate dementia’s complexity at your peril, and because of the complexity of people with dementia and the caring relationship the environment for people with dementia needs to be complex, and actually adaptive to changing needs. Above all, it has to have resources in the right place.

The pain of all this is the we’ve known what’s not been right for ages. I can flag up policy reports from the 1990s demanding that it’s the right time for care planning, care coordination, and breaking down the barriers between health and social care.

But who is listening?


The problem with “person-centred integrated care” is that unless you’re very careful you can get totally engulfed in slogans. If, for example, one of the main disabilities from your dementia is not being able to hear people in a loud room, or have problems in higher order visual processing, talk of the machinery of care in national policy documents may not be your top priority. But, if supported, you can raise it to the top of the agenda like Agnes Houston did.



Nonetheless, people in policy still make mistakes. I remain aghast at the woeful omission of ‘caring well’ in the Department of Health 2020 implementation plan. “Real people” are needed to fill in the gaps too.


Take, for example, my example of extra seating for shoppers from Anchor Trust. This could have been easily branded “dementia friendly seating”, or such like, but think for a moment of the horrific unintended consequences as you take your seat on the ‘bandwagon of acceptance’. It’s very rare for someone to live only with dementia – a person with dementia is likely to live with a number of (interacting) conditions.

A “dementia friendly seating” initiative, along with branded leaflets on a small nearby table, would mean that in a shop people with dementia would out themselves and become immediately labelled by their diagnosis if they took up the offer of extra seating in a shop. But at least they could read more about dementia when all they wanted to do was to do a bit of shopping.

And there’s no particular reason why this should be a ‘dementia only offer’. Many people for all sorts of reasons have mobility problems.

I learnt as I came to concluding the manuscript of my third book on dementia on integrated care that you can never underestimate the power of the system to confirm their bias in producing the system most convenient for the system and not for patients/service users. There are some people who are totally genuine, and who carry on with dignity.


And the people in research aren’t necessarily highly virtuous either. I’ve often recently only understood the purpose of papers in dementia from reading the list of conflicts of interests at the end (early diagnosis, pre-dementia and cognitive frailty being the new holy grail for snake oil salesmen). Researchers can too often fall into the trap of defending their own obsessions, and this can mean a truly magnificent consolidation of certain types of language, e.g. wandering, challenging behaviours. But you have to be a brave soul to be the exception making a stand.

In case you were wondering, I was of course invited to Llandudno for the second annual event in beautiful North Wales where all people are indeed invited to contribute to how dementia services would be better. I went last year. The atmosphere was brilliant. People there weren’t showing off. There was no aggressive oneupmanship. Yes, who’d have thunk it. People there were nice.


I brought along my books, but I didn’t show them to anyone. I chickened out.


And I think commissioners, who are real people, also do need to speak to academics, who are real people, as well as practitioners/professionals, who are real people, as well as carers, who are real people, and leads in social enterprises, who are real people, and of course people with dementia, who are real people too.


It really isn’t rocket science (nor does it need a CQUIN) to value carers.


It’s often called ‘who’s in the room’ – part of the problem has been people excluded by not being invited (same old speakers, same old chumocracy, same old mailing list, same old exorbitant entrance fee, same failed solutions).

The problem is that this chumocracy is quite incapable of seeing the wood from the trees. Ideas when they arise organically can be unbelievably rich.


Prof Edgar Cahn, for me the father of “co-production”, used to liken it to having a road map where half of the route was deliberately obliterated making it impossible for you to find your destination.

Co-production is not a series of manuals, or a certificate. Patient option or experience is not a product of a product. All of this is an ethos, and you either have it or you haven’t.


This event next week deserves every success – and of course I have nothing other than admiration for it.


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Anything can happen to anyone at any time

let life go


When I woke up on the top floor of the Royal Free in North London at about 10 pm, it was left to a junior night-duty nurse to explain to me that I had been in a coma for six weeks.

I was later to be told that Tony Blair was no longer Prime Minister; and that there had been a foot and mouth health crisis.

I had a very brief medical career, but it always struck me how life-challenging diagnoses seemed regularly to be given to the nicest of people.

While I ‘get’ the current drive towards compassion in the NHS, any person who has been a doctor or nurse on a medical ward will tell you about how you do have to park emotions elsewhere when you’re confronted with emotionally very challenging issues.

What I do not think is acceptable is politicians of all parties, imposing neoliberal austerity, airbrushing under-resourced secondary care wards with the ‘fault’ of clinicians who do not have the time or resources to care.

You see, following my cardiac arrest and epileptic seizure in the summer of 2007, heralding my period unconscious on the ITU of the Royal Free, I believe that anything can happen to anyone at any time.

I then spent two months as an inpatient of a neurorehabilitation ward of the National Hospital for Neurology and Neurosurgery, where indeed I had been a junior doctor.

One of my best friends was a man about my age who had accidentally fallen down a pothole, had been admitted as a neurosurgical  emergency, and had an entirely new titanium skull fitted.

I have already been dead in a sense; but in my subsequent life, I live each day as it comes. This totally changes my perspective on life.

I don’t have time for ‘woe is me’ stories, not because I am a heartless bastard; but because it will surprise you with the amount of personal pains people have in private.

I think there are dangers with adopting a ‘victimhood’ stance. I don’t spend time thinking about how I could’ve avoided becoming physically disabled in adult life. But likewise the people I have seen who have out of the blue decided ‘enough is enough’ have taken their decisions out of the blue.

One close friend of mine killed herself, also a medical student but who had a housing crisis, drank two bottles of wine and drove her car off a cliff in Cornwall. I remember tidying up her room when her parents came to clear up all her belongings in student accommodation before the funeral.

Only weeks earlier, she had been telling me about her wish to be a neurophysiologist.

If we all concentrate on the past or future, we lose neglecting what is happening today. But today we can do things and will be surrounded by people who won’t be there one day.

I think we are all on a learning curve, and no matter how senior you are, nor how many qualifications you have, you must always be willing to listen, and sometimes admit you have failed. But likewise when things go well things how they went well, and what can be learnt from them.

I feel mistakes have been made in English dementia policy, like having incentives for diagnoses in dementia without addressing requirements of the workforce, but I have no involvement with the machinery of NHS England. My ‘ambition’ is to carry on what I am doing, with the people I want to do it, and expect nothing in return.

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