In the eyes of the legal system, Hadiza Bawa-Garba was a junior doctor who caused the death of a little boy named Jack and fully deserving of her manslaughter conviction and lifetime ban from the medical profession.
But among doctors trying to do their best in over-stretched, under-resourced public hospitals around the world, including in Australia, Dr Bawa-Garba is them. This "watershed" case in the UK has thrown into sharp relief their vulnerability of being blamed for the failures of a broken system.
"It could have been me; it could have easily happened here," said Dr Andrew McDonald, a paediatrician with nearly four decades of experience at Campbelltown Hospital.
"I'm not sure if I would have acted any differently with the child and that's why it's resonating with me and so many doctors."
In 2015, British trainee paediatrician Dr Bawa-Garba was convicted of manslaughter on the grounds of gross negligence over the "needless" death of six-year-old Jack Adcock. In January, the UK High Court ruled she must be struck off the UK medical register, banning her from the profession for life.
The case has rocked medical circles around the world because while she did make errors, including mistaking Jack for another patient, she had just returned from maternity leave, was forced to cover the roles of up to four doctors, her supervising consultant was away, and the hospital's IT system was down, causing chaos.
Dr Brad Frankum, president of the Australian Medical Association (AMA) NSW, said members were so "disturbed" by the case that they have sought a legal opinion to inform their thoughts.
He said while Australia's public hospital system was in far better shape than the UK's, there were junior doctors working long hours with inadequate supervision, and should a similar situation occur here, he wasn't sure how it would play out.
"How on earth was the doctor convicted of manslaughter? We don't understand it and that's why we've sought a legal opinion," he said.
"Generally, criminal convictions have been against those with criminal intent, or who were unethical or doing something illegal, whereas this case is different, and it's truly disturbing."
He said if the Australian medical community missed the chance to respond to the mistakes and learn the lessons, "the whole safety and quality agenda would go back somewhat".
Dr Bastian Seidel, president of the Royal Australian College of General Practitioners, said it was "inconceivable" that a system designed to support patients and doctors would wholly and excessively lay the blame on a doctor for its failures.
He said it was another reminder for Australia to stop "eagerly copying and pasting" health policies in the UK and instead scrutinise them "with sophistication" and learn from their experiences.
The case was also alarming because the prosecutors used sections of Dr Bawa-Garba personal appraisals - required in the UK for learning and reflection - as evidence against her.
Some doctors on social media said they would now think twice about being honest and transparent in their self-appraisals.
A need for confidentiality
In Australia, the Medical Board of Australia has recently started to encourage doctors to reflect on their practice and learn from it.
"Now this needs to be confidential and privileged, because if it can be held against a medical doctor who did it in good faith, then we know people are not going to do it in a meaningful way," Dr Seidel said.
He demanded the board reassure doctors that their reflections would remain confidential.
A Medical Board spokesperson told Fairfax Media that they had ruled out adopting the UK process, which, as part of revalidation, requires British doctors to engage in a "defined self-reflection process with specific documentation for recording the outcome".
They did not provide a response to Dr Seidel's concerns about confidentiality or comment on Dr Bawa-Garba's case.
Thousands of doctors are raising funds to help overturn the ruling, with $500,000 raised so far, and thousands more are tweeting their support with #IAmHadiza.
Support from afar
Nearly 1500 Australian and New Zealand doctors have signed an open letter written by Sydney-based emergency registrar Dr Ruella D'Cruz, which says to describe the case as a "gross injustice [was] an understatement".
"We have experienced the fear of returning to a busy clinical environment after maternity leave," she wrote. "Sadly, you have experienced our worst nightmares. Make no mistake - this could have been any of us."
In 2011, six-year-old Jack died of septic shock at Leicester Royal Infirmary, 2.5 hour drive north of London, after being admitted with sickness and vomiting.
The jury heard Jack, who had Down's Syndrome and a heart condition, was the subject of a "catalogue" of errors including missing signs of his infection and mistakenly thinking he was under a do-not-resuscitate order.
Back at Campbelltown Hospital, Dr McDonald said Dr Bawa-Garba's story was dominating conversations in hallways and offices and especially upsetting for junior doctors.
"Every child should be seen every day by a consultant and a consultant should be available within 30 minutes of a call," he said. "Well, there are large areas within the state where that doesn't occur."
Even medical students, who regularly write self-reflections, have been thinking about what Dr Bawa-Garba's case means for them.
"Such a precedent could stop students from speaking openly and honestly," said Alex Farrell, president of the Australian Medical Students' Association.
"Keeping patients safe relies on a culture that encourages open disclosure and self-reflection."
How can one demand excellence from a doctor working in a broken system that only ever allows compromised care. It’s incomprehensible that the regulator does not take the context into account. Wake up #NHS and take note Australia. #BawaGarba— Dr Bastian Seidel (@DrBastianSeidel) January 28, 2018
Pinning the blame on an individual when it is the system at fault will lead to a culture of fear & the loss of crucial opportunities to learn from mistakes. @Jeremy_Hunt will you address this? A disaster for the medical profession & for #patientsafety #iamhadiza #BawaGarba— Dr Sammy (@sbattrawden) January 25, 2018
It is desperately sad a young boy lost his life in such circumstances, but I doubt we will ever see a clearer case of scapegoating an individual for systemic failings for a very long time #iamhadiza— Dr Seb Heaven (@drsebheaven) January 26, 2018
I once phone the GOLD director on call at night as SpR due to an extremely unsafe environment. They refused to talk to me and asked the general manager on call to speak to me. I was told “this is just how it is round here”. #IamHadiza #bawagarba— Dan Furmedge (@danfurmedge) January 26, 2018
“Every surgeon carries about him a little cemetery, in which from time to time he goes to pray, a cemetery of bitterness and regret, of which he seeks the reason for certain of his failures." - Rene Leriche #iamhadiza— Lisa Pryor (@pryorlisa) January 30, 2018
Great analogy and summation of the Dr Hadiza Bawa-Garba case where an overworked and under supported doctor was thrown under the bus by the GMC despite it being an organisation funded by the doctors it acts as the hangman for. #BawaGarba #iamhadiza pic.twitter.com/F7WSzK44Xu— Paul Tanter (@paultanter) January 28, 2018
Wouldn’t be appropriate for me as Govt Minister to criticise a court ruling, but deeply concerned about possibly unintended implications here for learning & reflective practice in e-journals. Am also totally perplexed that GMC acted as they did: patient safety must be paramount https://t.co/zFTFfe5al8— Jeremy Hunt (@Jeremy_Hunt) January 25, 2018