1. How do I raise concerns about my working environment and inadequate staffing?
Follow the steps in the flowchart below (click to open in full).
- You must raise this concern with your manager or the consultant in charge or the practice partner, straight away.
- Afterwards, keep a brief written record of your concern and the steps you have taken to deal with this. It’s important that you raise the concern at the earliest opportunity – afterwards, you can document this through the formal procedure.
- For doctors working in NHS trusts and NHS foundation trusts in England, make sure you know who your guardian of safe working is and how you contact them. In England, all organisations employing or hosting 10 or more trainees are required to appoint a guardian of safe working. Organisations with fewer than 10 trainees must make one available through another NHS organisation. Your guardian of safe working will be able to offer guidance and support if you are not able to speak up through your normal line management chain.
Actions for doctors in training
- For every employer you are working for, you should know the process for rota monitoring, so your employer understands the number of hours you are being required to work and any gaps in rotas. If you’re not sure, you should ask a senior colleague about this.
- You should usually raise any significant concerns with a named person in your deanery or local education and training board – for example, the postgraduate dean or director of postgraduate general practice education.
- Doctors in training in England should follow the process for logging exception reports to report work hour breaches and missed training sessions.
We recognise that many of these issues may not be resolved immediately but you need to raise your concerns, so that you know you have done the right thing for patients and so that those responsible for staffing take that responsibility.
2. Should I refuse to work if I think conditions are unsafe?
No. You should raise your concerns with a senior colleague either directly or ask someone to raise concerns on your behalf. You should work with colleagues to find a solution to provide the safest care possible in the circumstances to all your patients.
Doctors must use their professional judgment to raise concerns effectively. Whatever action you take, you should:
- know who to contact and how to contact them
- raise your concerns and keep a written record of the action you took.
Your employer is responsible for making sure your working environment is safe, you have the appropriate supervision and are supported. We also set out clear expectations for senior doctors about what to do if concerns are raised with them (see question 3). Individual circumstances will vary but if you follow our guidance on Raising and acting on concerns, you will have done all in your power to keep patients safe, voice your concerns and also be able to explain your actions if asked. Follow our flowchart if you think you need to escalate your concerns further.
3. What do you expect of leaders and organisations to help doctors who are concerned about their working environment?
If you are a doctor in a leadership or management position (including being the most senior doctor on shift), we set our clear expectations in our Leadership and management for all doctors guidance.
You should do everything possible to:
- make sure people you manage have appropriate supervision, whether through close personal supervision (for doctors in training, for example) or through a managed system with clear reporting structures
- if you are responsible for supervising staff, whatever your role, you must understand the extent of your supervisory responsibilities, give clear instructions about what is expected and be available to answer questions or provide help when needed. You must be satisfied that the staff you supervise have the necessary knowledge, skills and training to carry out their roles.
Raising and acting on concerns (set out in our Raising and acting on concerns guidance, page 13)
- make sure there are systems and policies in place to allow concerns to be raised and for incidents, concerns and complaints to be investigated promptly and fully
- not try to prevent employees or former employees raising concerns about patient safety – for example, you must not propose or condone contracts or agreements that seek to restrict or remove the contractor’s freedom to disclose information relevant to their concerns
- make sure clinical staff understand their duty to be open and honest about incidents or complaints with both patients and managers
- make sure all other staff are encouraged to raise concerns they may have about the safety of patients, including any risks that may be posed by colleagues or teams
- makes sure staff who raise a concern are protected from unfair criticism or action, including any detriment or dismissal.
Education and training
Organisations managing and delivering undergraduate and postgraduate medical education and training must follow our standards – Promoting excellence: standards for medical education and training. Doctor’s learning environment must be safe for patients and supportive for trainees and educators.
We expect organisations to make sure:
- there are enough staff members who are suitably qualified, so that trainees have appropriate clinical supervision, working patterns and workload, for patients to receive care that is safe and of a good standard, while creating the required learning opportunities
- foundation doctors have – at all times – on-site access to a senior colleague who is suitably qualified to deal with problems that may arise during the session
- trainees have an induction in preparation for each placement that clearly sets out:
- their duties and supervision arrangements
- their role in the team
- how to get support from senior colleagues
- the clinical or medical guidelines and workplace policies they must follow
- how to access clinical and learning resources.
4. What can the GMC do if a doctor’s training environment is unsafe?
Organisations managing and delivering undergraduate and post-graduate medical education and training must follow our standards – Promoting excellence: standards for medical education and training.
Usually concerns will be resolved locally, but where this doesn’t happen satisfactorily, these may be escalated to the local/national post-graduate dean’s office. Serious or prolonged concerns will be escalated to us.
We continually monitor the safety of training environments, including our programme of visits and the evidence from our National training survey. We will not hesitate to take action if the safety of trainees and patients is at serious risk, in the most serious cases, considering whether it is appropriate to remove trainees from particular locations. For example, we required doctors in training to be removed from East Kent Hospitals University NHS Foundation Trust in March 2017, in response to poor levels of clinical supervision.
5. What should I do if something goes wrong?
Sometimes things do go wrong. Our Duty of candour guidance requires health professionals to be open and honest with patients or families, where appropriate, where things have gone wrong.
Senior clinicians have a responsibility to set an example and encourage openness and honesty in reporting adverse incidents and near misses. You should always speak to your manager or consultant, to make sure you are following our Duty of candour guidance appropriately.
When something has gone wrong, you should:
- speak to the patient, or those close to them, as soon as possible. Share all you know and believe to be true about what went wrong, why and what the consequences are likely to be
- apologise to the patient, explaining what happened, what can be done if they have suffered harm and what will be done to prevent someone else being harmed in the future
- respond honestly to any questions from patients or their families
- report this at an early stage, so lessons can be learnt quickly and actions can be agreed within the healthcare team
- record information about clinical incidents.
6. So where does this leave us with reflective practice?
The focus of reflection should be on learning, rather than what has gone wrong. Educational and clinical supervisors should be supporting doctors in training to reflect openly, as set out in the Academy of Medical Royal College’s guidance on ‘Improving feedback and reflection to improve learning’. We are working with other organisations to provide clear guidance for all doctors on how to approach reflective practice.
As far as possible, patient details in any reflections and feedback should be entered anonymously, so that it is not possible to identify any individuals from what is written (page 7 of the Academy of Medical Royal College’s guidance on Improving feedback and reflection to improve learning). If you follow our Duty of candour guidance (see question 5), there shouldn’t be anything recorded in reflective notes that the patient, or those close to the patient, is not aware of.
7. Will the GMC ask doctors for reflective statements, as part of their investigations?
No. We, the GMC, do not ask a doctor to provide their reflective statements if we are investigating a concern about them.
In this case, Dr Bawa-Garba’s e-portfolio did not form part of the evidence before the criminal court and jury. As pointed out in a statement from the Medical Protection Society, this has been widely misreported. It was put forward in the Medical Practitioners Tribunal by Dr Bawa-Garba, as part of her defence.
As with most documents, recorded reflections, such as in e-portfolios, are not subject to legal privilege under UK law. As a result, these documents might be requested by a court if it is considered that they are relevant to the matters to be determined in the case. A doctor can also choose to disclose their reflective statements as part of their defence, in court or tribunal proceedings, to support their case and show how they have responded to an incident.
8. Why did you appeal this case in 2017?
The Tribunal failed to respect the findings of the criminal court’s judgement and in doing so, went behind the basis on which the jury had convicted Dr Bawa-Garba. That is something which is not lawful for the Tribunal to do.
For that reason, and to fulfil our statutory duty to maintain public confidence in the profession, it was necessary for us to appeal the Tribunal’s decision.
Charges of gross negligence manslaughter against medical practitioners are extremely rare. They are not about mistakes, such as missed diagnosis, a series of failings, or even several missed opportunities. As the High Court made clear in its judgement, in this case, ‘The degree of error, applying the legal test was that her own failings were, in the circumstances, “truly exceptionally bad” failings’. The High Court judge was also clear that wider systems issues and pressures were taken into account in the original criminal conviction, and in the previous 2015 appeal where that conviction was upheld.
9. Punishing doctors does not protect patient safety and the public. How is this decision protecting patient safety?
We must remember the tragedy at the heart of this case, the death of six year old Jack Adcock and the terrible loss, anger and grief for his family.
We will always be called upon to make difficult decisions about a doctor’s fitness to practise. When we do this, we have to consider how to protect the public in the fullest sense, which includes maintaining public confidence in the profession. The High Court concluded that allowing a doctor to continue to practise, with a conviction of gross negligence manslaughter, is highly likely to damage the public’s trust in the profession.
There are wider issues highlighted in this case, which are very concerning for doctors. This concerns us, as we believe that in order to keep patients safe, doctors need to feel supported and safe. We know these concerns aren’t going to be resolved quickly and we are working closely with the Royal Colleges, BMA and other organisations to form a plan of action to address these concerns.
10. Do you take system pressures into account when you are investigating a doctor’s fitness to practise?
Yes. We know that within a health care system – especially those that are under real pressure – not all doctors will be able to meet the expectations in Good medical practice every day.
Sometimes wider issues within the healthcare system have an impact on the care patients receive. When we consider a complaint, we look at potential individual or system failings (or a combination of both) and we take that into account when considering whether action is needed. In cases where a healthcare organisation has referred the doctor to us, we also confirm whether the doctor has previously raised any concerns about patient safety or systems. This helps us understand the context of the case and reduces the risk of doctors being disadvantaged for raising concerns.
Our focus is on whether the concern and the doctor’s response suggest that the doctor is likely to pose a risk to patients or to public confidence in doctors in the future, rather than on punishing doctors for what has gone wrong in the past. The risk will be lower for a doctor who shows insight into what has happened and retrains to make sure that mistake can’t happen again.
If you believe patients are at risk because of inadequate premises, equipment or other resources, you must raise your concerns (see question 1 for the action to take) and keep a brief written record of the steps you have taken.
11. Were system failures taken into account in this case?
Yes, they were. The systemic issues at the hospital where Dr Bawa-Garba was working were taken into account by the Crown Court in the original trial and were also considered by the Court of Appeal in 2015 when Dr Bawa-Garba sought and was denied permission to appeal her conviction.
12. Does this ruling mean that doctors’ will be struck off for making any kind of clinical error?
No. Mistakes happen in healthcare, even serious mistakes that result in serious harm to patients. There is a very high threshold set in the criminal law for gross negligence manslaughter to be established, as was the case with Dr Bawa-Garba.
We only take action if a doctor has made a serious or persistent breach of our guidance, which puts patients at risk or harms the public’s trust in the profession.
Over the last few years, the number of GMC investigations of single clinical errors has dropped by 50%.
13. What are you doing to address the wider issues raised by this case?
The pressure faced by health services is of great concern to us. We have already spoken out to highlight failing systems which are preventing doctors from providing high quality care and meeting the standards we have set. In December 2017, we urged organisations involved in training and recruitment to act now, to avert greater pressure over the coming years.
We will not hesitate to take action if the safety of trainees and patients is at serious risk – we required doctors in training to be removed from East Kent Hospitals University NHS Foundation Trust in March 2017, in response to poor levels of clinical supervision.
We are already working with the Royal Colleges and the BMA to make sure doctors are clear on how to report concerns about system pressures and doctors in leadership roles are taking the necessary action. We will also work with health professional leaders, defence bodies, patient, legal and criminal justice experts from across the UK to explore how gross negligence manslaughter is applied to medical practice, in situations where the risk of death is a constant and in the context of systemic pressure.
We will continue to put forward our view on issues that affect doctors’ abilities to meet our standards.