Jack Adcock wasn鈥檛 himself when he returned from school.
He later started vomiting and had diarrhoea, which continued through the night.
In the morning Jack was taken to the GP by his mother, Nicola, and referred directly to Leicester Royal Infirmary鈥檚 children鈥檚 assessment unit (CAU).
Less than 12 hours later he was dead.
鈥淟osing a child is the most horrendous thing ever. But to lose a child in the way we lost Jack 鈥 we should never have lost him,鈥 Mrs Adcock says.
08:30
Trainee doctor Hadiza Bawa-Garba arrived at work expecting to be on the general paediatrics ward - the ward she鈥檇 been on all week.
She had only recently returned to work after having her first baby. Before her 13 months鈥 maternity leave, she had been working in community paediatrics, treating children with chronic illnesses and behavioural problems.
But when medical staff gathered to discuss the day鈥檚 work, they were told someone was needed to cover the CAU 鈥 the doctor supposed to be doing it was on a course. And Dr Bawa-Garba volunteered to step in.
She also carried the bleep 鈥 which alerts the doctor that a patient needs seeing urgently on the wards or in the Accident and Emergency unit, across four floors of the busy Leicester Royal Infirmary 鈥 and was required to respond to calls from midwives, other doctors or parents.
Soon after Dr Bawa-Garba took over, the bleep went off 鈥 a child down in the accident and emergency unit, several floors below, needed urgent attention and she missed the rest of the morning handover.
10:30
Back in the CAU, Dr Bawa-Garba was asked to see Jack Adcock by the nurse in charge, Sister Theresa Taylor, who was worried he had looked very sick when he had been admitted.
She was the only staff nurse that day. Because of staff shortages, two of the three CAU nurses were from an agency and not allowed to perform many nursing procedures.
鈥淛ack was really lethargic, very sleepy. He wasn鈥檛 really very with it,鈥 says Mrs Adcock. She told medical staff he had been up all night with diarrhoea and sickness.
The boy鈥檚 hands and feet were cold and had a blue-grey tinge. He also had a cough.
鈥淚 knew that I had to get a line in him quickly to get some bloods and also give him some fluids to rehydrate him,鈥 says Dr Bawa-Garba. He didn鈥檛 flinch when she put his cannula in.
Because of a pre-existing heart condition, Jack had been taking enalapril 鈥 a drug to control his blood pressure and help pump blood around his body 鈥 twice a day.
But Dr Bawa-Garba says she didn鈥檛 want him to have the enalapril, because he was dehydrated and it might have made his blood pressure drop too much.
Because of this, she says, she left it off his drug chart.
She then asked for an X-ray to check Jack鈥檚 chest. Blood was taken 鈥 some was sent down to the labs, while a quicker test was done to measure his blood acidity and lactate levels 鈥 the latter being a measure of how much oxygen is reaching the tissues. The tests revealed his blood was too acidic.
鈥淎 normal pH is 7.34 鈥 but Jack鈥檚 was seven and his lactate was also very high. A normal is about two and his was 11, so I knew then he was very unwell,鈥 Dr Bawa-Garba says. She gave him a large boost of fluid 鈥 a bolus 鈥 to resuscitate him.
Her working diagnosis was gastroenteritis and dehydration.
But she didn鈥檛 consider that Jack might have had a more serious condition. It was a mistake she regrets to this day.
11:00
Jack had been admitted under the care of Dr Stephen O鈥橰iordan, the consultant who was supposed to be in charge that day 鈥 but he hadn鈥檛 realised he was on call and had double-booked himself with teaching commitments in Warwick and hadn鈥檛 arrived at work.
Another consultant based elsewhere in the hospital had said she was available to help and cover him if needed 鈥 although she had her own duties.
After an hour of being on fluids to rehydrate him, Jack seemed to be responding well.
鈥淗e was a little more alert and we thought he was getting better,鈥 Mrs Adcock says.
Dr Bawa-Garba thought that too.
One of the less experienced doctors in the unit had been unable to do Jack鈥檚 next blood tests. They had tried but couldn鈥檛 get blood, so Dr Bawa-Garba went to do it herself.
This time, when Dr Bawa-Garba went to take blood from his finger, Jack resisted, pulling away.
鈥淭hat kind of response, to me, said that he was responding to the bolus,鈥 she says. 鈥淎lso, the result I got showed that the pH had gone from seven to 7.24. In my mind I鈥檓 thinking this is going the right way.鈥
However, not enough blood had been taken to get another lactate measurement.
12:00
Dr Bawa-Garba looked for Jack鈥檚 blood results from the lab. She had fast-tracked them an hour-and-a-half earlier. But when she went to view them on the computer system, it had gone down.
The whole hospital was affected. This meant not only that blood test results were delayed, but also that the alert system designed to flag up abnormal results on computer screens was out of action.
She asked one of the doctors in her team to chase up the results for her patients, and took on some of that doctor鈥檚 tasks.
Those tests would have indicated that Jack may have had kidney failure and that he needed antibiotics.
15:00
By this point, Jack was sitting up in the bed drinking juice.
鈥淚 automatically thought he was perking up,鈥 says Victor, Jack鈥檚 father.
Because he had stopped vomiting, Dr Bawa-Garba prescribed some Dioralyte 鈥 rehydrating salts.
But the fluid he was losing from having diarrhoea had not been documented by his nurse.
Dr Bawa-Garba also reviewed Jack鈥檚 X-ray, which had been ready for a few hours. Dr Bawa-Garba says no-one had flagged it was available.
She says she had been busy with other patients 鈥 including a baby with sepsis that needed a lumbar puncture 鈥 and this was the first opportunity she had had to review it.
The X-ray showed that Jack had a chest infection so she prescribed antibiotics.
But Dr Bawa-Garba says she wishes she had given him antibiotics sooner.
This was the last time Dr Bawa-Garba treated Jack, who was also being cared for by an agency nurse. The nurse was doing his observations - including his temperature, heart rate and blood pressure - but did not record them regularly.
16:00
Consultant Dr Stephen O鈥橰iordan arrived at the hospital.
鈥淚 hadn鈥檛 worked with him before, so I introduced myself,鈥 Dr Bawa-Garba says.
She then went to chase up Jack鈥檚 blood results, which still hadn鈥檛 come through 鈥 the doctor she had assigned to do it hadn鈥檛 managed to get them.
Dr Bawa-Garba tried a number of extensions before managing to speak to someone. They read out Jack鈥檚 results and she noted them down. She says she was looking out for one particular test result called CRP, which would confirm whether Jack鈥檚 illness had been caused by bacteria or a virus.
She noted it was 97, far higher than it should have been, so she circled it. But she says she was concentrating so much on the CRP that she failed to register that his creatinine and urea were also high 鈥 signalling possible kidney failure.
16:30
During the afternoon handover, Dr Bawa-Garba told Dr O鈥橰iordan about Jack 鈥 his diarrhoea and vomiting, heart condition, and enalapril medication. She says she told him Jack鈥檚 lactate level was 11, and mentioned some of the other blood test results. She said she had started him on antibiotics for a chest infection, and asked his advice about the fluids Jack was being given.
She says Dr O鈥橰iordan noted down what she said and ordered repeat blood tests. Dr Bawa-Garba says she had assumed he would go to see Jack - based on the description she had given and the fact he had asked for further tests - but he didn鈥檛.
19:00
By this time, Jack had been moved to ward 28 under the care of a different team. On his way up there, he had been sick again.
It was at this point that another failing in Jack鈥檚 care occurred.
Mrs Adcock says she asked a nurse looking after Jack on that ward if she could give him his enalapril 鈥 the medication to regulate his blood pressure. He was due his second dose of the day.
She recalls the nurse telling her she鈥檇 checked with another doctor on duty.
Mrs Adcock says she was told the nurse wouldn鈥檛 be able to give the medication to Jack, as it had not been prescribed, but his mother could. So Mrs Adcock gave it to him.
The nurse later said she had also asked for a doctor to come to see Jack.
鈥淲e鈥檇 got Toy Story on but he was still knocking his oxygen mask off,鈥 Mrs Adcock says.
鈥淚 was just saying, 鈥楥ome on sweetheart go to sleep,鈥 and I was rubbing his face. I鈥檒l never forget 鈥 he closed his eyes and I thought something鈥檚 not quite right. His tongue, or his lips, looked blue. I ran out of the room, saying, 鈥楥an someone come and look at Jack?鈥欌
20:20
Dr Bawa-Garba had been on call for more than 12 hours when an emergency call went out for a patient who had suffered a cardiac arrest on ward 28 and doctors and nurses rushed to help.
In the morning, Dr Bawa-Garba had had to intervene to stop doctors from trying to resuscitate a terminally ill boy who had a 鈥渄o not resuscitate鈥 order.
She assumed it was the same boy. What she didn鈥檛 know was that Jack had subsequently been moved to the same ward as the boy who had crashed in the morning 鈥 ward 28.
A terrible confusion was about to follow.
鈥淲hile we鈥檙e running up the stairs, all I was thinking is, 鈥業t鈥檚 the child with the do-not-resuscitate again 鈥 that someone is trying to resuscitate. This is a mistake,鈥欌 she says.
When she reached the fourth floor, at least 11 people were already in the side room, she says.
Meanwhile, Nicola Adcock was waiting outside the room. In that moment, Dr Bawa-Garba didn鈥檛 recognise her. She says:
Dr Bawa-Garba says she was then told by another doctor that the patient was not the same boy as earlier 鈥 but was Jack Adcock.
鈥淚 was shocked and I was like, 鈥榃hy is Jack crashing?鈥欌 she says.
She told the team to continue the resuscitation.
鈥淚 remember going hysterical and just thinking, you know, 鈥楶lease look after my little boy,鈥欌 says Mrs Adcock. 鈥淎nd then I remember somebody taking me back into the room and telling me, 鈥楯ack needs his mummy.鈥欌
At 21:21 the decision was made to stop resuscitation. Jack had died of sepsis. Experts later said the interruption to the resuscitation had not contributed to his death 鈥 but he shouldn鈥檛 have been given enalapril and he should have been given antibiotics much earlier.
At the Adcocks鈥 home in Glen Parva, a suburb of Leicester, Jack鈥檚 sister Ruby has moved into his old room. His has been recreated in the room she vacated. Stars featuring handwritten messages from Jack鈥檚 schoolmates, saying how much they will miss him and his cheeky laugh, adorn the navy blue walls of the replica bedroom.
鈥淚t鈥檚 my way of coping,鈥 says Mrs Adcock. She says she has yet to grieve.
The investigations, court proceedings, and appeals have taken a toll on the family.
She describes Jack as a 鈥渏oyful little boy鈥 and says he and his younger sister, Ruby, adored each other.
Jack used to love dancing, swimming and going to watch Leicester City football team, says his father, even though he had been in and out of hospital during his short life.
鈥淲e were season ticket holders but since that happened [Jack鈥檚 death] I haven鈥檛 been able to go,鈥 he says. 鈥淚 can鈥檛 face it.鈥
The night Jack died, Mr and Mrs Adcock were taken into a room off the ward, where they were met by doctors they鈥檇 never seen before.
鈥淲e were told, 鈥業鈥檓 really sorry but your son鈥檚 passed away,鈥 says Mrs Adcock. 鈥淚t just didn鈥檛 sink in.鈥 She remembers them saying he had had pneumonia and an internal bleed.
She asked to see her son. The last time she had seen him, he had been asleep and had looked peaceful. 鈥淗e had no tubes, he had nothing,鈥 she says.
This time, 鈥渢here was blood 鈥 I just couldn鈥檛 believe it was him, my baby, gone鈥.
Everyone on the ward was crying, she says, including Dr Bawa-Garba, who was sobbing. 鈥淣obody expected Jack would die.鈥
The doctor came over to express her condolences and Mrs Adcock thanked her for looking after Jack.
鈥淚 wish I could take those words away. I never knew then what I know now,鈥 she says.
The following day, Saturday, the family was invited back to the hospital to meet a group of doctors, nurses and managers from the trust to discuss what had happened.
Minutes taken by one of Mrs Adcock鈥檚 friends from university, whom the family had invited to the meeting, give an indication of what was discussed.
The hospital representatives apologised for the boy鈥檚 death and said they would investigate.
鈥淭hey said he just wasn鈥檛 looked after; he didn鈥檛 have the right support; he wasn鈥檛 given the right care,鈥 Mrs Adcock says. She wanted to know about the interrupted resuscitation and so they talked about that too.
The family was also told that a junior doctor had failed to recognise the severity of Jack鈥檚 condition, according to the minutes.
The police then arrived 鈥 there was to be an investigation after the unexpected death of the child.
鈥淚 remember being absolutely terrified, thinking, 鈥業 haven鈥檛 done anything, why are the police here?鈥欌 Mrs Adcock says.
After Jack鈥檚 post-mortem examination, two days later, the family was told that he had died of a streptococcal infection and had developed sepsis and they could make plans for his funeral.
鈥淓verything was in place. There was an article going in the paper on the Friday to say when his funeral was going to be,鈥 Mrs Adcock says.
But then they were asked to cancel their plans and meet the police at the coroner鈥檚 office to discuss an inquest.
鈥淎s you can imagine at that point, we felt physically sick 鈥 the anger raged. We just could not believe what we were hearing, so automatically we said, 鈥楽o you鈥檙e telling us someone鈥檚 responsible for our son鈥檚 death?鈥欌 Mrs Adcock says.
There was then a second post-mortem examination in case criminal proceedings were opened.
鈥淚t took three months to get my little boy back, to be able to lay him to rest,鈥 Mrs Adcock says.
Not a day goes past, Dr Bawa-Garba says, when she doesn鈥檛 think about the day Jack died.
The 41-year-old mother of three says the impact on her and her family has been huge.
She has had to move house and unpleasant material was posted on social media.
鈥淚 had parents from my daughter鈥檚 school asking if I was OK because they were getting leaflets in their letterboxes saying that they should sign a petition to say that I should be struck off,鈥 she says.
The case attracted a lot of media coverage.
鈥淚鈥檓 a very private person, but I had my face in the newspaper.鈥
Dr Bawa-Garba had enjoyed an unblemished career before Jack鈥檚 death and was well-regarded by her colleagues.
Born in Nigeria, she had wanted to be a doctor since she was about 13 years old, after recovering from malaria. At 16 she moved to the UK to study for her A-levels.
After her first degree at Southampton University, she studied medicine at Leicester and set her sights on becoming a paediatrician.
鈥淚've been in the UK for more than half my life,鈥 she says. 鈥淚 love the NHS. I love the fact that people can get access to free medical health and that you can be part of that process.鈥
But that all changed the day she covered for a colleague at the CAU.
鈥淭he last picture I have of Jack is him sitting up drinking from a beaker, nothing prepared me to see him crash,鈥 she says.
鈥淎fter I realised that we were actually resuscitating Jack, I just couldn鈥檛 understand why he had crashed. When the team wanted to stop, I didn鈥檛 want to stop - because in my mind I'm thinking he鈥檚 not meant to crash,鈥 she says.
Afterwards, she went to the nurses鈥 station and sobbed.
鈥淚 just couldn鈥檛 control myself and I'm not usually a weepy person,鈥 she says. 鈥淚 just kept thinking, 鈥楬ow did that happen? Why did he crash? What went wrong?鈥欌
Dr Bawa-Garba recalls the moment that Mrs Adcock came up to her to thank her for her help. 鈥淚 said to her, 鈥業'm really sorry about the outcome 鈥 I don't know how this happened,鈥欌 she says.
Later that night, Dr Bawa-Garba called Dr O鈥橰iordan 鈥 the consultant who had arrived in the afternoon, after double-booking himself that day 鈥 to tell him about Jack鈥檚 death. She went home at 23:00 鈥 some 15 hours after she had started her 12-hour shift 鈥 and updated Jack鈥檚 notes with what had happened at the resuscitation.
The following day, she was back at work at the assessment unit.
She knew the hospital was meeting the Adcocks and asked if she could attend. But she says Dr O鈥橰iordan told her that she had to get on with her clinical duties.
The consultant then added to the notes that Dr Bawa-Garba had made.
He wrote that Dr Bawa-Garba had 鈥渘ot stressed鈥 to him that Jack鈥檚 lactate level was 11.
On Sunday, struggling to process what had happened, Dr Bawa-Garba phoned Mrs Adcock to say she was sorry for the family鈥檚 loss.
鈥淚 just wanted to reach out to see how mum was holding up because it must be devastating,鈥 she says.
The following day, she says, she was admonished by Dr O鈥橰iordan for making that call and told not to have any more contact with the family because an investigation was to be launched.
He then told her that they needed to discuss Jack鈥檚 death properly because he thought she hadn鈥檛 highlighted to him how ill Jack was, she says. He wanted to talk about how things could have been done differently to stop it happening again, she adds.
Dr Bawa-Garba had already started to write down her reflections.
鈥淲hen you have a case that has had an impact on you, you write down how you feel and what you would change,鈥 she says. 鈥淚 made my own action plan about how I would be able to address those things that I wish I had done differently.鈥
On 25 February, a week after Jack鈥檚 death, Dr O鈥橰iordan asked Dr Bawa-Garba to meet him in the hospital canteen, rather than the office he shared with other consultants. She was told to list everything that she could have done differently, she says.
So she continued that personal reflective process with Dr O鈥橰iordan in the canteen.
鈥淚 was beating myself up about every single detail and obviously wishing that I had recognised sepsis, so we spoke about that and I was very open and explained everything,鈥 she says. 鈥淚t contained what I felt I could鈥檝e done better plus some of the things that Dr O鈥橰iordan also felt that I could鈥檝e done better.鈥
Jack died from sepsis. Sepsis is when the immune system overreacts to an infection and attacks the body鈥檚 own organs and tissues.
According to the UK Sepsis Trust, about 14,000 people die each year because it is not diagnosed or treated early enough.
At the meeting, Dr O鈥橰iordan took notes, which he then transferred to what is called a training encounter form, she says. This contained one section for Dr O鈥橰iordan to write on and one for Dr Bawa-Garba to document her learning points and reflections.
However, she didn鈥檛 agree with all Dr O鈥橰iordan said and didn鈥檛 sign the form.
Both her reflections and the training encounter form were uploaded to her e-portfolio, an online system used for learning purposes.
As soon as the meeting finished, Dr Bawa-Garba says she was sent home by Dr O鈥橰iordan.
Dr O鈥橰iordan declined Panorama鈥檚 invitation to comment on Dr Bawa-Gaba鈥檚 account of the meeting.
Recognising her need for further training, the hospital took Dr Bawa-Gaba off the on-call rota and put her on to the paediatric intensive care unit under the supervision of a consultant.
There she would see lots of children with sepsis, some of whom would get better then get worse 鈥 like Jack, she says.
鈥淚 was probably slower than I used to be, because I was micromanaging and double-checking everything and second-guessing myself all the time,鈥 she says.
Using what she had learned from Jack Adcock鈥檚 death, Dr Bawa-Garba says, she helped carry out a sepsis study and formed a junior doctor weekly teaching programme where doctors would discuss 鈥渘ear misses鈥 or incidents when patients had died so they could learn from them.
The hospital had carried out its own investigation and Dr Bawa-Garba continued to work there.
But five months after Jack鈥檚 death, Dr O鈥橰iordan left the Leicester Royal Infirmary and moved to Ireland.
Because Jack鈥檚 death was unexpected, the hospital conducted an investigation to identify what had gone wrong with the little boy鈥檚 care. They produced a report in August 2011 and updated it six months later.
It not only pointed to errors made by Dr Bawa-Garba and nursing staff - including Dr Bawa-Garba鈥檚 failure to recognise the severity of Jack鈥檚 illness - it also found a series of 鈥渟ystem failings鈥.
鈥淚 think that we let Jack Adcock down - there鈥檚 no doubt about that in my mind,鈥 says Andrew Furlong, medical director since 2016 of University Hospitals Leicester, which includes the Leicester Royal Infirmary.
There were six root causes for Jack鈥檚 poor care, the report said, listing 23 recommendations for improvement and 79 actions to minimise the risk of another child dying in such unacceptable circumstances.
The recommendations were wide-ranging but included:
- Robust processes for helping staff return to work after periods of protracted leave or maternity leave
- A dedicated presence of consultants on the children鈥檚 assessment unit
- New guidelines on the use of agency nurses
- Better visual prompts for staff about abnormal blood results
鈥淏est practice shows that when you鈥檙e trying to identify learning, the way to do that is in an open culture, where people can give evidence without fear of sanction or blame,鈥 Mr Furlong says.
Panorama has spoken to doctors who worked in the paediatric department shortly before Jack鈥檚 death. None felt able to go on the record.
They said doctors and nurses at the hospital had been raising concerns about staffing before Jack鈥檚 death.
They said consultant cover had been patchy and that factional infighting between consultants had caused problems for trainee doctors - it wasn鈥檛 something they could speak out about, they had had to keep their head down.
Junior doctors did try to raise their concerns that trainees were being used to plug rota gaps, often at the last minute. The CAU was one of the areas where there was never enough staff, and the hospital recognised that this posed a risk.
One doctor said she would pray before she went into work because she was worried something bad would happen.
In response, Mr Furlong says that as the only children鈥檚 emergency department serving 1.2 million people, the CAU was always busy.
鈥淭hat isn鈥檛 unique to this trust, nor was the difficulty in recruiting doctors and nurses, too few were coming out of training nationally, a fact which the NHS locally and nationally is still struggling with. At the start of every shift, the nurses and doctors in charge routinely review staffing levels and move resources to where they are most needed,鈥 he says.
After Jack鈥檚 death, the police started their own investigation and the Adcocks praise them for the support they have given the family.
But they say they heard very little from the hospital. They were sent a copy of the Leicester Royal Infirmary investigation and invited to discuss it, but they didn鈥檛 want to.
In February 2012 鈥 a year after Jack鈥檚 death, and just after Dr Bawa-Garba had given birth to her second child 鈥 she received a phone call from the police. At first, she thought she had misheard what she was being told.
鈥淭he officer said, 鈥榃e鈥檙e investigating Jack鈥檚 death as a possible manslaughter case and we need you to come down to the station,鈥欌 she says.
She went along thinking it would be a similar process to the hospital investigation. But suddenly she found herself under arrest and being read her rights. Her photograph and fingerprints were taken.
During the six-hour interview, all she could think about was her two-week-old daughter who would need breastfeeding. During phone calls home, she could hear the hungry baby crying.
The police investigation came to nothing. Seven weeks later, Dr Bawa-Garba was told that no charges were going to be brought against her.
More than a year later, in July 2013, Jack鈥檚 inquest started at Leicester Town Hall.
鈥淲e didn鈥檛 really know anything until it went to the inquest,鈥 says Mrs Adcock. 鈥淲e couldn鈥檛 speak to anyone 鈥 we weren鈥檛 really told anything.鈥
It was only then, the Adcocks say, they heard the 鈥渢rue facts鈥 and 鈥渓istened to the detail鈥 about the errors that Dr Bawa-Garba had made.
According to Mrs Adcock, the expert witness at the inquest, Dr Gale Pearson, a paediatric intensive care consultant, stated that if Jack 鈥渉ad been given the right treatment, antibiotics, correct bolus, intensive care, consultant treatment, he would have not died when he died, how he died, the way he died 鈥 he may have still been here鈥.
鈥淚 think I collapsed, nobody could believe it,鈥 Mrs Adcock says.
The inquest was adjourned shortly after Dr Pearson鈥檚 expert testimony and the case was referred back to the Crown Prosecution Service, which reviewed its decision to prosecute.
The family are clear about who they blame for Jack鈥檚 death 鈥 Dr Bawa-Garba and one of the nurses who had treated him. If they had done everything they could, the Adcocks say, they would have been devastated but could have said 鈥淭hank you,鈥 and walked away. But as Mrs Adcock puts it, 鈥淎ll they did was contribute to my son鈥檚 death.鈥
Dr Bawa-Garba continued to work at Leicester Royal Infirmary, but one evening in December 2014, while she was on call on the neonatal unit, she was contacted by her educational supervisor, who asked to meet her.
Dr Jonathan Cusack was the head of the unit, so she didn鈥檛 think much of it. But, as she sat down, he told her she had been charged with manslaughter.
鈥淚 don鈥檛 think I registered because I said, 鈥楨r, OK 鈥 but I need to finish my shift and I have teaching tomorrow.鈥 I was supposed to be teaching some medical students the next day.
Dr Bawa-Garba passed her bleep on to another doctor and went home, her head spinning with thoughts about what would happen to her family if she were to be convicted of manslaughter and sent to prison.
As the police were investigating Jack Adcock鈥檚 death, other failings in patient care across Leicestershire were emerging.
Following the Mid Staffs scandal 鈥 where hundreds of patients were exposed to 鈥渁ppalling鈥 levels of care at Stafford Hospital 鈥 a new measure to help hospitals spot problems was introduced.
The Summary Hospital-Level Mortality Indicator (SHMI) uses adjusted data from individual trusts to flag up a higher-than-expected number of deaths. It acts as an early warning system highlighting a need for further investigation.
In 2013, Leicester GPs had started to become concerned about the University Hospitals of Leicester Trust鈥檚 SHMI. It had been higher than it should have been since the SHMI was introduced in 2010.
After deliberating with the Trust, they asked Dr Ron Hsu, then a public health consultant and now associate professor at the University of Leicester, to investigate further.
He met representatives from the local Clinical Commissioning Groups, the hospital and NHS England to devise and agree a plan.
Teams of doctors and nurses were tasked with going through the records of patients who had either unexpectedly died in hospital or died within 30 days of leaving between 1 April 2012 and 31 March 2013. It didn鈥檛 look at paediatrics.
They focused on a sample that would help them identify systematic clinical issues. This is where you learn the most, Dr Hsu says.
In large rooms set aside in the hospital, the teams pored over patients' notes looking at the kind of care they were receiving and identifying things they thought had gone wrong.
The bar was set high 鈥 a team of doctors or nurses had to be unanimous before they agreed a patient had received poor care, Dr Hsu says.
When Dr Hsu came to tally the results, he did not believe what he saw. 鈥淚t was shocking. Based on what I read I was expecting around 10% of patients to have received unacceptable care,鈥 he says.
But in fact nearly a quarter of patients in the report had received 鈥渦nacceptable care鈥 鈥 serious errors had been made that would have increased the risk of harm.
In over half, there were 鈥渟ignificant lessons to learn鈥 鈥 aspects of care that could be done better.
It included issues with 鈥渄o not resuscitate鈥 orders, delayed antibiotics, failure to detect serious illness despite multiple clinical signs, unexpected deterioration, medication errors, and IT failures.
The problems ran across all health care in Leicestershire and Rutland, but the 鈥渧ast majority鈥 of lessons came from the hospital.
鈥淭he issues were obviously longstanding and the consultants and nurses working in the hospital were not necessarily surprised by what we were finding,鈥 says Dr Geth Jenkins, a former GP in Earl Shilton and a member of the team that carried out the review.
Dr Hsu asked to meet the medical directors of the Trust.
But at a meeting between the local clinical commissioning groups, hospitals, community organisations and NHS England to discuss the findings, the discussion soon turned from how to fix the problems to how to get the message out, Dr Hsu says.
鈥淭hey were concerned about their reputation,鈥 he says.
That December he was asked to see officials from NHS England. 鈥淭hey were concerned about the abruptness of the presentation, they would like it softened, as it were, maybe made user-friendly,鈥 he says.
Later that month, he says he received a list of 50 changes 鈥 mostly relating to the colour and presentation of the report and the size of the charts. Then, the following February, he received another raft of changes.
Dr Hsu says he鈥檚 been around long enough to know if reports don鈥檛 work out well for someone, people have ways of of ensuring that the report doesn鈥檛 really get anywhere.
鈥淭hey were worried that people will lose faith in the health services,鈥 he says. 鈥淲e were at the time, the fifth or the sixth largest NHS trust in England and it鈥檚 a trust that whatever happens to it, you couldn鈥檛 ignore.鈥
Dr Jenkins says:
The University Hospitals of Leicester NHS Trust was not the worst, neither was it the best, he adds.
鈥淚f they found these kinds of issues when the Trust鈥檚 SHMI was high but not that high, what would they find with other hospitals that had higher ones?" he asks.
Nine months after Dr Hsu submitted his report, it was posted on the Trust website. A summary version was produced for the press and the public.
The media were carefully managed, Dr Hsu says.
鈥淚t took ages for the conclusions to become public,鈥 says Dr Orest Mulka, a former GP in Measham, and one of the reviewers.
鈥淎nd when I discovered that the media, including the 成人快手, had portrayed them as relating to the care of terminally ill patients receiving palliative care, I thought this was completely untrue. Most of the patients who died were emergency admissions who were not expected to do so.鈥
Mr Furlong says the Trust was the first to use this review method and now others are using similar techniques to look at what can be learned from patients who have died.
The hospital appointed Dr Ian Sturgess to consider improvements in the emergency sector. But some local GPs were frustrated and thought there was a resistance to change and a reluctance to talk openly about the problems.
In October 2014 they sent a letter sent to former Health Secretary Jeremy Hunt and Simon Stevens, chief executive of NHS England, warning of 鈥渂roken systems serving patients and carers in our area鈥.
鈥淓very week we receive reports from our constituent GPs informing us of incidents of distressing medical and nursing care that patients are being exposed to at Leicester Royal Infirmary,鈥 the letter said.
The GPs went on to say that in their view the hospital was 鈥減otentially on a par with Mid Staffordshire Hospital鈥.
It鈥檚 a description Mr Furlong rejects. Far from ignoring problems, he says, the Trust went looking for them.
鈥淚n the Mid Staffs enquiry they found that there had been hundreds of avoidable deaths, the reviewers drew no such conclusion in this review,鈥 he says.
NHS England declined to comment to the 成人快手.
Mr Furlong says that improvements have been made and that the review has now been repeated, with results due for publication in September.
While the review cannot be extrapolated to all admissions, both Dr Mulka and Dr Jenkins see parallels in what they found with the care of Jack Adcock.
鈥淭he issues were all laid bare - poor staffing levels; communication problems and poor handovers; IT systems not working; no senior staff on duty, with juniors left to do everything," Dr Jenkins says.
"They all walked into a toxic environment that day," he adds.
On 5 October 2015, Dr Bawa-Garba found herself in the dock in Nottingham Crown Court, along with two other defendants - nurses Theresa Taylor and Isabel Amaro.
The cells below were a constant reminder of what might happen to her.
The three pleaded not guilty to the charge of manslaughter by gross negligence at the start of what was to be a four-week trial.
鈥淚 remember sitting there and listening to their account of my actions and I felt like a criminal,鈥 says Dr Bawa-Garba.
The case attracted a lot of media attention. Dr Bawa-Garba would travel from her home in Leicester up to Nottingham.
鈥淚 remember vividly one time we were sitting on the train and I was in The Metro paper. My picture was there and the passenger sitting opposite me kept looking at the paper and looking at me and looking up,鈥 she says.
Several staff from the hospital were witnesses for the prosecution and barristers representing the other defendants each cross-examined Dr Bawa-Garba.
It was the same for CAU ward sister Theresa Taylor. Isabel Amaro didn鈥檛 give evidence.
The jurors were instructed to decide whether the three defendants were guilty of unlawfully killing Jack Adcock, basing this decision exclusively on the evidence put before them.
Aspects of the trial have caused consternation among the medical profession.
鈥淒octors became particularly concerned when they heard about all of the systems failings at the hospital and felt these weren鈥檛 heard fully in court,鈥 says Dr Cusack, Dr Bawa-Garba鈥檚 educational supervisor, who attended parts of the trial.
The hospital鈥檚 own investigation, which flagged up all the contributory factors and failings that had led to Jack鈥檚 death, wasn鈥檛 put before the jury, he says. Not all failings were heard, he says.
A number of other aspects of the case have also given rise to controversy.
On the fifth day of the trial, Dr Stephen O鈥橰iordan, the consultant who was meant to be on duty the day Jack died, took the stand. As the consultant, he had ultimate responsibility for the patients admitted on the CAU that day.
Attached to his witness statement was the training encounter form containing details of his discussion with Dr Bawa-Garba in the canteen eight days after Jack鈥檚 death - the form Dr Bawa-Garba refused to sign.
Dr O鈥橰iordan told the court that he recalled the pH was 7.08 and 鈥渢he lactate was high鈥 saying he couldn鈥檛 remember if Dr Bawa-Garba had told him the actual value at their afternoon handover, before Jack died. He said:
The point of a handover, he said, was the passing of information from one junior doctor to another - the consultant鈥檚 role was supervisory to ensure the information was transferred.
Some doctors, however, contest this saying that the handover is to provide an opportunity for consultants to decide how best to manage patients, and to pick up on points that trainees have failed to flag.
鈥淒octors work in teams and the consultant is in charge of that team. While doctors are responsible for their actions, many feel Dr Bawa-Garba was let down by the consultant on call both on the day that Jack died and subsequently,鈥 Dr Cusack says.
The role of the enalapril, the drug given to regulate Jack Adcock鈥檚 blood pressure, has also generated debate. Some doctors have expressed concern that its role in Jack鈥檚 cardiac arrest has been underplayed. Mrs Adcock says she feels that these doctors are blaming her for her son鈥檚 death.
At the coroner鈥檚 inquest in August 2014, Dr O鈥橰iordan鈥檚 barrister suggested that enalapril had been a significant factor.
But the coroner, Mrs Catherine Mason, dismissed this idea.
鈥淚 have no evidence of that at all,鈥 she said. There was nothing in the report by Dr David O鈥橬eill, the pathologist, or from toxicology, that suggested it played a role, she said. She then repeated the point, saying that there was 鈥渘o evidence that the enalapril was incorrect or caused or contributed to his death鈥.
Measurements of the levels of enalapril in Jack鈥檚 blood were not taken as they were thought not to be useful.
At the criminal trial, experts agreed that Jack shouldn鈥檛 have been given the drug in the condition he was in, though all accepted that Mrs Adcock had behaved perfectly responsibly by giving it to him.
They didn鈥檛 agree on how much it had affected him, though.
Dr O鈥橬eill said whether or not enalapril played a role was beyond his expertise. But when asked if it was a 鈥渟ignificant factor鈥 in Jack鈥檚 rapid deterioration, he said this was 鈥渃onsistent with the clinical history鈥. His post-mortem results could not confirm or refute it.
The jury also heard from Dr Simon Nadel, a paediatric intensive care consultant in London, who thought enalapril had aggravated Jack Adcock鈥檚 condition, but wasn鈥檛 the cause of death. Another prosecution expert agreed.
Dr Nadel said the little boy was 鈥渨ell on down the slippery slope by then鈥 and had a 鈥渂arn door鈥 case of sepsis. This was the most important cause of his death, he said.
Dr Bawa-Garba鈥檚 defence expert, however, thought the signs of sepsis were 鈥渕ore subtle鈥.
After two weeks, it was Dr Bawa-Garba鈥檚 turn to give evidence.
Mr Andrew Thomas QC, for the prosecution, told Dr Bawa-Garba that no-one was suggesting that she deliberately set out to harm Jack Adcock. What was at stake was whether she fell below the standard of a reasonably competent junior doctor.
He pressed Dr Bawa-Garba on the reflection she did after Jack鈥檚 death.
鈥淟ist for us, please, all of the mistakes,鈥 Mr Thomas said.
鈥淎fter this case happened, I reflected on my practice and this can be found in my e-portfolio, and I listed deficiencies that I felt were in the care that I provided on that day,鈥 Dr Bawa-Garba replied. One of them, she said, was her failure to register warning signs in the blood tests.
Mr Thomas told her to pause as people were going to write the list down. He then pressed her further and one by one, she listed how she felt she should have done better.
鈥淚 wish that I had been clearer in my communication with the consultant,鈥 she said
鈥淭hat's two. Keep going,鈥 Mr Thomas said.
鈥淲hen I reassessed Jack, I was falsely reassured because he was alert, drinking from a beaker, responding to voice, pushing his mask away because he didn't want it on his face,鈥 she replied. She added: 鈥淚 should not have relied on the nurses to get back to me with the clinical deterioration as I normally do.鈥 She should have looked at the nursing chart, she said.
鈥淭hat鈥檚 three. Number four?鈥
鈥淚 underestimated the severity of his illness,鈥 Dr Bawa-Garba said.
鈥淣umber five?鈥
鈥淥n the reflection I did following this incident, those were the points that I looked at,鈥 she said.
The next day was spent exploring all the points in detail. Dr Bawa-Garba continued to describe where she should have done better.
Dr Cusack says the use of her reflections made by the prosecution has made doctors fearful about admitting their errors. 鈥淎ll doctors are expect to regularly reflect honestly and openly on their practice to improve patient care,鈥 he says.
At the end of the trial, the judge summed up the case to the jury. The prosecution relied on the fact she ignored 鈥渙bvious clinical findings and symptoms鈥; did not review Jack鈥檚 X-ray and give antibiotics early enough; failed to obtain the morning blood test results early enough and act on the abnormalities they showed; and failed to make proper clinical notes.
The judge told the jury they could only convict the health professionals in front of them if they were negligent and that their negligence significantly contributed to Jack鈥檚 death or its timing. The negligence had to be gross or severe, he said - what they did or didn鈥檛 do had to be truly, exceptionally bad.
He said they should set aside any criticisms or feelings towards others involved in Jack鈥檚 care. They had to consider the circumstances within which the defendants were working when considering if they were guilty.
On 4 November 2015, the jury found Dr Bawa-Garba guilty. She was led away in handcuffs to a cell while her team worked out her bail conditions.
鈥淚 sat in that small room and prayed,鈥 she says.
Then she asked for a pen to write. After initially being denied one, in case she harmed herself, she was given a pen outside the cell.
鈥淚 remember writing and writing until the ink ran out in the pen,鈥 she says. 鈥淚 had two very young children - my oldest is severely autistic and goes to a special needs school. So I made plans that if I was to go to prison he would have to go out and live with my mother in Nigeria.鈥
For the Adcocks it was the day they had been waiting for. 鈥淔or a split second you think, 鈥榊es, we鈥檝e got justice for our son鈥檚 death,鈥欌 says Mrs Adcock.
Dr Bawa-Garba spent the next six weeks trying to plan for every scenario. She returned to court in December for sentencing. She had brought a rucksack with her in case she was sent to prison.
鈥淚 remember on the morning of the sentencing telling my parents that I didn鈥檛 want them there in the court in Nottingham,鈥 she says.
Dr Bawa-Garba was given a two-year suspended sentence. Nurse Isabel Amaro received the same sentence. Ward sister Theresa Taylor had been found not guilty.
Dr Bawa Garba applied for leave to appeal against her conviction, but this was denied in November 2016.
At the heart of this story is the tragic death of a much-loved little boy and the loss felt by the family. But there鈥檚 been a much wider impact too.
In 2017, the General Medical Council鈥檚 tribunal service suspended Dr Bawa-Garba for a year. They said that while her actions fell 鈥渇ar below the standards expected of a competent doctor鈥, they had taken into account other factors.
These included that fact she had learnt from her errors; had an unblemished record before and after Jack Adcock鈥檚 death; and the system failures at the Leicester Royal Infirmary.
The tribunal鈥檚 decision angered Mrs Adcock.
鈥淗ow can somebody make that many mistakes, be found guilty by a jury and be able to practise again? It doesn鈥檛 give the public any faith in the NHS,鈥 she says.
So Mrs Adcock approached the GMC to see if she could appeal. She set up an online petition, with thousands of people pledging support.
Charlie Massey, chief executive of the GMC, says that after receiving legal advice the GMC applied to the High Court to overturn the decision made by its own tribunal.
He denies being influenced by the Adcocks鈥 petition, and says the GMC acted out of the need to protect public confidence in the profession, given the seriousness of the conviction.
Dr Bawa-Garba was struck off in January 2018, meaning that she could no longer practise medicine in the UK.
鈥淭he best way to protect patients is by supporting doctors. But we are also a regulator, and sometimes we have to make tough and unpopular decisions,鈥 Charlie Massey says.
The decision has certainly been unpopular among the medical profession. Dr Bawa-Garba鈥檚 striking off caused outrage, and led to allegations that she had become a scapegoat for a failing and unsafe NHS.
A social media storm ensued, accompanied by the hashtag 鈥#IamHadiza鈥, with doctors wearing T-shirts and badges in her support.
One said:
鈥淒rs working flat out in a broken and unsafe system,鈥 said another.
鈥淗uge solidarity with this doctor who could be any one of us NHS doctors working in an overstretched, purposefully underfunded and dangerously understaffed service,鈥 added another.
For Dr Hsu, the outcry from around the country suggested that what he had seen at Leicester was widespread across the NHS.
A crowdfunding campaign also got under way to enable Dr Bawa-Garba get another legal opinion. It raised over 拢360,000 in about a month with contributions from around 180 countries.
Dr Chris Day, a junior doctor and one of the people behind the crowdfunding, says he was overwhelmed by the response.
鈥淚 think people want to know how it was possible that a junior doctor could get convicted for gross negligence manslaughter, going about her duties as a junior doctor - and when there were so many systemic factors at play,鈥 he says.
After Dr Bawa-Garba was struck off, The British Association of Physicians of Indian Origin, an organisation that aims to promote diversity and equality, has expressed concerns that healthcare workers from BAME groups are disproportionately referred to their respective regulators. They have written to the GMC.
Indeed, one official review concluded that BAME groups are also disproportionately prosecuted for gross negligence manslaughter - although it only looked at a small number of cases.
The GMC鈥檚 Charlie Massey says he understands these concerns. He says that nearly twice as many black and minority ethnic doctors are referred to the GMC by their employer than white doctors.
鈥淎nd that's important, because the vast majority of referrals that come to us from employers, do result in investigations, whereas it鈥檚 a minority of complaints that are made to us by the public,鈥 he says. A review is underway to look at the disproportionate referral rate.
Others in the medical profession have found different ways of registering a protest.
One group of doctors tore up their GMC registration certificates in front of its headquarters in London and others took themselves off the register completely.
Dr Peter Wilmshurst, a Midlands-based cardiologist, wrote to the GMC to ask them to investigate him. All doctors make mistakes and that is understandably scary for patients, he says.
鈥淚鈥檝e made clinical mistakes including delayed diagnosis and errors in treatment. Some sick patients died. I suspect that many would have died anyway but in some cases my errors are likely to have contributed to poor outcomes and some patient deaths,鈥 he says.
鈥淚 therefore feel obliged to ask the GMC to investigate my clinical practice over the last 40 years to see whether I should be struck off the medical register.鈥
But Mrs Adcock says the doctors are mistaken in their interpretation of what happened. 鈥淭he reason the doctors are doing what they鈥檙e doing, they鈥檙e scared for themselves. I understand that because they鈥檙e thinking if we make an honest mistake we鈥檙e going to be charged. That isn鈥檛 the case. They need to look at the number of errors that doctor made on the day for the judge to say 鈥榯ruly exceptionally bad鈥,鈥 she says.
In 2013, Professor Don Berwick MD, president of the Institute for Healthcare Improvement in the US, was asked by the then prime minister, David Cameron, to advise about how to improve patient safety in the NHS following the Mid Staffs scandal. His report made a raft of recommendations including moving away from blaming an individual to looking to learn from errors.
鈥淲e said if there鈥檚 fear in the system people are frightened about identifying hazards, about speaking up when they make a mistake about speaking up when something goes wrong then how could it ever get safer?鈥 he says.
鈥淵ou could fire everybody, punish everybody and put in an entirely new workforce, you will have the same injuries and the same errors occur again unless you鈥檝e actually changed the systems of work,鈥 he adds.
He says that when there鈥檚 been a serious tragedy families are understandably angry.
鈥淲e have to help them understand what happened, to be open about what happened, to apologise for what happened,鈥 he says.
But he says he has sympathy for Dr Bawa-Garba.
鈥淓ven though she made mistakes she was trapped - she was trapped in a set of circumstances which set her up for failure.鈥
Dr Bawa-Garba has been on a long journey. The story began in an overstretched hospital in February 2011 when she was 34. She was charged with manslaughter in December 2014 and convicted in November the following year. She was struck off the medical register in January this year. And on Monday she was reinstated to the medical register by the Court of Appeal.
The judges ruled that Dr Bawa-Garba's actions had been neither deliberate or reckless and she should not have been struck off.
The GMC has accepted the judgement.
鈥淭he lessons that I鈥檝e learnt will live with me forever. I welcome the verdict because for me that鈥檚 an opportunity to do something that I鈥檝e dedicated my life to doing, which is medicine. But I wanted to pay tribute and remember Jack Adcock, a wonderful little boy who started this story,鈥 Dr Bawa-Garba said.
鈥淢y hope is that lessons learnt from this case will translate into better working conditions for junior doctors, better recognition of sepsis, and factors in place that will improve patient safety.鈥