Abstract
Complaints can shatter the confidence and decision-making ability of even the most experienced of doctors, so here the Medical Protection Society (MPS) guides GPs through the top ‘ten C's’ to counter complaints and potential claims.
With some 133600 complaints being received by the NHS in 2007 and over 32% of those linked to Primary Care, the average GP could be forgiven for thinking that complaints are an inevitable part of daily practice life. Local resolution of complaints, following the new NHS Complaints regulations, stresses the importance of learning from previous errors.
The chances of being faced with a clinical negligence claim or General Medical Council (GMC) enquiry can be mitigated by following good risk management.
Competence
Always act within your limitations and never undertake a task that is beyond your competence. It is far better to ask for help or check a course of clinical action beforehand, rather than risk the chance of something going wrong by being too afraid to ask for help.
Confidentiality
Confidentiality is an important legal as well as ethical principle — doctors must follow the 1998 Data Protection Act as well as the GMC's guidance in Confidentiality: Protecting and Providing Information.
Simple steps can be taken within general practice to avoid a leak of confidential patient information: reception areas, often the setting for overhearing sensitive information, should be monitored; access to electronic records should be restricted to those who need it for the requirements of their job; and if patient information is sent by email, appropriate encryption software should be used.
Consent
Before performing even the briefest of physical examinations, you must always obtain consent; otherwise, you are vulnerable to a civil claim in negligence or civil and criminal proceedings in assault. The patient must be capable of giving consent, consent must be voluntary and the patient must be sufficiently informed to make a considered decision.
Chaperone
The GMC, in Good Medical Practice, states that, wherever possible, you should offer the patient the security of having an impartial observer or ‘chaperone’ present during an intimate examination. This applies whether or not you are the same gender as the patient. If a chaperone is offered and declined, make a note of this in the patient's medical records.
Clinical records
Good Medical Practice states that ‘you must keep clear, accurate and legible records, reporting the relevant clinical findings, the decision made, information given to the patient, and any drugs prescribed or other investigation or treatment’.
Never try to rewrite notes at a later date; if you need to alter medical records, make it clear that you are introducing a retrospective correction and clearly sign and date the alteration. Be aware that patients have a legal right to access their records, which can also be scrutinized by the courts during an inquest or clinical negligence trial. Derogatory statements, offensive patient acronyms and criticisms of colleagues will not be well received.
Careful prescribing
A quarter of all NHS claims relate to prescribing errors. The four most common errors are
Wrong dosage Inappropriate medication Failure to monitor treatment for side effects and toxicity Communication failure
Case study 1. ‘While I'm here, Doctor’
The ‘casual aside’, often thrown in at the end of a consultation, can cause problems if not properly recorded. On leaving Dr C's consultation, Mrs J voiced concerns that her husband's worsening abdominal pain was appendicitis. Dr C sought no further information and made no record in Mr J's notes. Mr J was later admitted to hospital with a ruptured appendix, and in a subsequent claim was awarded moderate damages.
MPS Casebook (2008) 16 (2).
Doctors should give the generic rather than trade drug name and watch out for spidery handwriting — especially with similar sounding drug names or the potential for dosage
miscalculation from a blurry decimal point. Prescribing should always be in accordance with the British National Formulary, and a full explanation of possible side effects should be given to each patient.
Conduct
An abrasive and offhand manner are least likely to be tolerated if a patient or relative is anxious and in pain. In fact, in 2007, 20% of all complaints about GPs to the Healthcare Commission were in response to poor attitude. A calm, professional and sympathetic manner is necessary at all times, however, unreasonable the patient may seem.
An American study by Wendy Levinson into ‘Physician — Patient Communication’ found that doctors who had never received a claim laughed and used humour more, used ‘statements of orientation’ to explain procedures to patients and spent approximately 3 minutes longer with each patient per consultation than doctors who had received clinical negligence claims.
Cover
The GMC advises that ‘you must take out adequate insurance or professional indemnity cover for any part of your practice not covered by an employer's indemnity scheme, in your patients’ interests as well as your own’.
Check with your medical protection organization that you have the appropriate amount of cover to reflect the work you do, especially if your line of work changes frequently. Remember that NHS indemnity only covers clinical negligence claims.
Communication
Good communication is vital both between doctor and patient and between doctor and doctor. A good GP listens to patients, asks for and respects their views about their health and responds to their concerns and preferences. An inadequate explanation of symptoms and potential risks can be linked in a patient's eyes to poor competency. Forty-three per cent of complaints to the Healthcare Commission were related to limited discussion about treatment options.
Case study 2. Human error
An MPS GP failed to spot that a computer-generated prescription from the hospital for Mrs B's lymphoma treatment said ‘melphalan 5 mg + 2 mg twice daily’. In error, he prescribed a double dose for 6 weeks, instead of administering the drug for no more than 4 days at a time, at intervals of 6 weeks. The overdose resulted in bone marrow depression from which Mrs B later died.
MPS GP Registrar — Prescribing — Autumn 2008.
Cover your back
If in doubt, seek advice from a senior colleague or an MPS medicolegal adviser. Finally, ensure that you have sufficient help available for the management of any complications should they arise.
The RCGP estimates that there are around four written complaints per practice annually. Sometimes, the best way to avoid further complaints about the handling of a complaint is to respond promptly, informally and with sympathy.
In almost 1 in 10 cases referred to the Healthcare Commission in 2007–08, the person making the complaint was simply seeking an apology or an acknowledgement that care could have been improved. From a doctor's perspective, a recent survey of MPS members revealed that 90% believed an explanation and apology reduced the potential for claims.
Saying sorry does not necessarily equate to admitting liability. To err may well be human, but to acknowledge defines Good Medical Practice.