Dr Bawa-Garba did not, however, ask Dr O’Riordan to review Jack. “I remember writing and writing until the ink ran out in the pen,” she says. She was told to list everything that she could have done differently, she says. It was at this point that another failing in Jack’s care occurred. Phone: 021 4941323. “I hadn’t worked with him before, so I introduced myself,” Dr Bawa-Garba says. The BMJ has seen a copy of the form. A crowdfunding campaign also got under way to enable Dr Bawa-Garba get another legal opinion. Soon after Dr Bawa-Garba took over, the bleep went off – a child down in the accident and emergency unit, several floors below, needed urgent attention and she missed the rest of the morning handover. On 4 November 2015, the jury found Dr Bawa-Garba guilty. After Jack’s death, the police started their own investigation and the Adcocks praise them for the support they have given the family. . Later that night, Dr Bawa-Garba called Dr O’Riordan – the consultant who had arrived in the afternoon, after double-booking himself that day – to tell him about Jack’s death. The tests revealed his blood was too acidic. 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. 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. The consultant then added to the notes that Dr Bawa-Garba had made. For the Adcocks it was the day they had been waiting for. The GMC’s Charlie Massey says he understands these concerns. “I remember sitting there and listening to their account of my actions and I felt like a criminal,” says Dr Bawa-Garba. They focused on a sample that would help them identify systematic clinical issues. The investigations, court proceedings, and appeals have taken a toll on the family. Bawa-Garba’s fate will be decided in the High Court on 7 December when the GMC attempts to overturn a decision by the Medical Practitioners Tribunal Service to keep her on the medical register. The judges ruled that Dr Bawa-Garba's actions had been neither deliberate or reckless and she should not have been struck off. The 41-year-old mother of three says the impact on her and her family has been huge. “Everything was in place. NHS England declined to comment to the BBC. He met representatives from the local Clinical Commissioning Groups, the hospital and NHS England to devise and agree a plan. The police then arrived – there was to be an investigation after the unexpected death of the child. She had brought a rucksack with her in case she was sent to prison. His practice focuses primarily on investment (both institutional and private equity) and on development (acting for developers and investors), with a particular emphasis on transactions requiring solutions to issues arising on structuring and financing. But she didn’t consider that Jack might have had a more serious condition. In over half, there were “significant lessons to learn” – aspects of care that could be done better. Nor did the hospital comment, when asked by The BMJ, on the appropriateness of how Bawa-Garba was asked to reflect on the incident by O’Riordan. Dr Bawa Garba applied for leave to appeal against her conviction, but this was denied in November 2016. She knew the hospital was meeting the Adcocks and asked if she could attend. “They were concerned about their reputation,” he says. Mr Thomas told her to pause as people were going to write the list down. According to Mrs Adcock, the expert witness at the inquest, Dr Gale Pearson, a paediatric intensive care consultant, stated that if Jack “had been given the right treatment, antibiotics, correct bolus, intensive care, consultant treatment, he would have not died when he died, how he died, the way he died – he may have still been here”. “I hadn’t worked with him before, so I introduced myself,” Dr Bawa-Garba says. “It’s my way of coping,” says Mrs Adcock. The BMJ has learnt that, five days after Jack’s death, Bawa-Garba was asked to meet Stephen O’Riordan, the duty consultant at the time of the incident, in the hospital canteen. “List for us, please, all of the mistakes,” Mr Thomas said. “I therefore feel obliged to ask the GMC to investigate my clinical practice over the last 40 years to see whether I should be struck off the medical register.”. Mr Furlong says that improvements have been made and that the review has now been repeated, with results due for publication in September. 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