Jack Adcock's parents, Nicola and Victor, brought their six-year-old boy to the Leicester Royal Infirmary, after he showed breathing difficulties as well as a high temperature and heart rate. Once Jack went into cardiac arrest, a team of medics began to resuscitate him, but they were soon interrupted by Dr. Hadiza Bawa-Garba who said he was under a "do not resuscitate" order.

Jack died shortly after the decision. What Bawa-Garba hadn't realized at the time was that Jack had been moved to a new ward, and the other boy — who was actually on the "do not resuscitate" list — had been discharged already.

"But what was important to me was not to resuscitate a child that was not to be resuscitated," said Bawa-Garba.

A "do not resuscitate" order is placed on a patient when they and their family have agreed upon the terms to not revive after their heart stops. This living will is designed to prevent unnecessary suffering that could otherwise be avoided if the patient passes away. This decision is typically based on a quality versus quantity of life assessment and the overall well-being of the patient.

Bawa-Garba immediately realized there was a mistake once another doctor asked her the reason for Jack being on a no-resuscitation list. "He is for resus — it's the wrong patient," she then shouted.

An hour went by but the frantic medic team couldn't save the little boy — the mix up had cost him his life. Jack also had Down's Syndrome, along with other health problems, and was not new to hospital visits. He had gone to the hospital earlier the same day after experiencing sickness and diarrhea.

Bawa-Garba is a 36-year-old pediatrician recently returned to Liecester Hospital after a 13-month maternity leave. She said that because of her time off from work, she became "deskilled in the management and treatment of shock." In addition, she had already worked a 12-hour shift by the time she was confronted with Jack's fragile medical state.

"I should have checked the face before stopping. But I had been working for 12 hours with no break," Bawa-Garba admitted.

Doctors are accustomed to working long shifts with no break on end. However, in 2011, a group of 26 doctors and patient safety experts released a report in attempt to avoid the already alarming number of medical errors. The new resident work rules would limit all new resident physicians to work shifts of 12 to 16 hours, but more experienced members could still pull a shift as long as 28 hours straight.

"Few people enter a hospital expecting that their care and safety are in the hands of someone who has been working a double-shirt or more with no sleep," Dr. Lucian Leape, an adjunct professor of health policy at Harvard School of Public Health and co-author of the report, told Reuters.

Unfortunately, since the 16-hour limit was put into place for new residents, there has been no significant improvement in the quality of care provided by doctors.

"What started as a good system has evolved into a system where the residents are extremely sleep deprived, caring for some of the sickest patients in the country, and that's a set-up for disaster," said Dr. Christopher Landrigan, one of the report's co-authors.

Landrigan has bleak hope that the report will actually change resident rules for all doctors across the board in the immediate future because of traditions and costs. And clearly, two years later, the rules still remain unchanged.