“Jack was really lethargic, very sleepy. He wasn’t really very with it,” says Mrs Adcock. She told medical staff he had been up all night with diarrhoea and sickness.
The boy’s hands and feet were cold and had a blue-grey tinge. He also had a cough. I knew that I had to get a line in him quickly to get some bloods and also give him some fluids to rehydrate him,” says Dr Bawa-Garba. He didn’t flinch when she put his cannula in.
Because of a pre-existing heart condition, Jack had been taking enalapril – a drug to control his blood pressure and help pump blood around his body – twice a day.
But Dr Bawa-Garba says she didn’t 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’s chest. Blood was taken – some was sent down to the labs, while a quicker test was done to measure his blood acidity and lactate levels – the latter being a measure of how much oxygen is reaching the tissues. The tests revealed his blood was too acidic.
“A normal pH is 7.34 – but Jack’s 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,” Dr Bawa-Garba says.
She gave him a large boost of fluid – a bolus – to resuscitate him. Her working diagnosis was gastroenteritis and dehydration. But she didn’t consider that Jack might have had a more serious condition. It was a mistake she regrets to this day.
Jack had been admitted under the care of Dr Stephen O’Riordan, the consultant who was supposed to be in charge that day – but he hadn’t realised he was on call and had double-booked himself with teaching commitments in Warwick and hadn’t arrived at work.
Another consultant based elsewhere in the hospital had said she was available to help and cover him if needed – although she had her own duties.
After an hour of being on fluids to rehydrate him, Jack seemed to be responding well. “He was a little more alert and we thought he was getting better,” Mrs Adcock says.
Dr Bawa-Garba thought that too. One of the less experienced doctors in the unit had been unable to do Jack’s next blood tests. They had tried but couldn’t 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.
“That kind of response, to me, said that he was responding to the bolus,” she says. “Also, the result I got showed that the pH had gone from seven to 7.24. In my mind I’m thinking this is going the right way.”
However, not enough blood had been taken to get another lactate measurement. Dr Bawa-Garba looked for Jack’s 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’s tasks.
Those tests would have indicated that Jack may have had kidney failure and that he needed antibiotics.
By this point, Jack was sitting up in the bed drinking juice. “I automatically thought he was perking up,” says Victor, Jack’s father.
Because he had stopped vomiting, Dr Bawa-Garba prescribed some Dioralyte – rehydrating salts. But the fluid he was losing from having diarrhoea had not been documented by his nurse. Dr Bawa-Garba also reviewed Jack’s 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 – including a baby with sepsis that needed a lumbar puncture – 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.
Consultant Dr Stephen O’Riordan arrived at the hospital. “I hadn’t worked with him before, so I introduced myself,” Dr Bawa-Garba says. She then went to chase up Jack’s blood results, which still hadn’t come through – the doctor she had assigned to do it hadn’t managed to get them.
Dr Bawa-Garba tried a number of extensions before managing to speak to someone. They read out Jack’s results and she noted them down. She says she was looking out for one particular test result called CRP, which would confirm whether Jack’s 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 – signalling possible kidney failure.
During the afternoon handover, Dr Bawa-Garba told Dr O’Riordan about Jack – his diarrhoea and vomiting, heart condition, and enalapril medication. She says she told him Jack’s 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’Riordan 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’t.
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’s care occurred. Mrs Adcock says she asked a nurse looking after Jack on that ward if she could give him his enalapril – the medication to regulate his blood pressure. He was due his second dose of the day.
She recalls the nurse telling her she’d checked with another doctor on duty.
Mrs Adcock says she was told the nurse wouldn’t 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. “We’d got Toy Story on but he was still knocking his oxygen mask off,” Mrs Adcock says. “I was just saying, ‘Come on sweetheart go to sleep,’ and I was rubbing his face. I’ll never forget – he closed his eyes and I thought something’s not quite right. His tongue, or his lips, looked blue. I ran out of the room, saying, ‘Can someone come and look at Jack?’”
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 “do not resuscitate” order. She assumed it was the same boy. What she didn’t know was that Jack had subsequently been moved to the same ward as the boy who had crashed in the morning – ward 28. A terrible confusion was about to follow.
“While we’re running up the stairs, all I was thinking is, ‘It’s the child with the do-not-resuscitate again – that someone is trying to resuscitate. This is a mistake,’” 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’t recognise her. She says: I walk in and say, ‘He’s not for resuscitation,’ because I thought it was the child with the ‘do not resuscitate’ order.”
Dr Bawa-Garba says she was then told by another doctor that the patient was not the same boy as earlier – but was Jack Adcock. “I was shocked and I was like, ‘Why is Jack crashing?’” she says.
She told the team to continue the resuscitation. “I remember going hysterical and just thinking, you know, ‘Please look after my little boy,’” says Mrs Adcock.
“And then I remember somebody taking me back into the room and telling me, ‘Jack needs his mummy.’” 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 – but he shouldn’t have been given enalapril and he should have been given antibiotics much earlier.
At the Adcocks’ home in Glen Parva, a suburb of Leicester, Jack’s sister Ruby has moved into his old room. His has been recreated in the room she vacated. Stars featuring handwritten messages from Jack’s schoolmates, saying how much they will miss him and his cheeky laugh, adorn the navy blue walls of the replica bedroom. “It’s my way of coping,” says Mrs Adcock.
She says she has yet to grieve. The investigations, court proceedings, and appeals have taken a toll on the family. “I blame Dr Hadiza Bawa-Garba for my son’s death and I will never, ever, ever, ever forgive her.”
She describes Jack as a “joyful little boy” 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.
“We were season ticket holders but since that happened [Jack’s death] I haven’t been able to go,” he says. “I can’t face it.” The night Jack died, Mr and Mrs Adcock were taken into a room off the ward, where they were met by doctors they’d never seen before. “We were told, ‘I’m really sorry but your son’s passed away,” says Mrs Adcock. “It just didn’t sink in.” 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. “He had no tubes, he had nothing,” she says.
This time, “there was blood – I just couldn’t believe it was him, my baby, gone”. Everyone on the ward was crying, she says, including Dr Bawa-Garba, who was sobbing. “Nobody expected Jack would die.” The doctor came over to express her condolences and Mrs Adcock thanked her for looking after Jack.
“I wish I could take those words away. I never knew then what I know now,” 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’s 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’s death and said they would investigate.
“They said he just wasn’t looked after; he didn’t have the right support; he wasn’t given the right care,” 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’s condition, according to the minutes. The police then arrived – there was to be an investigation after the unexpected death of the child. “I remember being absolutely terrified, thinking, ‘I haven’t done anything, why are the police here?’”
Mrs Adcock says. After Jack’s 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. “Everything was in place.
There was an article going in the paper on the Friday to say when his funeral was going to be,” Mrs Adcock says. But then they were asked to cancel their plans and meet the police at the coroner’s office to discuss an inquest. “As you can imagine at that point, we felt physically sick – the anger raged. We just could not believe what we were hearing, so automatically we said, ‘So you’re telling us someone’s responsible for our son’s death?’” Mrs Adcock says.
There was then a second post-mortem examination in case criminal proceedings were opened. “It took three months to get my little boy back, to be able to lay him to rest,” Mrs Adcock says. Not a day goes past, Dr Bawa-Garba says, when she doesn’t think about the day Jack died. “I am sorry for not recognising sepsis and I am sorry for my role in what happened to Jack.”
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.