The doctor involved in the death of a Chesterfield toddler has been cleared to continue practising medicine, despite committing “serious misconduct”.
Dr Baljinder Ubhi, known as Tim, had failed to carry out a slew of vital checks on four-year-old Gracie Foster, who died several hours after he discharged her from Chesterfield Royal Hospital.
This week, five years on, Dr Ubhi appeared in a Medical Practitioners Tribunal Service hearing in Manchester.
It ruled that despite finding “serious misconduct” and that Dr Ubhi had “cut corners” he was not “impaired” and so would be allowed to continue practising medicine – which he has done so since 1992.
However, it did agree to attach a warning to Dr Uhbi’s registration.
It lays out the series of events that found him charged with serious misconduct and “is given as a deterrent to you and to all doctors of recognising the duty of care to any patient”.
The warning also says doctors must remember to be “open and honest when things go wrong”.
The hearing was told that Dr Ubhi had thought of Gracie every day since the incident and has sought to improve his practice.
Chesterfield Hospital Trust has said it hopes Gracie’s family can take “some small comfort” from the fact that care of other children has been improved as a result of the incident.
Gracie’s mother, Michelle Foster, has told the Local Democracy Reporting Service that she is disappointed to have not received an apology from Dr Ubhi.
She says that had Gracie received the proper care she is “likely to have survived”.
Gracie, from Old Whittington, arrived at Chesterfield Royal Hospital to have her tonsils removed but fell ill while waiting.
The Lenthall Nursery and Infant School pupil was then sent home by Dr Ubhi, a locum (temporary) paediatrics consultant.
Gracie died hours later after being rushed to Sheffield Children’s Hospital from meningococcal septicaemia – a form of life-threatening sepsis (blood poisoning).
An inquest at Chesterfield Coroners’ Court in September 2018, found that there were “gross failures” by healthcare professionals representing “neglect” which contributed to her “preventable” death by natural causes.
The MPTS hearing found that Dr Ubhi “failed” to adequately review Gracie’s medical records or obtain a patient history.
It also found that Dr Ubhi failed to assess Gracie’s behaviour, heart rate, breathing rate, capillary refill time, skin colour or extremities skin temperatures.
The tribunal, brought forward by the General Medical Council, was due to last two weeks but Dr Ubhi admitted to all of the charges.
During the hearing, the GMC said that Dr Ubhi’s response to Gracie’s death had contributed to the stress, pain and upset of her family for several years.
Dr Ubhi agreed that he had been “defensive” and that this had an adverse effect on others.
Dr Uhbi’s defence team agreed that his actions amounted to “serious misconduct” and that his involvement had led to the “tragic” outcome.
The doctor is said to have been “profoundly affected” by the incident and has since undertaken a range of professional courses on paediatrics and sepsis.
His team said “there was no realistic prospect of Dr Ubhi ever repeating this type of conduct again” and that Dr Ubhi “wore his failures publicly”.
Dr Ubhi admitted that he had been “cutting corners on the day in question due to how busy he was as a paediatrician”.
A case of meningitis had recently been reported at Gracie’s school.
Chesterfield Royal Hospital NHS Foundation Trust submitted evidence to the tribunal, saying that had the fact that a case of meningitis at Gracie’s school been made known to staff, her care “almost certainly” would have been handled differently.
Louise Sweet, chairman of the tribunal, wrote: “Dr Ubhi’s actions fell far below the standards of conduct reasonably expected of a doctor and is sufficiently serious to be characterised as serious misconduct.
“The Tribunal acknowledged that Dr Ubhi’s misconduct is capable of being re-mediated.
“The Tribunal noted that the failures in the care that he provided Gracie occurred almost five years ago.
“During the intervening period there have been no further complaints with regards to his clinical practice.
“Dr Ubhi described the inquest as a ‘turning point’ for him in terms of how he viewed the impact of this incident.
“The tribunal noted that Dr Ubhi had been open and honest with his colleagues about the failures in the care he provided Gracie.
“The tribunal accepted Dr Ubhi’s evidence that he has thought about Gracie every day since and has used this experience to inform his current practice.
“In all the circumstances, the tribunal concluded that Dr Ubhi does not present a risk to members of the public.
“The tribunal considered that Dr Ubhi’s insight and remediation has developed over a number of years since the events. He is mindful of the serious impact on Gracie, her family, and public confidence in the profession.”
Carolle White, a specialist in medical negligence at law firm Nelsons, which has supported Gracie’s family, spoke on behalf of Ms Foster.
She said: “It has taken more than four years for Dr Ubhi to acknowledge that Michelle was right all along about Gracie’s condition that day.”
Dr Ubhi had said that Gracie was moving freely around the ward when he saw her and that she seemed well – disputing Ms Foster’s claims, which she says was “torturous”.
During the tribunal hearing he admitted he was not truthful.
Ms White continued: “It has been really hard for her (Ms Foster) to hear witnesses backtrack over their original statements and, because of this, she has doubted herself for many years and suffered greatly as a result.
“The staff at the hospital never changed their thinking from Gracie being a patient waiting for surgery to her being a really poorly little girl.
“The seriousness of her condition was underestimated, and meningococcal septicaemia went undiagnosed and untreated.
“Had such treatment been provided, Gracie is likely to have survived.
“It is very disappointing that Gracie’s family has not received a direct apology from Dr Ubhi – in spite of him accepting that he portrayed the version of events incorrectly, which has caused Michelle so much stress over the past four years.”
A spokesperson for the hospital trust said: “Our thoughts and condolences remain with Gracie’s family and this must be another difficult time for them after the tragic loss of their daughter.
“Dr Ubhi worked as a locum consultant at Chesterfield Royal Hospital NHS Foundation Trust from October 2015 to the spring of 2016.
“The MPTS tribunal considered a number of allegations relating to the care and treatment he provided during that short time – focusing in particular on Gracie’s case and a lack of medical history and clinical investigations.
“We learnt a number of lessons five years ago, improving the way we look after children who are in hospital for a planned surgical procedure, with much more monitoring and observations taking place – and swift action on signs of deterioration.
“We hope Gracie’s family have taken some small comfort from the fact that the care of other children improved as a result of their circumstances.”