Collateral damage
Post date: 04/01/2014 | Time to read article: 6 minsThe information within this article was correct at the time of publishing. Last updated 14/10/2021
The sooner you call MPS about an ethical or legal dilemma, the sooner the matter can be resolved. Professor Carol Seymour, Dr Tom Mosedale, Dr Richard Brittain and Sara Williams explore how and why Collateral-damage foundation doctors get into troubleCollateral-damage foundation doctors get into trouble
Collateral damage† is damage to people or property that is unintended or incidental to the intended outcome; in new doctor terms it could be the unintended harm to a patient, or poor communication that leads to a complaint. The collateral damage around such factors can be mitigated the sooner advice is sought.
We all worry about making mistakes, harming patients, disagreeing with our consultants or being summoned to the GMC – these are not part of the routine curriculum taught in medical school. It is reassuring to know that when things do go wrong during our foundation years, MPS can be a valuable source of support, while also providing advice and educational material to prevent medicolegal problems later on.
Why call MPS?
In 2010 and 2011 MPS’s medicolegal helpline received 820 calls from foundation doctors. Figure 1 (below) reveals the top calls that were received, excluding general advice (273 calls). The most common queries will now be discussed followed by advice on how to handle them.
Inquests and fatal accident inquiries
One in five calls to MPS from foundation doctors was to receive advice on inquests or fatal accident inquiries.
"One in five calls to MPS from foundation doctors was to receive advice on inquests or fatal accident inquiries"
A case will be referred to a coroner in certain circumstances, eg, when a patient may have died from a medical intervention or the cause of death is unknown. A coroner will also make inquiries about when the death of a patient occurs within 24 hours of a hospital admission or a surgical procedure. You must assist the coroner with their investigation, the purpose of which is a fact finding exercise to determine who died, when, where, and how and in what circumstances.
MPS can support by advising on draft reports, which could also later be reviewed by an appointed educational/clinical supervisor. As foundation doctors will be looking after NHS patients, the legal services department of your trust will be able to provide legal advice and support and, if appropriate, will assist you at the inquest or fatal accident inquiry.
However, if there is a conflict of interest between a foundation doctor and the trust, MPS may assist by providing legal representation.
Complaints
The second most common call relates to complaints. Receiving a complaint from a patient or family member is stressful, particularly for a new doctor, who lacks experience in dealing with them.
As a foundation doctor, the most effective way to deal with a complaint is to acknowledge it, and direct the patient or relative to PALS (Patient Advice and Liaison Services).
The next step is to discuss the complaint with your educational supervisor. It is worth making your own personal notes, in case you need to refer back to them at a later stage. Foundation doctors may be asked to provide a statement of their involvement with a patient, when a trust is investigating a complaint.
MPS can address any concerns you have regarding a complaint and can advise on your statement before you submit it to the trust.
Figure 1 - Main reason for call |
Total calls 2010/11 |
% of calls |
| Inquest/fatal accident inquiry | 106 | 19.4% |
| Complaint | 70 | 12.8% |
| GMC | 60 | 10.9% |
| Writing a report | 51 | 9.3% |
| Employment matter | 49 | 8.9% |
| Adverse incident report | 37 | 6.8% |
| Disciplinary matter/NCAS | 29 | 5.3% |
| Criminal investigation into member’s actions | 26 | 4.8% |
| Confidentiality | 24 | 4.4% |
| Clinical judgment | 23 | 4.2% |
| Membership enquiry | 18 | 3.3% |
| Hospital inquiry | 15 | 2.7% |
| Consent | 14 | 2.6% |
| Disclosure/access to clinical records | 13 | 2.4% |
| Ethics | 8 | 1.5% |
| Claim for compensation | 3 | 0.5% |
| Business matter/fees | 1 | 0.2% |
| Total | 532 | 100 |
GMC
The thought of being investigated by the GMC so early in your career is frightening, but it does occasionally happen. Figure 1 (above) reveals that many foundation doctors call MPS regarding their fitness to practise, eg, medical council and disciplinary matters and criminal investigations.
The GMC will investigate a doctor’s fitness to practise if there are concerns about professional misconduct, poor performance, criminal convictions (or caution), or physical/mental ill health. Outcomes of such investigations may include no further action, a warning, practice restrictions, suspension, or erasure from the medical register.
MPS often takes calls from foundation doctors after the GMC has alerted them that they are under investigation. In many cases this is because they have failed to report a caution or a conviction, eg, driving or alcohol related offences. Any conviction or caution must be reported to the GMC without delay.
"The thought of being investigated by the GMC so early in your career is frightening, but it does occasionally happen"
Top three comedy calls
- “I’ve just burnt the mess carpet!”
- “The library has issued me with a massive fine – can I fight it?”
- “Can we hire strippers for the rugby AGM?”
Writing reports
One in ten calls was about writing reports. An adverse incident can be investigated in many different ways – your written report may be the starting point of an investigation into the circumstances leading to or surrounding an incident.
Above all else your report should be based on your recollection of events, the medical records and your usual practice.
"Your report should be based on your recollection of events, the medical records and your usual practice"
Employment and training issues
Advice on what to do after a dispute arises in the workplace is a common reason why foundation doctors contact MPS. These include disputes over contracts, salary and banding.
Detailed advice regarding this is outside the scope of the benefits of MPS membership, except if it is referred by a fitness to practise committee. The BMA website is the best source of support regarding these issues.
Confidentiality
Many doctors contact MPS for advice around confidentiality, eg, raising concerns about a patient, whistleblowing, etc. MPS can advise on medicolegal issues, but cannot give clinical advice. Visit the MPS website for a wealth of factsheets on common medicolegal issues and concepts.
Case study
Dr J is midway through his foundation year two placement working in general practice. The practice is small and there is only one GP principal Dr M, who is also the F2 supervisor.
"Mr Z asks Dr J not to document the paracetamol overdose, or to discuss the management of his case with Dr M"
One morning Dr J sees Mr Z, a 50-year-old patient with back problems; he requires referral to an orthopaedic specialist. Mr Z tells Dr J that he takes a lot of codeine. Dr J is concerned that Mr Z is in danger of becoming dependent on it; she tries to persuade him to take paracetamol instead. Mr Z refuses and says he won’t take paracetamol because 30 years ago he had a massive overdose.
Dr J explores Mr Z’s medical records, but there is no evidence of the overdose. Midway through the consultation, Dr M pops his head round the door to advise on the referral.
When he leaves, Mr Z asks Dr J not to document the paracetamol overdose, or to discuss the management of his case with Dr M. Dr J responds by stating that the GMC requires her to write notes of all the relevant factors, and this is relevant. She also states that she is working under supervision and will need input from Dr M.
Mr Z gets aggressive and intimidates Dr J into not recording the historical overdose. The consultation ends on a bad note as Mr Z storms out. Dr J contacts MPS for medicolegal advice on the situation.
MPS advice, by Dr Angelique Mastihi
Situations such as these can be very difficult, particularly as a junior doctor. Unfortunately, patients do on occasions provide information to doctors, which they then ask is not recorded. Dr J’s initial stance was the correct one; it is not possible to ignore information. Any relevant information that the patient provides during the consultation should be recorded contemporaneously. See GMC, Good Medical Practice, paragraph 3(f).
The practice may wish to consider how it publicises the fact that some of the doctors are in training and therefore may need to discuss patient care with the supervising doctor.
If a patient makes it clear that they are not happy for their medical information to be shared within the wider team, the doctor must consider whether that disclosure is essential for the provision of safe care. See GMC, Confidentiality, paragraph 27.
"Dr J’s initial stance was the correct one; it is not possible to ignore information"
Summary
Doctors in their foundation years will confront difficulties and it is reassuring that organisations exist to provide support and expert advice.
Further information can be found in your Preparing for your F1 Post guide, an 80-page handbook exploring the key medicolegal concepts you need to be aware of. If you would like a copy please contact [email protected].
Professor Carol Seymour is an MPS medicolegal adviser, Dr Mosedale is an F1 doctor and Dr Brittain is a medicolegal researcher at MPS. With thanks to Liz Oxford for her help with this feature.
Reference
† The headline refers to the 2002 action film Collateral Damage. This is not a bona fide medicolegal term.
