As Søren Kierkegaard wrote, ‘Life can only be understood backwards, but it must be lived forwards.’ This aphorism sprang to mind when I read about the disgraced paediatric orthopaedic surgeon Yaser Jabbar who worked at Great Ormond Street Hospital. It has been revealed that he practised in a substandard way for years, and the trust must now ask itself why he was tolerated for so long. As it does, an ongoing review into the care of over 700 patients will undoubtedly reveal more instances of harm.
There are parallels with other rogue doctors, for example the breast surgeon Ian Paterson who is now serving a lengthy sentence for unnecessary and incorrect surgical mastectomy procedures. His behaviour was criminal, whereas that of Jabbar appears merely wayward at this stage. There are concerns that he did not obtain informed consent for some procedures, and that some operations were unnecessary or not indicated – these are more serious allegations. In terms of presumed guilt, his removal to Dubai combined with an odd and dismissive response to inquiries has, in the minds of many, been confirmed.
Jabber was ‘found out’ when a locum colleague covered his workload while he was recovering from an accident. She identified that his clinical decisions and results were unacceptable. A lot of the detail of this case is behind the Sunday Times paywall, so I won’t put in a link. Others newspapers have covered the story, but in less detail. If the report by the Royal College of Surgeons (RCS) is ever made available, we will understand more.
The public reads about these scandals long after the events. In Jabbar’s case, he was on gardening leave for 11 months before leaving the trust in 2022, two years before the story was publicised in The Sunday Times. It does not really matter when we, the public, find out. What really matters is how soon the affected are told, in what way they are supported, and how transparent the trust is. Now that we do know about it, it is appropriate to ask the general question – how can the NHS detect patterns of persistent substandard care and intervene earlier?
Let’s imagine a nameless surgeon working in an unspecified field. They are appointed based on their completion of training in recognised specialist centres, an accomplished CV (including relevant academic publications) and a satisfactory performance at interview – 45 minutes in which a candidate’s values, insight and humanity are supposed to be assessed.
They start work. Any early misgivings are met with explanations based on the difficulty or complexity of their patients’ underlying conditions. After all, there aren’t many surgeons out there who can provide this service. And complications happen, don’t they. Such medical exclusivity also makes it hard for non-experts – in governance roles for instance – to make judgements about clinical outcomes.
Their manner is occasionally brusque and over-bearing, in multi-disciplinary meetings for instance, but this is a highly stressful environment and you don’t get on by being passive. Decisions are required.
One or two patients and families complain. The responses to these complaints provide standard explanations but go no further. The families come to believe they are just unlucky exceptions. There are not enough complaints to create a pattern, certainly not one clear enough to justify a review of practice. Also, individual patients do very well, and these exemplars are held up by the surgeon as evidence that they are competent; these patients are grateful, and letters or cards of appreciation are featured in the surgeon’s annual appraisal.
After five years data is presented showing that the unit’s outcomes are not good enough, compared to peer departments. Senior managers become uncomfortable. Is there something wrong in this department? An external review is commissioned. The investigators are asked to assess the whole department as a whole, not individuals. It would be prejudicial to focus on one person; that is not how things are done. The final report concentrates on (a lack of) team working and culture. Not everyone gets on; decisions are often made in isolation. Some of the consultants compete in the private sector.
Years pass. Patients move through the department. The level of concern rises and falls like a slow tide. Perhaps the level of care is normalised – ‘this is what happens here’. And then, one day, something happens to cut through. A fresh pair of eyes, a whistleblower, or a behaviour that cannot be tolerated… leading to a realisation that the organisation has been harbouring a surgeon who works at the edge of acceptable practice, and who often wanders across the line.
The question I ask myself is – at what stage in this imagined timeline should an intervention have taken place? From a patient’s point of view, it is obvious. At the very beginning, when concerns were first raised. If the surgeon had been taken away from the clinical interface while those concerns were explored, further harm would not have been done. But was there have been enough data on which to form an opinion? Probably not. Am I saying that if there are concerns the department should just watch carefully for a while? How long? Six months, a year? Is it fair to the patients who are treated by them during this period, oblivious to the fact that the surgeon they meet in the clinic room is under review?
Complete openness at this stage is probably not possible. A doctor’s performance may fluctuate during their career, and improvement plans may be required. Although the highest standards are expected, by definition half of us are below average. It is probably not reasonable for patients to be informed that such a process is under way. So when should the line be drawn? What form of evidence constitutes a clear signal that an individual must be stopped, pending a full and impartial investigation?
The answer to this question is not obvious. One unexpected death or complication is not sufficient. A trend is required. One or even several complaints does not suffice – there are always mitigations, reasons, explanations. Perhaps it is more subtle. I have come to think that outcomes – although apparently black and white – are debatable, but that behaviours and attitudes are easier to judge. An individual’s response to feedback; their willingness, or lack of it, to accept that there may be a problem; their failure to engage in audit, reflection and improvement. These are the hallmarks of a doctor, or a team of doctors, who will not recognise that they have crossed a line, will not self-correct, and who will carry on providing unsafe care until the litany of incidents resolves into an unmistakable pattern.
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