Bawa-Garba’s unit was understaffed and she was working a double shift with compromised consultant cover, looking after many more patients than usual. Because of a shortage of nurses, she was doing so without experienced ward staff to rely on. An IT failure prevented crucial test results being relayed expeditiously to her. And her hospital had no system for referring deteriorating patients to senior colleagues.

Bawa-Garba’s unit was understaffed and she was working a double shift with compromised consultant cover, looking after many more patients than usual. Because of a shortage of nurses, she was doing so without experienced ward staff to rely on. An IT failure prevented crucial test results being relayed expeditiously to her. And her hospital had no system for referring deteriorating patients to senior colleagues.