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GPhC Advises on Revalidation Plans Following the Bawa-Garba Manslaughter Ruling

Published: 10th February 2018


This week the General Pharmaceutical Council (GPhC) has issued a statement to reassure pharmacy professionals over the reflective element of its revalidation process after the government announced a review of medical malpractice cases. 


This review is as a result of the case of trainee paediatrician Hadiza Bawa-Garba who was struck off the medical register after being convicted of manslaughter on the grounds of gross negligence after mistakes in the care of a six-year-old boy who died from sepsis. 


Duncan Rudkin, chief executive of the General Pharmaceutical Council (GPhC), acknowledged that Dr Bawa-Garba's case had “caused concern among pharmacy professionals”. 


Mr Rudkin said: "It is a difficult and tragic case and we will be considering any implications with others. We will actively engage with the rapid review commissioned by the Secretary of State and led by Professor Norman Williams, and carefully consider all of the outcomes of that review.”


“It is widely accepted that the safety and quality of care that people receive is improved when pharmacy professionals are able to reflect on and learn from feedback and incidents. That is why we make clear in our standards for pharmacy professionals that they must speak up when things go wrong, and in our standards for registered pharmacies that pharmacy owners have an obligation to support pharmacy professionals to do this and promote a culture of openness, honesty and learning.”


“We understand that pharmacy professionals may be worried about reporting errors and taking part in processes to learn from errors. But it is vital for patient safety that errors are reported and discussed. For this reason our revalidation proposals seek to encourage and support pharmacy professionals to reflect on where their practice could be improved during their peer discussion. We recognise there may be concern over how these reflections could be used, and so we want to be clear that we will not ask pharmacy professionals or peers to record what was discussed. Instead they will be asked to record how the process of having a peer discussion has benefited their practice. Records should not contain any details which could identify a patient. We will be producing further information to help pharmacy professionals understand what they are expected to do”


Mr Rudkin also stressed that only the “most serious cases” are taken to the regulator’s fitness-to-practise process.  "A single dispensing error would only be taken forward if there were other aggravating factors,” he explained.


Mr Rudkin added that the GPhC would “actively engage” with the rapid review which was commissioned by Jeremy Hunt on 6th February. The review will look into whether gross negligence manslaughter laws are fit for purpose.  Mr Hunt told the House of Commons that medical malpractice review would “ensure the vital role of reflective learning, openness and transparency is protected so that mistakes are learned from and not covered up”.


The GPhC's “revalidation” proposals to change the CPD framework, which will begin to come into force in April this year.


Tess Fenn, President of APTUK, said "APTUK welcomes the GPhC statement and their engagement with the Governments rapid review.  As the process of revalidation is introduced APTUK will support its members to understand what it means for pharmacy technicians and will seek to provide reassurance in light of this case. Reporting and learning from errors is essential to enhance patient safety and improve the quality of care.”