The conclusion of the well publicised case involving the hospital doctor Hadiza Bawa-Garba and the tragic death of a young child in her care provides us with many aspects of current healthcare to consider. Whilst this case has exercised the medical profession over the past 5 years, the lessons to be learnt are not confined to that sphere alone. There are issues that will impact on the dental profession as well, especially in relation to her own reflections in her e-portfolio and admission of culpability, which were reportedly used in the case against her.

The widely reported and admitted mistakes made by Dr Bawa-Garba were not entirely brought about by her negligent treatment – there were significant system failures which both compounded and indeed were agreed to have contributed to these mistakes. Examples of IT failures, staff shortages – both clinical and support staff – and unrealistic numbers of patients to be seen and treated were seen by the courts and regulators as contributing to the mistakes made. There are many colleagues in both primary and secondary dental care who are facing similar challenges on a daily basis up and down the country and these pressures, which can lead to mistakes, are likely to become a more common occurrence. Until there are changes that allow dentists to address the preventative needs of patients rather than being confronted with the ever accelerating treadmill that the current GDS contract demands then the pressures and resulting mistakes will only get worse.

Facing these pressures which directly impact on stress, morale and the health of colleagues is hardly going to improve the well publicised recruitment and retention issues currently facing primary care practices. Additional investment to address the system failures and staff shortages has long been called for and the constant demand for efficiency savings in NHS dentistry when there are no more efficiencies to be made will lead to more staff leaving the profession placing an even greater burden on the remaining few. It is a vicious cycle.

Let us take a steer from the aviation industry where a no-blame culture to mistakes has seen a significant improvement in safety for those travelling by air...

The GDC recently introduced eCPD which places greater emphasis on reflective learning. Presumably the aim is to allow the insight of mistakes made by a colleague through reflection to contribute to avoiding those mistakes in the future. If, however, as reported in the Bawa-Garba case, some elements of that reflective learning are made available during any resulting disciplinary or regulatory investigations then it is hardly likely that a clinician is going to be entirely forthcoming in their admission of mistakes made and learning recognised to avoid them occurring in the future. If we are to genuinely learn from our mistakes then any response has to remain confidential with the colleague remaining confident that it will not be made available at a later date to wider authorities. In light of this case the General Medical Council (GMC) are currently developing guidance on reflective learning to assist both clinicians and those involved in fitness to practice investigations. Perhaps now would be a good time for the GDC to adopt the same approach for our profession.

The behaviour of the GMC over the manner of the way it handled Dr Bawa-Garba's case has been widely criticised and led the British Medical Association to respond by suggesting it had lost the confidence of doctors and must now act to rectify its relationship with the medical profession. When the doctors' regulator goes to court to attempt to overturn a decision made by one of its own committees then clearly all is not well in the GMC garden. This sounds dreadfully familiar and suggests that challenges facing our profession with our regulator are not simply isolated to this sphere of the healthcare sector. Lessons seem to be taking a long time to learn!

The final, and overarching issue that this case has highlighted is that of the blame culture which the medical and dental professions have experienced over the past couple of decades. Let us take a steer from the aviation industry where a no-blame culture to mistakes has seen a significant improvement in safety for those travelling by air. Those who have made mistakes do not feel pressurised to conceal their errors for fear of retribution from service users and authorities alike. Unless we see a fundamental change in the manner that healthcare manages the errors, which as human beings we will continue to make, then there are unlikely to be improvements to patient safety and rather, a burgeoning of defensive practice which is neither good for the patients or the profession.

Dr Bawa-Garba didn't go to work on that fateful day expecting events to unfold as they did. But mistakes were made and the medical profession is engaged actively with NHS England, the Department of Health and Social Care and the GMC to learn and move forward positively. Dentistry must recognise the impact this case will have on our profession and seize the opportunities presented here.