Seminar 6 - Iatrogenic Death and the Dr as the Accused Flashcards
Would a a doctor making a singular mistake warrant a FAI
No
These are only used for medical death in the setting of a systemic failure
Outline the events of the Adcock-Bawa Garba case
Jack Adcock was a 6 years old male with Down’s syndrome who died in hospital following sepsis and cardiac arrest
He presented , critically ill and unresponsive and was initially diagnosed with gastroenteritis and dehydration and he was treated accordingly.
Later blood tests and chest x-rays confirm a Group-A Strep infection and Jack was treated with antibiotics for the resulting pneumonia
However this was not enough to save him as he went into septic shock
The duty to attend and comply at court always requires a written court order - true or false
False
It is generally presumed without the need to resort to a written order
What are the most common complications due to medical devices
Infection, malfunction, haemorrhage and thrombosis
List common side effects of taking antibiotics
Anaphylaxis
Toxic epidermal necrolysis
Opportunistic infections
Which factors may be considered when determining whether the scientific methodology used in the expert witness’ testimony is valid
Whether the theory or technique can be and has been tested
Whether it has been subjected to peer review and publication
Its known or potential error rate
The existence and maintenance of standards controlling its operation
Whether it has attracted widespread acceptance within a relevant scientific community
What is the purpose of yearly appraisals
They provide information to the responsible officer so they can inform the GMC is the license can be continued
Is death certification a legal or medical process
A legal process
Who should you contact in cases of death due to complications from medical devices
It may be useful to contact the manufacturer of the device as they may have additional information such as demonstrating correct use/ placement or access to logs of electronic devices
What happens if you fail to attend court after being cited
You are in contempt of court
Can be charged or fined
On which subjects should you give expert testimony and opinions upon
Only on issues that are within your professional competence
What is preponderance of evidence
The standard of proof, commonly used in civil litigation, that requires the party with the burden of proof to demonstrate that an allegation or argument is more likely to be true than false.
Who is responsible for revoking medical licenses
The GMC
What is the role of Healthcare Improvement Scotland (HIS)
They investigates a sample of MCCDs (medical cause of death) to ensure adequate reporting to PF
This ensures professionals are reporting deaths correctly and reporting them to the PF when required
In court you should always understand exactly what questions you are being asked to answer - true or false
True
Must be clear what you are providing an opinion on
In the context of medical related deaths when would and wouldn’t a discretionary FAI be appropriate
Would - if there appeared to be systemic failings leading to the death
Wouldn’t - one doctor making a singular mistake resulted in the death
List some key features that should be looked for on internal examination of a technical operative/peri-operative death
Body cavities should be checked for collections of blood, purulent fluid or stool/ stomach contents
Relevant organs and tissues should be checked for signs of ischaemia, necrosis, infection, injury, or haemorrhage, both macro- and microscopically - patient’s will need to have survived for several hours for ischaemia to start to show
Nearby vasculature should be examined and wall integrity established, especially where there is evidence of haemorrhage - can use a large bore needle with water to uncover any breaks in vasculature
If there was an infected batch of blood products that caused the death of multiple patients would that warrant an FAI
Yes a discretionary one - sudden death and in public interest to do it
How should you approach your trade union once you’ve been informed your under investigation
Contact BMA Law/ HCSA
If GP inform the partners at your practice
Ask BMA Law/ HCSA to respond on your behalf
Don’t make comment until you have taken professional advice
What is the role of an expert witness
Help the court on specialist or technical matters that are within the witness’s expertise
A doctor found guilty of criminal negligence is likely to face what action from the GMC
Fitness to practice procedures
What was the hypothesis of the Independent Review of gross negligence manslaughter and culpable homicide in Scotland
Specific guidance and support for investigating CH in a medical context should be developed
The Scottish system was found to lack a body with the oversight and ability to enforce improvements - true or false
True
How did the Dr BG case cause other doctors to lose faith in the GMC
Many felt she was used as a scapegoat to protect the public image of the NHS.
Work hours and staffing issues have been in the news for many years and haven’t been addressed fully.
GP body expressed a vote of no confidence in the GMC and many others expressed their support for Dr Bawa-Garba (e.g. over £300,000 raised for legal fees via crowdfunding and 700 medics signing an open letter)
In what forms can evidence be offered at a trial
Live testimony (from the parties, expert witnesses or other witnesses that support or rebut the case);
Testimony that is recorded prior to trial;
Medical records;
Photographs; and
Videos
How should a witness express their certainty
Either use a published hierarchy or an explicit hierarchy
Published is best
What is the most used medical defence agency for indemnity cover
The MDU
Describe the outcome of the 2013 inquest in the Bawa-Garba case
Another paediatric consultant acted as expert witness and testified that if the mistakes hadn’t been made Jack wouldn’t have died.
This led to the case being referred back to the crown prosecution service.
List some key features that should be looked for on external examination of a technical operative/peri-operative death
Careful examination of surgical incision sites and any indwelling devices
Indwelling devices should still be in place if death occurs soon after surgery and should not be removed if death will be referred to coroner
Chest radiograph may be taken if pneumothorax or thoracic air embolus is suspected - can be AP or lateral
Doctors have a “professional duty of candour” - true or false
True
They must be honest in reflective logs
They should be able to admit mistakes to patients and apologise for them
Before Donoghue v Stevenson what was required for liability for personal injury in tort law
the presence of physical damage inflicted directly (trespass to the person) or indirectly (trespass on the case).
This did not include ingestion of noxious substances - which was the cause in this case
When do fitness to practice hearings occur
After referral from GMC
Carried out by the MPTS
What happens if a judge/jury are convinced beyond reasonable doubt that the defendant is guilty
This means the prosecutor has met the burden and proved the defendant’s guilt beyond a reasonable doubt
The defendant should be pronounced guiltu
List the 4 main categories that deaths that occur in hospital/ under medical care can fall under
Natural
Therapeutic
Accidental
Homicide
Preponderance of evidence is used in what type of court
Civil cases
What are the statements and reports used as evidence based upon
Contemporaneous notes
What causes malignant hypethermia
Autosomal dominant mutation
Triggered by inhaled anaesthetic +/- suxamethonium
Exposure to agent causes an increase in intracellular Ca2+ which drives an increase in metabolism, leading to increased temperature (up to 43’C) and metabolic acidosis
In order to act as an expert witness as a doctor what do you have to understand
The law and codes of practice that affect your role as an expert witness - you must also follow them
How to write a report that follows the procedures set out by the courts
How to give oral evidence
Why is it hard to monitor trends in iatrogenic death
Due to poor reporting
Especially when using ICD codes, as these do not always correspond to causes of death relating to human factors.
What services do the GMC provide for doctors to protect themselves against legal actions
They have a guide on what to do if reported to the GMC - important doc
They also support a free confidential emotional support service run by the BMA for doctors reported to GMC
What is the aim of the initial declaration of truth in a witness statement
to render the individual liable for criminal prosecution if they have lied
What is the role of a professional witness
Provide professional evidence of their clinical findings, observations and actions, and the reasons for them
What is the definition of medical duty of care
Refers to the relationship between doctor and patient
When a patient enters a hospital, a duty of care is created between the doctor and the patient
This can apply to any doctor who comes into contact with the patient e.g. if a patient collapses in the middle of a hallway then any doctor passing by owes them a duty of care
What are the 5 key actions of the GMC
They maintain the UK medical register,
Set the standard for the professional values, knowledge, skills and behaviors required of all doctors
Set standards for undergraduate and postgraduate medical education.
They make sure doctors stay up to standard.
They investigate and act on concerns about doctors.
How is Scotland going to improve the quality of its investigations into deaths occurring in medical care
HIS currently rolling out Quality of Care reviews aiming to guide organisations on their approach and learning from adverse events
What happens if the plaintiff fails to meet the burden of proof by preponderance of evidence
The defendant will not be held liable
The defendant can request the judge enters a directed verdict
Give an example of explicit hierarchy
I will use the following verbal scale to express the certainty of my results. It runs from definitely excluding to definitely including:
A did not come from B It is unlikely that A came from B There was nothing to suggest either that A came from B or that it did not A could have come from B A probably came from B A most probably came from B A came from B
List some causes of anaesthesia related iatrogenic death
Malignant hyperthermia
Complications of Intubation and Ventilation
Is being part of a medical defense agency free
No
Not a free service and membership is quote based ( usually free for students)
You can merge factual evidence with your opinion when giving expert witness testimony -true or false
False!
Should make clear what is factual evidence and what is your opinion based on your professional judgement and experience
What scheme is used for medical indemnity in Scotland
Clinical Negligence and Other Risks Indemnity Scheme
In which civil cases is clear and convincing evidence typically required as burden of proof
It is generally reserved for civil offenses that have special elements to establish such as:
Claims involving fraud
Claims involving wills and inheritances
Cases involving important family decisions such as withdrawing life support from a relative
List examples of medical negligence
Delayed diagnosis Failure to Diagnose Negligent prenatal care Birth Injuries Medication and prescription errors Surgical errors Anesthesia errors Failure to warn
What is the Daubert Standard based on
A supreme court case
What is a non-technical (peri) operative death
One due to other complications of surgery and/ or extended hospitalisation
(e.g. not a direct complication of the surgical technique itself)
Includes exacerbation of pre-existing disease and late post-operative complications such as bowel obstruction due to adhesions or fistulae formation
What mistakes did Dr Bawa-Garba make in the Jack Adcock case
It is alleged that her initial assessment was rushed, and that reassessment was inadequate
She underestimated how unwell Jack was after he responded well to initial fluids
She missed the abnormal urea and creatine when she finally got the results of Jack’s blood tests - apparently distracted by very high CRP
Which tool is often used to assign cause of death
WHO’s International Classification of Disease (ICD)
There is a lack of data data on the number of cases investigated for CH and GNM - true or false
True
Criminal conduct cases for medical manslaughter sit on a spectrum - give examples of this
At one end the fatal mistake can occur due to a momentary lapse of concentration or a misheard instruction
At the other extreme, the action is not a mistake but instead deliberate harm is inflicted on the patient (e.g. Shipman)
How common is the charge of medical culpable homicide in Scotland? What are the reasons for this?
It is not very common in Scotland - the data available indicates that there have been no doctors successfully prosecuted for CH in cases of alleged medical negligence
This is partly due to the requirement of “recklessness” in criminal Scot’s law, and the fact that decisions on prosecutions are taken with regard to the wider public interest
What does evidence of bilateral DVTS suggest in terms of cause of death
Evidence of bilateral DVTs suggests that immobilisation (eg. following surgery) was more likely to be a factor in thrombus formation
Describe the confusion which occurred when Jack Adcock went into cardiac arrest
After Jack arrested the crash call was sent out an Dr Bawa-Garba attended.
Originally doctors thought he was a DNR as another boy had been on the same ward and crashed earlier with a DNR.
Dr BG announced this which slowed resuscitation efforts.
Another staff member corrected her but once restarted they were unsuccessful.
What happens if you do and don’t meet Daubert standard
If met then the judge will accept the expert witness opinion
If non met then they wont
What must the plaintiff convince the jury of in cases using preponderance of evidence
Jury will need to be convinced, based on all the evidence, that there is a greater than 50% chance that defendant caused the harm alleged in the lawsuit
They will weigh the evidence and decided if preponderance has been met
What is the main difference between murder and culpable homicide (scots law)
Murder is considered a willful act - either you intended to kill or behaved recklessly and did not care about consequences
Culpable homicide is when you cause death but did not intend to and your behavior was not ‘wickedly reckless’
Is being part of a medical defense agency mandatory for doctors
Not mandatory to have one but HIGHLY suggested
Why must doctors engage fully with appraisals and revalidations
To protect themselves
To maintain their license
To better themselves as doctors to safeguard themselves against future medico legal issues
Impact of systemic failures is given little legal weighting - true or false
True
No consideration on how system affects human factors
Often leads to harsh outcome for the individual
The term public interest always refers to the entire UK population - true or false
False
“public” can relate to a relatively localised public e.g., a small community, or the wider public at large
What are the 3 stages of the 3 stage negligence test
Stage 1 – The person in question is owed a duty of care
Stage 2 – There has been a breach of that duty of care
Stage 3 – As a direct result of the breach, legally recognized harm has been caused
What is an acute haemolytic reaction
Occurs after blood transfusion
There is destruction of donor blood cells by host antibodies
What should you do if you change your view on any relevant aspect of a case you are involved in
You have a duty to make sure those instructing you, the other party and the judge are made aware of this without delay
You can ask the court or get legal advice in these cases
What is the highest standard of burden of proof
Beyond reasonable doubt
What is the Daubert Standard
The standard used by a trial judge to assess whether an expert witness’s scientific testimony is based on scientifically valid reasoning that can be properly applied to the facts of the case
What is the purpose of the GMC
The GMC is there to “protect patient safety and support medical education and practice across the UK”.
Who sets statutory law
A body of legislation e.g., government.
What is the English equivalent to Scots delict law
Tort Law
Civil wrongs that are actionable in court
What are the yearly appraisals base on
Good Medical Practice
What is tort law derived from
Latin verb ‘tortere’ which means to hurt
Therefore the idea of hurt is an important consideration in establishing negligence
What were the initial police charges brought against Bawa-Garba in 2012
Dr Bawa-Garba was informed that she was being investigated for manslaughter
However, this came to nothing and she was told there were no charges
Where do you get private indemnity from
Like any form of insurance there are many different providers
Probably best to go with one of the 3 medical defence agencies (MDU, MPS, MDDUS) as they provide additional benefits for the cost
How can you identify anaphylaxis post-mortem
Serum tryptase can be tested for post-mortem, but will be affected by survival time post event
For some medications such as penicillin, IgE antibodies against specific allergens can also be tested for
Histologically, sections of the airways may show submucosal oedema and/or mast cell and eosinophil infiltration
What do medical trade unions do
They will support and represent doctors in medico-legal issues as well as other diverse issues effecting the profession – equal pay, banding issues, NHS employment contracts
In criminal cases, the defendant is always presumed innocent - true or false
True
Innocent until proven guilty
The prosecution must prove this beyond reasonable doubt
Medical error is rarely the cause of transfusion related adverse events - true or false
False
It is the common cause
e.g. Blood being given to wrong patient due to identification errors
What is meant by a no blame culture
Not prosecuting individual doctors for one-off mistakes, but holding organisations accountable for systemic failures.
What is the burden of proof
The obligation to present evidence on the subject of the lawsuit or the criminal charge to prove or disprove a disputed fact
Parties have to convince the trial of fact of their position
Who sets common law
It is set by judges
Can be amenable if the circumstances are not suited to the common law.
According to the Independent Review of GNM and CH, how many expert witness should be sought to determine culpability for a CH prosecution of a doctor
More than 1
Obesity is a strong risk factor for complications from intubation and ventilation - true or false
True
This because there is difficulty intubating and decreased chest wall compliance
Who has the burden of proof in a criminal case
The prosecution
Have to prove them guilty beyond reasonable doubt
Did the resus interruption contribute to Jack Adcock’s death
It was later found that it hadn’t
However, the BP meds and antibiotic delay had
Standardization of expert witness selection would achieve what
Provide assurance on how recent an expert’s experience is in relevant field, their qualifications and relevance to the case.
Could standardise on skills, knowledge, training and how they should be quality assured
When do we use beyond reasonable doubt as the burden of proof
In criminal cases
Who has the burden of proof in clear and convincing and what court is it used in
The claimant (person making the original claim) Civil court
The Bolam test/standard is definitive - true or false
False
Sometimes the courts will go against the body of opinion e.g. case of Bolitho
Pathologists should have a basic knowledge of common surgical procedures - true or false
True
Should have good knowledge of the most common ones and their complications
Allows them to properly investigate operative deaths
If surgery is complex/rare then the surgeon can be consulted
Is it mandatory to have medical indemnity cover
Yes
Since 2013 it’s a legal requirement to have indemnity cover
A forensic pathologist giving opinions on the cause of death of the victim is what type of witness
Expert witness
What is meant by ‘beyond reasonable doubt’
Essentially the court has to be convinced that there is “no doubt” that something is true
List common medical devices seen at autopsy
Pacemakers
Orthopedic implants
Intravascular stents
What factors should be considered when assessing public interest in an FAI
The nature and gravity of the offence
The impact of the offence on the victim and other witnesses
The age, background and personal circumstances of the accused
The age and personal circumstance of the victim and other witnesses
The attitude of the victim
The motive for the crime
The age of the offence
Mitigating circumstances
The effect of prosecution on the accused
The risk of further offending
The availability of a more appropriate civil remedy
Powers of the court
Public concern.
What services does the MDU provide
Indemnity cover for clinical negligence claims and good Samaritan acts that meets GMC requirements and covers legal costs and potential claims
24hr medico legal advice
Support and defence for GMC complaints, inquests, disciplinary or trust hearings, criminal investigations relating to practise
Press support if involved in a high profile case
Access to case studies, ethical dilemmas, e modules, podcasts, videos, CPD accredited courses and webinars
Who needs to accept the statements and reports
Both defence and prosecution
How did the TFG review suggest improving the enforcement of changed from FAIs etc.
Create a regulatory body
A regulating body could enforce learning from FAIs/CIs within and across the Boards in Scotland
This would prevent recurrence of issues and improve patient safety
Describe the involvement of the patient’s family in their medical death investigation
The HIS have clear guidance regarding the involvement of the patient’s family/advocate in the investigation
However, the TFG review felt that it was not consistently followed
When does medical negligence become a criminal case
When a death occurs
Without death it tends to be a civil case
How do you access help from the medical protection society
24hrs telephone if emergency or online contact form ( make sure patients details are annon. if required)
What is the role of the HCSA
Advised and represents doctors in both NHS and private work
For clear and convincing evidence (burden of proof) the trier of fact needs to have a firm conviction or belief in its factuality - true or false
True
Would a medical death be a discretionary or mandatory FAI
Would come under a discretionary FAI
This only applies to deaths due to systemic failure and not a doctor making a singular mistake
E.g., Infected blood products from blood bank resulting in multiple deaths
How is the standard of the reasonable man used
The courts will use this hypothetical person to help determine if a party has acted as a reasonable person would
Acts as a human control of sorts
For example, in a civil action for negligence
What was the aim of the Independent Review of gross negligence manslaughter and culpable homicide in Scotland
Review the key aspects of the healthcare system in Scotland and Scottish law relating to culpable homicide
How often do revalidations occur
Every 5 years
What is a factual conclusion
A simple statement of fact
Conclusion drawn on analytical results are an inescapable fact
Basic scientific conclusion remains factual
Any legal implications flow directly from it
What should a professional witness base their statement
Based as far as possible on clinical records and notes made at the relevant period of time
What is the definition of duty of care
The legal obligation of an individual/company to adhere to a reasonable standard of care if they are performing an act/or producing a product that could potentially harm someone
List the main subtypes of iatrogenic death
(peri) operative - technical and non-technical Anaesthesia-related Medication Reactions Haemodialysis Transplant-/ Transfusion-related Hospital Acquired Infections Pulmonary Thromboembolism Complications from Medical Devices
What is malignant hyperthermia
An autosomal dominant condition often triggered by inhaled anaesthetic +/- suxamethonium
Leads to an increase in metabolism and therefore increased temperature and acidosis
What must any witness do before giving evidence in court
Take oath or affirmation that you will ‘tell the truth, the whole truth and nothing but the truth’
Must make sure if not religious use the affirmation not the oath
What is the point of medical indemnity
Insures that if a clinical negligence claim is made against you you don’t have to pay for it personally at the time
What is considered an adverse event in medical care
All events that could have contributed or did result in, harm to people or groups of people.
This includes harm to patients and service users, as well as harm to staff
When and where did the Bawa Garba case occur
Initial event was in 2011 at Leicester Royal Infirmary’s Children’s Assessment Unit
What were the creditable aspects of the Scottish system as found by the Independent Review of GNM and CH
Processes leading up to investigation
Inquiries by the PF/coroner were consistent
Police investigation and decisions to prosecute were transparent
If haemodialysis is likely to have contributed to a death, what should the pathologist look for
May want to focus on sites of bleeding, especially looking for signs of thrombosis, infection or aneurysm.
What is involved in the emotional support service run by the BMA for doctors reported to GMC
Service that provides emotional support, not legal support
Free for everyone even if not BMA member
Independent and confidential from the GMC
6hrs of telephone support, face to face support at hearing and orientation meeting morning of hearing
Describe the hospital investigation in the Bawa-Garba case (results are another card)
Immediate investigation launched
Police were also involved at this stage as it was an unexpected death of a child.
Two post-mortems were performed (in case it did become a police case)
Dr Bawa-Garba was asked to reflect on the case and her thoughts were recorded in her e-portfolio.
She was taken off the ‘on-call’ rota and sent to the PICU for further training.
Staff had previously raised concerns about staffing
Improving data collection on culpable homicide prosecutions involving doctors would address the staff’s main concerns - true or false
False
They are more concerned about the support and challenges present not the statistics
Outline the Bolitho case
2 year old Patrick Bolitho suffered respiratory, hypoxic brain injury and death secondary to croup whilst in hospital
After each croup episode the Senior registrar was called but did not attend and he deteriorated and died
Everyone accepted that the Senior Registrar had failed in her duty of care but the question was whether the damage was due to that breach
It was instead found that only intubation before the final collapse would have averted the tragedy and the judge accepted that even if she had attended after the episodes she wouldn’t have performed the procedure at those times.
However 5/8 expert witnesses said they would have intubated earlier - judge went against this, therefore breaking the Bolam standard
Why is causation hard to establish is medical negligence cases
It is actually very hard to establish where the harm actually occurred in relation to an episode of medical care
e.g. paralysis after aortic aneurysm repair may be caused by the surgery or the provision of epidural analgesia
In what situations would the BMA be able to provide
NHS, GMC and CQC investigations Appeals against license withdrawal Fitness to practise hearings 1st tier health tribunal hearings High court appeals Criminal charges If you are invited to give evidence to HM Coroner’s Office
What is a witness summons
When the court compels attendance
What additional information should be made available to the pathologist in the case of a technical operative/peri-operative death
Patient’s surgical history and the operative notes should be available to review prior to or during the autopsy
It may be helpful to have the surgeon attend, particularly following specialised or complicated procedures, or where the pathologist is unfamiliar with the procedure
What is meant by beyond reasonable doubt
The prosecutor must prove the case to an extent that no reasonable person could reasonable doubt the defendant’s guilt
What are the similarities between medical defence agencies and trade unions
Both give medico legal advice and representation (BMA through BMA law)
Neither are free
Describe the role of the Medical Practitioner Tribunal Service (MPTS)
The MPTS run the fitness to practice hearings.
They are a statutory committee of the GMC but are independent in their decision making and operate separately from GMC investigations - don’t take part in investigation itself
They can restrict or remove a doctor’s right to practice medicine in the UK.
If a party in a civil case believe that the evidence shows that no reasonable jury could conclude that defendant was liable what can happen
They can ask for a directed verdict against plaintiff
Why do most medical negligence cases focus on the individual
Because it is easier to take legal action against an individual rather than make an entire organisation (such as the NHS) legally accountable
When does a lawful act become a criminal one
When committed with a criminal state of mind
In an negligence case what must the claimant prove
They must establish on the balance of probabilities that negligence has occurred by the hospital or doctor
What is the difference between preponderance of evidence and clear and convincing evidence
Preponderance only requires a minimum likelihood of 50% that the person is guilty
For clear and concise you must be substantially more than 50% certain of guilt
How certain do you have to be about CoD before recording it on the death certificate
Officially you only have to be 51% certain (most likely cause)
Generally the doctors/pathologists are more certain!
Was Dr BG removed from the medical register
The GMC initially argued she should be an overturned the MPTS findings
However, Dr Bawa-Garba appealed this decision and was successful, she would instead serve her 1-year suspension
When is resipsa loquitur used
In the absence of any other reasonable explanation for a phenomenon and the evidence speaks for itself
e.g. the finding of a retained swab in the abdomen at laparotomy can only be assumed to be due to its negligent loss during a previous laparotomy
Can culpable homicide be committed inadvertently
No
A person cannot be guilty unless they are aware of the risks and choose to run with it.
e.g. drink driving (you know the risks and choose to do it anyway)
What type of culture does Scotland want to promote around CH investigations and FAIs
No blame culture
This would involve learning and reflective practice for doctors undergoing investigations when fatalities occur
When is negligence considered gross
If negligence occurs as a result of carelessness, and the carelessness has been so severe that it is judged to be ‘gross’
What are doctors mainly concerned about in relation to culpable homicide cases
Availability of appropriate support & supervision and the challenges and pressures of the working environment
If you are called as a professional witness but then are asked questions as if you were an expert witness what do you do
Ask the judge for clarity on what you are supposed to be answering and state that you may not be an expert witness in that capacity
i.e. your the pathologist in the case and are there as a prof witness but don’t know enough about the rare condition the individual had so you cant provide information about it and how it may have effected the case because you are not an expert in this
No doctors have successfully been prosecuted for medical culpable homicide in Scotland - does this mean there is a lack of accountability
No
Processes such as FAIs, civil claims seeking compensation, and health & safety legislation can address such errors.
