On deadly ground

Mr T replied stating that he didn’t trust his GP. He asked to meet up with Dr P. She told him that she couldn’t do so and suggested she speak to his GP on his behalf. He became angry and upset. Dr P was concerned about Mr T so she contacted his consultant psychiatrist who arranged to review him later that week. Mr T ‘de-friended’ Dr P a few days later.

A month later Mr T complained to the senior partner at Dr P’s practice. He was unhappy that Dr P had declined to meet him as he had felt that they were friends. He was disappointed that she had contacted his psychiatrist, although he admitted that he was feeling a lot better and back on his medication.

The senior partner and Dr P met with Mr T to discuss his concerns. Dr P apologised to Mr T and stated that she should never have accepted his friend request. She told him that she had been concerned about him and had felt she had to contact his psychiatrist to try to access help for him.

Mr T accepted Dr P’s apology. He asked her to share the experience, anonymously, with her colleagues, so that they could all learn from this incident.

Ms J carried out her threat, alleging that Dr V’s clinical decision-making was unsound and also that she had been rude and abusive – in particular using racist terms to subdue Ms J. Ms J also alleged that Dr V spoke about her condition in a loud voice, which breached patient confidentiality.

The Medical Council concluded its investigation with no further action necessary. Dr V’s excellent record-keeping ensured a comprehensive account of her clinical decisions and this allegation was rebutted at an early stage.

Dr V had been accompanied by her assistant throughout her doctor’s round, and had also been observed at a distance by a member of the prison staff. Both were reliable witnesses and since no concerns were raised by them, Dr V was able to refute Ms J’s allegations of a confidentiality breach and Dr V’s abusive manner.

Learning points

Here the Medical Council was not concerned about the medical care provided, since Dr V had kept a comprehensive and contemporaneous clinical record, but by Dr V’s conduct. The allegations made, if proven, would be serious and might demonstrate impairment of Dr V’s fitness to practise. It should be remembered that the veracity of the allegations need only be demonstrated “on the balance of probabilities”.

In this situation the importance of a chaperone was paramount. Every patient must be afforded dignity and privacy, and this typically means offering a chaperone for an intimate examination. However, this is not the only time when a chaperone should, or can, be offered. It should be remembered that a chaperone also protects the doctor from unfounded allegations, as demonstrated in this case, and if the patient refuses the presence of a chaperone then you may wish to defer the examination or refer the patient on to a colleague who would be willing to conduct the examination, so long as there is not unreasonable delay and the clinical situation does not demand urgent assessment.

Confidentiality

GP Dr W was visited by 50-year-old patient Mrs B with a history of drug dependency, alongside her daughter V. During the consultation, Dr W inadvertently made reference to the fact that Mrs B was HIV positive; V was not aware of this. Dr W immediately apologised for this disclosure. He wrote to Mrs B that evening acknowledging the breach of confidentiality and again apologising for it.

Mrs B was very angry and complained to the Medical Council, forwarding Dr W’s letter, making reference to other concerns about the care she had received. The Medical Council wrote to Dr W indicating that they would not be investigating the matter, but asking him to provide details of his employers.

Learning points

Dr W should not have assumed that the daughter was aware of her mother’s HIV status. At the start of the consultation he should have asked Mrs B whether she was happy for her daughter to stay and should not have mentioned anything the patient or daughter had not brought up themselves. If it had been necessary to mention Mrs B’s HIV status he should have asked the daughter to leave as he had a potentially sensitive matter to explore with her mother.

Capacity

Mrs G, an elderly patient with type 2 diabetes, respiratory disease and dementia, fell during the night in the care home where she lived. Her care home called an ambulance immediately as Mrs G was in a lot of pain and was distressed by the fall.

When Mrs G arrived at the hospital she was assessed by the staff in the Emergency Department and an X-ray revealed a fractured neck of femur. Mr L, an orthopaedic surgeon, examined her, and was of the opinion that Mrs G needed surgery. Mrs G was distressed and confused, and Mr L believed that she lacked capacity to consent to surgery. He attempted to contact her next of kin, but he was unable to do so as they were in Greece. As Mrs G lacked capacity to consent to the proposed treatment, Mr L was not sure how to proceed, so he called MPS.

Learning points

This query related to an incident in the United Kingdom; the Mental Capacity Act 2005 provides the legal framework for making decisions on behalf of adults who lack mental capacity to make decisions for themselves. Unless there is a personal welfare lasting power of attorney in place, no-one else can provide consent on behalf of another adult. In addition, the Court of Protection can settle disputes over the healthcare and treatment of a person lacking capacity. Any proposed treatment must be in the patient’s best interests.

Mr L was reminded of the factors to take into consideration when assessing mental capacity, as set out in the Mental Capacity Act. It should not be assumed that the patient lacks capacity simply because she has a diagnosis of dementia. In this instance, Mrs G’s immediate family were on holiday and were not contactable.

MPS advised Mr L to gather as much information as possible in order to arrive at a ‘best interests’ decision regarding further treatment if Mrs G was unlikely to regain the capacity to consent. The extent of Mr L’s enquiries depended on the urgency of the treatment. If the proposed treatment was non-urgent Mr L should continue to attempt to contact Mrs G’s family, and gather information from other sources (such as staff at the care home and the GP).

The member of staff who ultimately delivers the treatment is the decision maker, and assessments of capacity and best interests had to be carefully documented in Mrs G’s records.

Probity

Dr M was employed by a university to undertake a research project, which was funded by a charity, for two years. After his employment ended, the university’s faculty of medicine agreed that Dr M could continue aspects of his project work, supported by his grant; at the same time Dr M was also beginning specialty training in general medicine.

Dr M was eventually reported to the Medical Council, where a panel hearing assessed his fitness to practise. It was found that Dr M’s fitness to practise was severely impaired by his lack of honesty, integrity and probity – the basic attributes of being a good doctor. His attempts at deception and manipulation of colleagues exacerbated his original dishonest acts.

Dr M admitted to the charges but revealed that he had been under severe stress due to the recent death of his sister; further psychiatric examination led to Dr M being diagnosed with a major depressive disorder, which the Medical Council accepted as having contributed to his original actions.

The panel concluded that despite his mental health issues, Dr M’s conduct was unacceptable for a doctor and and brought the profession into disrepute, undermining public confidence in the profession. A three-year set of conditions was imposed on Dr M’s practice, including notifying the Medical Council of any post he accepted which required Medical Council registration; agreeing to the appointment of a workplace reporter, as approved by the Medical Council; and informing the Medical Council of any further formal disciplinary proceedings. Dr M was also placed under the supervision of a medical supervisor, nominated by the Medical Council.

Doctors are notoriously bad at looking after their own health. Stress and anxiety can affect a doctor’s ability to practise safely, and an impaired practitioner is a significant medicolegal risk. There are usually local support networks for doctors affected by mental health issues, and any concerns about your own health should be raised with senior colleagues. MPS also has a worldwide counselling service available to members.