In 2011, Jack Adcock — a six-year-old boy with Down's syndrome, a congenital heart disease and heart failure — was admitted to Leicester Royal Infirmary in the United Kingdom.
He'd been sick overnight, with diarrhoea and vomiting. His breathing was shallow and he looked unwell.
The registrar on duty in the emergency paediatrics ward that day was Dr Hadiza Bawa-Garba.
Her consultant, (senior doctor) Dr Stephen O'Riordan, was teaching in another town that morning and Dr Bawa-Garba was doing the work of at least one other paediatric registrar, who was on leave. So Dr Bawa-Garba was covering various wards of the hospital, including maternity, taking calls from GPs, and dealing with other emergencies.
It was also her first day on duty for emergencies involving sick children, in an unfamiliar hospital and having recently returned from 14 months of maternity leave.
It was mid-morning when Dr Bawa-Garba first saw Jack Adcock. She put him on intravenous fluids and ordered blood tests and a chest X-ray.
One blood test showed his blood was too acidic — a sign of severe illness — but that improved later in the morning after Jack was given fluids.
It was another two hours before Jack's chest X-ray was done, and it took Dr Bawa-Garba longer to see it — but once she did, she realised the boy had pneumonia and that was the cause of his illness.
What she did not realise, and what no-one else realised, was that the infection had caused Jack to go into septic shock — he was having trouble maintaining enough output from the heart to stay alive.
Dr Bawa-Garba prescribed Jack antibiotics for his pneumonia, but he didn't get them for another hour. Around this time, the doctor's consultant returned to the hospital. He saw Jack's blood test results but didn't see the child.
Jack was already on a drug called enalapril for his heart condition. This drug takes the stress off the heart and lowers blood pressure and therefore shouldn't be used when someone is in shock.
Dr Bawa-Garba knew this, and deliberately didn't write him up for the drug. But despite there being no continuing prescription for it, someone later gave Jack enalapril — and he went into cardiac arrest.
When she arrived at the resuscitation she mistook Jack for another child in the ward who had a 'do-not-resuscitate' order on his notes and called off the resuscitation.
Another junior doctor present corrected the misunderstanding and efforts were resumed a minute later but they failed to revive Jack. He died less than 12 hours after being admitted to the hospital.
Mistakes made: But who's to blame?
Dr Bawa-Garba was convicted of manslaughter on the grounds of gross negligence in November 2015. She was then suspended from practice for 12 months by an independent tribunal.
But Britain's regulator of doctors, the General Medical Council, appealed that decision. They wanted her permanently struck off the medical register, arguing the doctor failed to act on signs Jack was seriously ill and therefore contributed to his death.
Last month the High Court of England and Wales found in favour of the GMC and struck off Dr Bawa-Garba for life.
In its decision, the High Court found that the tribunal had failed to adequately sanction Dr Bawa-Garba — given that a jury had decided her conduct was "truly exceptionally bad".
"This misconduct by manslaughter by gross negligence involved a particularly serious departure from the principles of "Good Medical Practice," and the behaviour was fundamentally incompatible with being a doctor," Justice Ouseley wrote in his High Court decision.
Among the failings of Dr Bawa-Garba listed by the court were that she ignored key signs Jack was critically ill (like the high amount of acid and lactate in his blood, warning signs of septic shock) and didn't raise concerns about Jack's health with the consultant when he arrived at the hospital about 4:30pm.
But the ruling sparked outcry from doctors in Britain and around the world, who say the case reflects systemic failures at the hospital and in the broader healthcare system, and that it could have happened to any one of them.
"I've worked for 10 years in the UK, including some of the most intensive hospital environments in the UK, and I've never faced a day such as reported as her having faced that day," said Dr Moosa Qureshi, a haematology trainee and cancer researcher at the University of Cambridge.
"The situation she was in was a situation which really was going to produce mistakes, and it wasn't only herself who was making those mistakes, though most of the blame seems to have been pinned on her."
Dr Qureshi is one of three doctors calling themselves 'Team Hadiza' — they've fundraised over 300,000 pounds ($530,000) to pay for legal fees should Dr Bawa-Garba appeal the High Court's decision.
Doctors are fearful the case could discourage medical professionals from owning up to their mistakes, and the cultural change it could effect within the British medical system.
"Mistakes happen in medicine, but the way we stop those mistakes is we have a culture of open learning, we share our mistakes, we reflect on them and we learn from them," Dr Qureshi said.
"One of the particularly alarming features of this case is that it seems that Dr Hadiza Bawa-Garba's reflections on her mistakes were used against her in court … in the long term that's going to be damaging to patient safety across the UK."
The GMC denies it used notes taken by Dr Bawa-Garba about that day, though accepts they may have been used in the Medical Practitioners Tribunal.
Nurse Isabel Amaro, who also treated Jack Adcock, was also convicted of manslaughter and struck off the nursing register. Dr Bawa-Garba's consultant, Dr O'Riordan, was not charged over the boy's death.
Could it happen here?
South-west Sydney paediatrician Andrew McDonald said most Australian consultant doctors would have had an experience like that of Dr Bawa-Garba's.
"Twice a week in Australia there is a serious adverse event in healthcare, child or adult. This already happens here."
Dr McDonald said the key difference was that the Australian system is better at recognising "system error".
While a similar analysis as to what went wrong would happen in Australia as in the UK, he said Australia's medical bodies are less likely to attribute blame to a particular doctor.
"It would be done by the same people, but the outcome I expect would be different. The New South Wales Medical Board or the Australian Health Practitioner Regulation Agency (AHPRA) are not perfect but I've never seen anything as vindictive and poorly informed as this."
Dr McDonald also criticised the consultant at the hospital for not going to see Jack Adcock when presented with his blood tests by Dr Bawa-Garba.
"I have no idea why he wasn't brought before the court, but before the court of his peers, consultants, to not go and see a child with a pH of 7.08 with an unexplained illness is just hopeless … this consultant has failed in his duty of care to provide safe care to this child," he said.
Chair of the Medical Board of Australia (the nearest equivalent of the UK's GMC) Dr Joanna Flynn, said a conviction of manslaughter for a doctor in Australia was incredibly rare — only "a handful of cases over perhaps 50 years".
She said it was even rarer for a conviction to be recorded against an Australian doctor.
"There is a process of open disclosure in Australia, and in fact in Victoria there is a proposal to introduce candour as a legislative requirement, which means that patients must be told if something bad has happened, why it happened, what has been learned from it, how it can be prevented," she said.
"There are protections so that explanation about what happened, and even acknowledgement that something went wrong, can't be used in litigation against the doctor in the context of an apology."
A needless death
While debate continues over the personal and systemic errors in the case, Dr Moosa Qureshi said the focus needed to be on preventing similar deaths in the future.
"This is a tragic, avoidable death of a young six-year-old boy, and really our hearts go out to the family of the young boy who has died needlessly," he said.
"But I fear that this is actually a trend rather than a glitch … these things happen all the time in medical practice and if we respond to them in this way we are really, really going to actually make things much worse because doctors are going to start feeling fearful of actually admitting mistakes."
"If that happens, then mistakes cannot be corrected and avoided in future."