Dr Rob Hendry - Medical Protection Society

VOLUME 19 | ISSUE 1 | JANUARY 2011 

UNITED KINGDOM 

YOUR LEADING MEDICOLEGAL JOURNAL 

On the 

defensive 

DOES THE THREAT OF LITIGATION 

INFLUENCE YOUR PRACTICE? 

PAGE 8 

A potted history of medicine 

THE 1800s – A TIME OF MEDICOLEGAL MAYHEM 

Sympathy in the surgery 

HOW FAR IS TOO FAR? 

Membership Governance 

INTRODUCING EXTRA SUPPORT AS PART OF MPS MEMBERSHIP 

MEDICAL PROTECTION SOCIETY 

PROFESSIONAL SUPPORT AND EXPERT ADVICE 

CASE 

REPORTS 

PAGE 16 

www.mps.org.uk

MeDical protection society 

EdUcatIon and rIsK managEmEnt 

reduce your risk of 

complaints and litigation 

mPs’s communication and interpersonal skills workshops 

Mastering your risk 

Provides practical tools, tips and strategies to improve 

communication behaviour and effectively manage patient 

expectations. 

Mastering adverse outcomes 

covers the effective and ethical management of patient 

care following an adverse outcome. 

Mastering professional interactions 

Examines inter-professional communication breakdown 

between doctors, one of the commonest causes of 

patient harm. 

“Excellent – a must for all doctors from all medical 

backgrounds.” 

“Increased awareness of how to decrease risks and 

improve consultations with patients.” 

Dates, locations and booking information: 

Features of the workshops: 

■ designed and facilitated by 

medical professionals 

■ cPd approved 

■ Highly interactive three hour 

workshops with group discussions 

and activities 

cost: 

mPs members – Free oF cHarGe 

(benefit of membership) 

non members – £150 inclusive of Vat 

places are limited so 

book now! 

We are running workshops in various locations throughout the UK and Ireland. For more information about dates, locations 

and to book your place, visit www.mps.org.uk/workshops or call us on +44 (0) 113 241 0696. 

see overleaf for full workshop outlines ›››

ON THE COVER 

8 On the defensive 

When you are preoccupied with the threat of 

litigation, you may start to practise defensively, 

says Sara Williams. 

7 A potted history of medicine 

Sarah Whitehouse trawls the medicolegal 

archives for some historical horror stories. 

12 Sympathy in the surgery 

Is crying in front of your patients ever acceptable? 

Sarah Whitehouse finds out. 

15 Membership Governance 

Dr Peter Mackenzie, MPS Head of Membership 

Governance, explains the support on offer to 

those members that need it most. 

ALSO THIS ISSUE 

4 Your MPS 

In addition to MPS Medical Director Dr Priya 

Singh’s regular column, you can also read about 

the latest offerings from Educational Services and 

find out what MPS has been up to in YOUR part 

of the world. 

6 Headlines and deadlines 

The latest news on legislation, events and open 

consultations in the UK. 

16 On the case 

Dr Rob Hendry, MPS Head of Medical Services 

(Edinburgh), introduces this issue’s selection of 

case reports. 

17 Case reports 

17 Missed opportunities 

18 Heart of the matter 

19 To operate or not to operate? 

20 Cuts and bruises 

21 Repeat offender 

22 Inappropriate delegation 

23 A pain in the buttock 

24 Over to you 

A sounding board for you, the reader – what did 

you think about the last issue of Casebook? All 

comments and suggestions welcome. 

26 Book reviews 

This issue, freelance journalist Sian Barton 

reviews Sick Notes, while Dr June Tay tells us all 

about Direct Red: A Surgeon’s Story. 

GET THE MOST 

FROM YOUR 

MEMBERSHIP 

Visit our website for further 

Casebook issues, a wealth 

of publications, news, events 

and other information: 

www.mps.org.uk 

�� 

Follow our timely tweets at: 

www.twitter.com/MPSdoctors 

Opinions expressed herein are those of the authors. Pictures 

should not be relied upon as accurate representations of clinical 

situations. © The Medical Protection Society Limited 2011. All 

rights are reserved. 

ISSN 1366 4409 

5 

18 

20 

23 

Casebook is designed and produced three times a year by the 

Communications Department of the Medical Protection Society 

(MPS). Regional editions of each issue are mailed to all MPS 

members worldwide. 

GLOBE (logo) (series of 6)® is a registered UK trade mark in the 

name of The Medical Protection Society Limited. 

MPS is not an insurance company. All the benefits of membership 

of MPS are discretionary, as set out in the Memorandum and 

Articles of Association. 

Cover: © FOTOCROMO/iStockphoto.com 

Welcome 

Dr Stephanie Bown – Editor-in-chief 

MPS Director of Policy and Communications 

I am very pleased to welcome you to 

your new-look Casebook. 

All the usual sections and content are 

still there but we took the opportunity 

to bring the look and feel more upto-date 

with modern journals and 

magazines. We hope you find the 

layout attractive and refreshing, as 

well as easier to navigate. 

As you know, MPS is a mutual 

organisation and and we are committed 

to giving you the very best in advice 

and support. The redesign of Casebook 

reflects this commitment – it has been 

redesigned with you, our members, in 

mind, and demonstrates that we are 

constantly striving to find new ways to 

improve our level of support to you. 

We are proud to be an international 

organisation, albeit with a UK head 

office, and see Casebook as an 

important route for ensuring that local 

voices are aired and heard, and that 

local issues are covered. The redesign 

allows for each regional edition – Ireland, 

South Africa, the UK, Asia, New Zealand 

and the Caribbean and Bermuda – to 

be a bespoke version that has received 

dedicated care to make it more relevant 

to the issues that you face. 

We recognise that every member of 

MPS is an individual with different 

needs and interests, and is of equal 

importance in a mutual organisation. 

It is this approach that ensures our 

various editions of Casebook are as 

unique as can be. This is demonstrated 

in this issue, in the article that caters 

for those members who can benefit 

from extra support in their practice. 

“Introducing…Membership Governance” 

is on page 15. 

I do hope you find this first edition 

of the new Casebook an informative 

and entertaining read. If you have any 

comments or suggestions on the new 

layout, please do let us know. 

3 

EDITORIAL 

UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk

4 

MPS UPDATE 

UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk 

CONTRIBUTORS 

Dr Stephanie Bown 

Editor-in-chief 

Gareth Gillespie 

Editor 

Sara Williams 

Assistant editor and senior writer 

Sarah Whitehouse 

Assistant editor and writer 

Dr Monica Lalanda 

Medical writer 

EDITORIAL BOARD 

Dr Tina Ambury, Dr David Delvin, Dr Lyn Griffiths, 

Dr John Lourie, Dr Sonya McCullough, Dr Jayne 

Molodynski, Rachel Morris, Dr Amanda Platts, 

Dr Frank Rugman 

LAYOUT BOARD 

Dr Nick Clements, David Croser, Dr Marika 

Davies, Dr Lyn Griffiths, Dr Tim Hegan, Dr Graham 

Howarth, Dr Su Jones, Dr Ming-Keng Teoh 

PRODUCTION 

Production manager – Philip Walker 

Design – Jayne Perfect 

Print: 

United Kingdom – TU Ink 

Ireland – TU Ink 

Caribbean – TU Ink 

New Zealand – Southern Colour 

Africa – HMPG 

Asia – Sampoorna 

CASE REPORT WRITERS 

Dr Sara Chambers 

Freelance GP 

Portsmouth 

Dr Anna Fox 

Salaried GP 

Leeds 

Dr Sean Kavanagh 

Freelance author and former 

physician, Yorkshire 

Dr Sabreena Malik 

Dr Gerard McKeague 

GP partner 

Belfast 

Dr Mareeni Raymond 

Academic ST4 GP 

North London 

Dr Zoe Schaedel 

PLEASE ADDRESS CORRESPONDENCE TO 

Casebook Editor, Medical Protection Society, 

Granary Wharf House, Leeds LS11 5PY, UK. 

casebook@mps.org.uk 

Thinking clearly 

MPS Medical Director Dr Priya Singh asks 

if we take our cognitive ability for granted 

Delivering medical care involves highlytrained 

professionals working in high risk 

environments, with dynamic conditions 

and time and workload pressures. We 

are expected, as individuals and as 

teams, to have situational awareness, so 

that we have the capacity to anticipate 

and to perform. 

Our clinical skills are best 

complemented by a range of nontechnical 

skills, with cognition an 

obvious essential. For communication 

to be effective we need to be in a 

position to be receptive – to our patient, 

to our environment and to our own 

thoughts and emotions. Anything that 

gives rise to distraction or negative 

emotion can impair our cognitive 

function, so creating a risk to the 

delivery of safe care. 

Given that so much of patient care is 

delivered by teams, poor communication 

has a significant impact on performance 

and clinical outcomes. So how can we 

protect our own, and others’, cognitive 

function? Largely by a combination of 

consideration and awareness. While 

sometimes a real challenge, it is always 

hugely rewarding – not least for our 

patient – when achieved. 

When leading teams, those who 

surround themselves with colleagues 

or advisers – who reduce or filter their 

situational awareness – run the risk 

of making flawed decisions. Beware 

“group think” – faulty decisions made 

because group pressures lead to a 

deterioration of mental efficiency, reality 

testing and, sometimes, moral judgment. 

If everyone in the team feels able to 

raise issues, confident that they will be 

heard rather than judged or dismissed, 

we are all more likely to think clearly and 

to see risks being identified and managed. 

Education update: 

The importance of good communication 

In a world of constant, instant 

communications it is surprising 

how frequently breakdowns in 

communication occur. Many will be minor 

misunderstandings, but some can have a 

devastating impact on the people involved. 

The importance of good communication 

is evident in studies that show that up 

to 70% of litigation is related to poor 

communication, where the patient 

often feels that they have lacked 

information or been misunderstood. 

Communication behaviour and 

performance are major contributing factors 

in many adverse patient outcomes, patient 

complaints and dissatisfaction, and claims 

against healthcare professionals. The 

good news is that if you can improve your 

communication skills, then research shows 

that you are likely to reduce your risk. 

Because MPS strongly believes in the 

value of education and risk management, 

we have developed a range of risk 

management workshops that will assist 

healthcare professionals in developing 

their communication skills, reducing their 

exposure to complaints and litigation. 

These workshops draw upon more 

than 100 years’ experience and expertise 

in helping doctors and other healthcare 

professionals with ethical and legal dilemmas 

that arise from their clinical practice, and to 

date they have been attended by more than 

10,000 healthcare professionals worldwide. 

The workshops form a significant 

part of an expanding portfolio of 

educational programmes for healthcare 

professionals. To get more information 

on the educational resources available to 

you, visit: www.medicalprotection.org. 

Visit www.medicalprotection.org/uk/education for 

details of MPS events, courses and workshops in your area 

© Brand X Pictures

EVENT FOCUS: SOUTH AFRICA Doctors of all levels and specialties were invited to attend MPS’s 

third annual “Ethics 4 All” seminar, in Cape Town, South Africa on 

3 November 2010. 

The seminar, which was chaired by MPS medicolegal consultant 

Dr Tony Behrman, was attended by 1,500 MPS members – the 

MPS 

Ethics 4 All 

MALAYSIA 

MPS supported the Medicolegal Society of Malaysia at their October conference 

on Managing Medicolegal and Medical Ethics Events and Disputes – The 

Current Challenges. MPS helped to promote the event and provided two 

speakers: Dr Stephanie Bown, MPS Director of Policy and Communications, and 

Dr Peter Loke, MPS Educational Services Faculty Member from Singapore. 

IRELAND 

MPS's first Making the Most of Your Consultant 

Post conference for Ireland was held at the Royal 

College of Physicians, Dublin, on 12 November 2010 

CARIBBEAN 

AND BERMUDA 

Dr Nancy Boodhoo, MPS 

Director of Operations in the 

West Indies, visited the region 

with regional membership coordinator 

Al Neaber. Dr Boodhoo 

and Mr Neaber delivered 

medicolegal presentations and 

met with other key medical 

and legal figures across the 

Caribbean region. 

SOUTH AFRICA 

The annual MPS Ethics for All lecture evening took 

place at the Cape Town International Convention 

Centre on Wednesday 3 November 2010. (See 

more details above.) 

largest gathering of MPS members to date. 

The three-hour programme featured a discussion from Trevor 

Dale – co-founder of Atrainability and expert in human factors in 

healthcare – on proven tools for reducing risk and maintaining 

the highest levels of patient safety. Esmé Prins then offered an 

insight on how the Consumer Protection Act and the Protection of 

Personal Information Bill will affect medical practice in South Africa. 

MPS Chief Executive Tony Mason also addressed delegates 

with an update on indemnity regulations. The “Ethics 4 All” seminar 

was set up in 2008 to help doctors earn annual CPD points. 

We anticipate that there will be similar events in November 2011 

in both Gauteng and Cape Town. 

NEW ZEALAND 

MPS near you… 

HONG KONG 

MPS and the Hong Kong Medical Association 

(HKMA) have launched a training course for 

medical experts in Hong Kong. Fifty medical 

professionals attended the inaugural course 

in September, designed to highlight the duties 

and responsibilities of doctors who act as 

medical experts in medical negligence claims. 

SINGAPORE 

MPS’s Head of Medical 

Services (Asia) Dr Ming- 

Keng Teoh and medicolegal 

adviser Dr Janet Page toured 

Singapore’s Formula One 

medical facilities, race track 

and control rooms. Dr Teoh 

and Dr Page observed crash 

extrication exercises by 

medical and support teams. 

John Tiernan, Director of MPS Educational Services, visited MPS 

offices to discuss priority events for 2011. John received a full briefing 

from MPS’s local medicolegal team on the defining features of New 

Zealand’s medicolegal system. 

5 

MPS UPDATE 


6 

HEADLINES AND DEADLINES 


NHS awaits changes to 

NEWS IN BRIEF 

Constitution on reporting concerns Health Bill scrutinised 

Changes to the NHS Constitution and its 

Handbook are imminent following the closure 

of a consultation, which set about tackling 

the “fear and secrecy” inherent in the NHS. 

The amendments will tighten the system to 

ensure that all NHS staff can report concerns 

freely when concerned about threats to 

patient safety. 

The move was instigated by the health 

secretary Andrew Lansley to prevent isolated 

failures such as those investigated at Mid- 

Staffordshire NHS Foundation Trust. 

He said: “The NHS Constitution must be 

brought up to date to enshrine the rights 

of staff. Staff should be working in an 

environment where they feel able to voice 

“The prevailing presumption was one 

of safety rather than of risk,” said 

Professor Bren Neale, describing 

the tragic death of her husband 

Dr John Hubley at an Independent 

Sector Treatment Centre in 2007. 

Professor Neale was sharing her 

experiences of clinical negligence at a 

unique conference called Risky Business, 

organised by Dr Allan Goldman from 

Great Ormond Street Hospital and a 

team of international safety experts. 

The conference provides a forum for 

health professionals to explore risk by 

learning lessons from the successes 

and failures of those working in 

different industries and walks of life. 

A study conducted in the Netherlands 

has found that the use of a surgical 

safety checklist significantly reduces 

surgical morbidity and mortality. 

The study, published in the New 

England Journal of Medicine (NEJM) on 

10 November, says that the World Health 

Organisation (WHO) Surgical Safety 

Checklist reduced surgery complications by 

more than a third, with deaths reduced by 

concerns and know that their concerns will 

be taken seriously. Staff will be expected to 

raise concerns and employers must support 

them and investigate where necessary. That 

means better patient care and better 

staff morale.” 

This consultation follows significant 

progress already made on whistleblowing. 

On 25 June 2010 new guidance was 

published for the NHS, developed through 

the Social Partnership Forum (SPF) with 

support from the independent whistleblowing 

charity Public Concern 

at Work. Access this guidance at: 

www.dh.gov.uk/en/ 

Publicationsandstatistics/Publications 

EVENT FOCUS: Risky Business 2010 

One may ask what lessons could 

be learned from F1 team Principal 

Ross Brawn, or Dean Richards, former 

director of Harlequins rugby team? But 

both presenters delivered hard-hitting 

messages about teamwork – give 

individuals what they need to be the 

best – and making mistakes – hold 

your hands up if you make a mistake. 

Other highlights included a debate on 

whether litigation improves patient safety, 

and a session learning from defining 

moments such as the 7/7 bombings 

and the BP Deepwater Horizon. 

A recorded live stream of the 

conference is available at 

www.risky-business.com. 

Surgical checklist saves lives 

NICE GUIDANCE WATCH 

This is a selection of the 

guidance NICE is expected 

to publish over the next 

few months, although 

publication dates may be 

subject to change. 

almost half. The study was conducted 

from October 2007 to March 2009. 

The NPSA has led on the checklist’s 

implementation in England and Wales. Dr 

Suzette Woodward, Director of Patient 

Safety at the NPSA, said: “The Netherlands 

study clearly validates what we know 

about the use of a surgical safety 

checklist, that it significantly reduces 

surgical morbidity and mortality.” 

in Parliament 

January Aripiprazole for the treatment of schizophrenia in people aged 15-17 

The Health Bill will begin 

to pass its way through 

Parliament this year. The 

Bill, published late last 

year following a lengthy 

consultation on the 

proposals, sets out the 

biggest change to the NHS in 

decades. The BMA estimates 

that the Bill will become 

an Act by July this year. 

GMC due to publish 

audiovisual guidance 

The GMC is due to update its 

guidance on using audio and 

visual recordings of patients. 

To access the updated 

guidance when it becomes 

available, visit www.gmc-uk. 

org/guidance/index.asp 

Watch out for 

■ May – GMC fitness to 

practise stats published 

Changes for NICE 

The Department of Health has 

announced some changes to 

the role of NICE in assessing 

new medications for the UK. 

From 2014, a valuebased 

pricing system will 

replace NICE’s binding 

“recommends” or “does 

not recommend” notice 

to the NHS, although 

NICE will continue to 

appraise new drugs. 

This system means it is 

likely that the government 

will negotiate directly with the 

pharmaceutical industry on 

price, after receiving NICE’s 

assessment. Health minister 

Lord Howe, who announced 

the changes, stressed the 

ongoing importance of NICE. 

February A clinical guideline on alcohol use disorders: management of alcohol dependence 

The diagnosis and assessment of food allergy in children and young people in primary care 

and community settings 

March Golimumab for the treatment of rheumatoid arthritis (after failure of previous antirheumatic drugs) 

Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's 

disease. This is a review of existing NICE guidance 

April First ever national guidelines on the recognition and initial management of ovarian cancer

Images courtesy of The National Archives & Wikipedia Commons 

A potted 

history of medicine 

Throughout history, doctors have treated patients, and 

doctors have made mistakes. Casebook has delved deep 

into the past to see what doctors used to get away with 

These cases are based on 

publications within the 19th 

Century Poor Law Union and 

Workhouse Records and the Royal 

Navy Medical Officer’s Journals – 

recently opened by the National 

Archives in the United Kingdom. 

Acid attack – a case of 

vicarious liability? 

Thomas S Fletcher was a surgeon 

at the Bromsgrove Workhouse, 

Worcestershire. One of his patients, 

young Henry Cartwright, died in 1842 

after being immersed in potassium 

sulphate – in an attempt to cure “the 

itch”, or scabies. The postmortem 

result described how his skin was 

inflamed and scalded. 

Dr Fletcher was found to have failed 

to supervise nurse Sarah Chambers, 

who placed the young boy in the 

acid. Was Dr Fletcher vicariously 

liable? Although the incident was 

investigated, Dr Fletcher was not 

struck off, owing to his “previous 

unblemished professional record, and 

kind attention to pauper patients”. 

Letter from Ralph Docker, Coroner for Worcestershire to 

the Poor Law Commission, 17 February 1842. National 

Archives: Ref MH 12/13905/153. 

Laudanum overdose – learning 

from adverse events 

Mrs Elizabeth Galloway of Newcastle 

was suffering from inflammation of the 

bowels. To aid her recovery, she was 

given a tincture of rhubarb, which was 

collected from the druggist, Mr Tinn, 

by her young daughter. Unfortunately, 

the druggist mixed up the wrong 

remedy; the cup contained laudanum 

rather than rhubarb. Mrs Galloway 

immediately worsened and the 

doctor was called. Her stomach was 

pumped, first with a mixture of brandy 

and ammonia, followed by water and 

strong coffee, but she later died. 

At the ensuing inquest, Mr Tinn 

was found to have administered the 

drug in an act of human error: “One 

of those mistakes to which all men 

were liable, however much they were 

to be deplored.” In an early example 

of learning from adverse events, 

the inquest recommended that in 

future, druggists should store poison 

separately from other medicines. 

BMJ Archives: Death from Laudanum: Given by Mistake, 

Prov Med Surg J, 1-1:334-335 (1841) 

Deadly nightshade 

In a similar case, Mary Ramshaw, 

from Northallerton, was knocked 

down and severely fractured her 

thigh. Dr Lumley was called, and 

prescribed both a mixture to take 

and an embrocation. Mrs Ramshaw’s 

daughter unfortunately administered 

the medicine from the wrong bottle 

and Mrs Ramshaw instantly began to 

convulse. Ten minutes later, she died. 

The embrocation she had accidentally 

been given contained belladonna 

(deadly nightshade). The inquest 

heard how Dr Lumley did not place 

any labels on the bottle to warn of its 

poisonous nature. The jury recorded 

in their verdict that “the medical 

attendant was not free of blame in the 

matter”, and stressed the importance 

of dispensing poisonous mixtures in 

roughened or fluted bottles, as well as 

ensuring appropriate labelling in future. 

BMJ Archives: Fatal Mistakes in Taking Medicine, 2:1120- 

1132 (1885) 

Under the influence 

A woman died following childbirth in 

1839. The postmortem revealed that 

the fatal injuries were caused by the 

unskilled use of “some instrument” 

during delivery. The surgeon was 

thought to have been intoxicated during 

the delivery and was charged with 

manslaughter – but was later acquitted. 

The Times, 12 April 1839. Ferner RE, McDowell S, 

Doctors charged with manslaughter in the course of 

medical practice, 1795-2005, Journal of the Royal 

Society of Medicine, Vol.99 (2006). 

Errors in time 

Medical negligence has been 

described as “a space, more than a 

thing” – a shifting, malleable interaction 

between time and place and, to 

varying degrees, society, law, ethics, 

medical practice, health professionals, 

and patients. 1 What is perhaps most 

interesting about the extracts from the 

medical archives is that the definition 

of medical negligence hasn’t shifted all 

that much. 

While the prescribed treatments 

and remedies mentioned may be 

different, the same high expectations 

of professional conduct, skill and 

integrity from doctors remain. Some of 

the issues are strikingly contemporary: 

vicarious liability, prescribing errors, 

significant event audits following adverse 

events, professional misconduct and, of 

course, human error. 

1 Price, K, Towards a history of medical negligence, 

The Lancet, 375:9710, 192-193 (2010). 

Compiled by Sarah Whitehouse 

7 

ARTICLE 


8 

SPECIAL FEATURE 


On the 

defensive 

Many doctors have an inflated perception of the risk 

of being sued, so practise with a dagger at their back. 

Sara Williams asks: are they missing the point? 

A 

US student went to her local 

emergency department 

suffering from stomach pains. A 

computed tomography scan revealed 

an ovarian cyst; she then presented 

her father with an $8,500 bill. Her 

father, a medical director, argued that 

a history, a pelvic examination and an 

ultrasound would have been adequate. 1 

The hospital defended the CAT 

scan claiming that an ultrasound may 

have missed something more serious, 

such as appendicitis or a kidney 

stone. Although her father agreed, 

he argued that the hospital should 

have started with the ultrasound 

and undertaken the CAT scan only 

if necessary. He then contacted the 

national media, accusing the hospital 

of performing defensive medicine. 

Do you order every test on every 

patient? Do you avoid certain 

procedures for fear of being sued 

over a clinical stumble? Do you 

refer every patient with a cough? 

If you answered “yes” to all of these, 

you are practising defensive medicine. 

As global medicine has become more 

litigious, such performance patterns 

are becoming more widespread. This 

“retrospectoscope” phenomenon not 

only draws attention away from good 

clinical diagnosis, in favour of tick-box 

medicine, but it could put patients 

at risk through risky procedures by 

medicalising the well patient. 2 

WHY DO DOCTORS 

PRACTISE DEFENSIVELY? 

Media scrutiny 

A Casebook survey (see page 9 for 

more information) revealed that 70% 

of MPS members identified media 

criticism of health professionals as a 

contributing factor to them practising 

defensively. In countries such as 

Singapore and Hong Kong, the press 

are very aggressive and critical of 

doctors. As most of the work is private 

practice, such criticism could affect 

their reputation and thus their income. 

Non-monetary cost of litigation 

The personal impact of litigation, such 

as the value of lost time, emotional 

energy and reputational damage, is 

often perceived to be more costly 

than the cost of taking precautions. 3 

Hero complex 

If a doctor ordered a significant 

number of tests, where the prevalence 

of disease was low, they would 

occasionally pick up on early-stage 

malignancies and other pathologies, 

earning them a reputation as a great 

doctor or a “hero” to patients. 

Societal expectations 

Speaking last year at a patient safety 

conference, internationally-renowned FOTOCROMO/iStockphoto.com

WHAT IS IT? 

Defensive medicine is commonly defined as the ordering 

of tests, treatments, etc, to help protect the doctor rather 

than to further the patient’s diagnosis. Although this is 

not “unnecessary care”, defensive medicine offers more 

economic and psychological benefit to the doctor than 

to the patient. 4 Dr David Studdert identified two types of 

defensive medicine: 

Assurance behaviour (positive defensive medicine) 

Many doctors describe 

litigation as a dagger 

at their back. However, 

it is good evidencebased 

practice, not 

defensive practice, that 

will deflect the blade 

psychologist Professor James Reason 

said that the worm at the heart of the 

medical system was that it was predicated 

on the belief in “trained perfectability”, 

where doctors are expected to get 

it right, and if they don’t we “name, 

shame, blame and retrain” them. 

Lawyer phobia 

According to leading psychiatrist Dr 

Tellefsen, who argues that more doctors 

practise defensively because they fear 

being sued, an anticipatory attitude could 

lead to avoidance and overcompensation. 6 

“Just in case” 

A male Emergency Department 

(ED) registrar, who wishes to remain 

anonymous, says that many junior 

doctors request “pointless” blood tests 

“just in case”, which creates more 

problems, such as investigating a test 

that is not needed. This suggests that 

poor clinical knowledge or lack of 

experience drives defensive medicine. 

Colleagues’ expectations 

According to the same registrar, in ED 

lots of tests are done because they are 

expected by other specialties, but are 

not necessary, eg, ordering a chest x-ray 

for someone who has angina, or testing 

the blood of a child with a broken arm, in 

case the surgeon asked for the results, 

even though this is not evidence-based. 

HOW PREVALENT IS IT? 

What is defensive medicine to one 

person may be high quality care to 

another. 7 An international Casebook 

survey (see Box A overleaf) asked 

more than 3,000 MPS members from 

seven countries whether they practised 

defensively to avoid complaints and 

claims. The key findings were: 

■ 73% said they practised defensively 

to avoid complaints and claims 

■ 77% said they practised more 

defensively now than in the past 

■ 78% noticed their colleagues practising 

defensively, eg, ordering more tests 

than were medically necessary. 

The survey attempted to find out how 

this translated into clinical practice, 

and identify what practices doctors 

– providing services of no medical value with the aim 

of reducing adverse outcomes, or persuading the legal 

system that the standard of care was met, eg, ordering 

tests, referring patients, increased follow up, prescribing 

unnecessary drugs. 

Avoidance behaviour (negative defensive medicine) 

– reflects doctors’ attempts to distance themselves from 

sources of legal risk, eg, forgoing invasive procedures, 

removing high-risk patients from lists. 5 

were adopting to avoid complaints 

and claims. These statistics show: 

■ 41% had chosen to stop 

dealing with certain conditions/ 

performing specific procedures to 

avoid complaints and claims 

■ 37% changed prescribing habits 

■ 61% conducted more investigations. 

However, not all examples of defensive 

medicine can be considered negative. 

The following statistics demonstrate 

“positive” defensive medicine: 

■ 54% referred more patients 

for a second opinion 

■ 76% were more careful to ensure 

follow-up arrangements were in place 

■ 83% kept more detailed records. 

The results suggested that female doctors 

were more cautious than their male 

colleagues, as women referred more 

patients for a second opinion, kept more 

detailed records and were more careful to 

follow up than their male counterparts. 

The results also indicated that male 

doctors practise more negative defensive 

medicine, compared to female doctors. 

They conducted more investigations 

and had a lower threshold for removing 

patients from lists, and more of them 

chose to stop dealing with certain 

procedures than their female colleagues. 

Other surveys and reports suggest 

that defensive medicine is a prevailing 

aspect of healthcare. According to Kessler 

it might add as much as 5% to 9% to 

overall health costs in some countries. 8 A 

widely-used example of defensive practice 

is the dramatic increase in caesarean 

sections, which have more than doubled 

in the UK over the last 20 years. A UK 

study explored the view of 151 clinical 

directors about why this was the case. 

One of the top three reasons given was the 

fear of litigation. Three in five respondents 

thought the local rate was too high. 9 

Last year, an American study looked 

at the issue of overtesting in late-stage 

cancer for the first time; it raised questions 

about overtreatment in healthcare. It 

identified a “culture of screening on 

autopilot”, where cancer patients with 

advanced cancers were being screened 

for other cancers that couldn’t possibly 

kill them. 10 Another factor linked to this 

is the increased risk CT scans pose 

9 



10 



patients. It is estimated that 

1.5-2% of all US cancers are 

attributable to CT scans. 11 

Dr Lawrence Ng, an MPS 

medicolegal consultant based 

in Singapore, says that during 

the last 20 years, doctors in Asia 

have become more careful in 

their diagnostic work. “There is a 

greater tendency to order more 

tests and x-rays to support one’s 

clinical diagnosis. Although in a 

patient safety-saturated culture 

it is prudent to do this, it does 

raise costs and patient anxiety.” 

WOULD DEFENSIVE 

MEDICINE LOWER THE 

RISK OF LITIGATION? 

No, defensive medicine is 

different from defensible 

practice, which is good 

practice – defensive medicine 

is not: it could, in fact, make 

your practice more risky. 

Kravitz et al attempted to 

quantify the risk presented by 

defensive medicine by analysing 

malpractice claims from a single 

north-eastern state in the USA. 

Claims ascribed to diagnostic 

and monitoring omissions 

accounted for less than 5%. 12 

The overall incidence rate was 

1.7 per 100 doctor-years, so 

the average doctor practising 

in one of the specialties studied 

would be sued for omitting 

a necessary diagnostic test 

once every 59 years! 

Doctors seeking to lower 

malpractice risk would avert 

very few lawsuits by ordering 

more diagnostic tests and 

monitoring procedures than 

they do now. In fact, ordering 

more tests could increase the 

malpractice risk, according to 

Michael Jones, who argues that 

doctors could be considered 

negligent for overtesting. 13 

Budetti supports these 

assertions: “The greatest irony is 

that defensive medicine may be 

counterproductive and actually 

might increase malpractice 

risk… Unnecessary treatment 

and invasive procedures… are 

themselves potentially serious 

violations of the standard of 

care and could be the basis 

of malpractice litigation.” 14 

MPS medicolegal adviser Dr 

Janet Page draws on both these 

points: she argues that as some 

tests may be invasive and have 

their own inherent risks, doctors 

Box A: To avoid complaints and claims, MPS members said they: 

Refer more patients for a second opinion 

Are more careful to ensure that the correct 

follow-up arrangements are in place 

Conduct more investigations 

Changed prescribing habits 

Kept more detailed records 

Have a lower threshold for removing 

patients from practice lists 

Stopped dealing with certain 

conditions/performing certain procedures 

could potentially be criticised for 

ordering investigations that are 

not in patients’ best interests 

(eg, if the risks associated with 

the procedures outweigh any 

potential benefit to the patient). 

So if a doctor refused to 

order a test that established 

medical guidelines state is not 

necessary, could they be sued? 

Dr Page answers: “A doctor 

can always be sued, but 

the claim is very unlikely to 

succeed if the doctor is acting in 

accordance with a responsible 

body of medical opinion (Bolam) 

and whether those decisions 

stand up to logical analysis and 

scrutiny (Bolitho). If a doctor 

takes the time and trouble to 

explain to patients the reason 

for the decision in the first place, 

it may reduce the chance of 

the patient bringing a claim.” 

According to Dr Page, overcautious 

doctors are unlikely to 

decrease the rate of negligence 

claims. Most claims arise 

not because of substandard 

care, but because of a failure 

in communication between 

the doctor and patient. 

So, defensive medicine could 

itself damage the doctor–patient 

relationship if a patient perceived 

that a doctor was acting simply 

to protect their own position, 

rather than out of a desire to do 

what was best for the patient. 

Another element of this is 

that in countries with a lot of 

private patients, they may be 

motivated by money, specifically 

getting their medical fees 

reimbursed. This will generate 

a proportion of claims that 

are clear “try-ons”; practising 

defensively is unlikely to impact 

on these cases, nor deter the 

patients from pursuing them. 

0 20 40 60 80 100 

% agreeing 

HOW TO AVOID 

PRACTISING DEFENSIVELY 

Remember the risk of 

being sued is low 

The chances of being sued are 

much lower than you think. If 

you study the number of clinical 

consultations and the percentage 

that result in a claim, it is a low 

incidence. Doctors should not be 

paranoid about being sued as this 

is not evidence-based thinking. If 

you can justify your decision not to 

order a test, it can be defended. 

Rachel Morris, an MPS solicitor, 

says: “If you are sued you will 

be asked why you did or did not 

do something. A defence will 

not be based on the number 

of tests you did, but the clinical 

reasoning behind your actions. 

“As long as you can look 

back and justify your decision in 

accordance with a responsible 

body of opinion, you are 

safeguarding your practice. That 

is why it is so important to keep 

good notes, so that you will be 

able to remember the clinical 

reasoning behind your decisions.” 

STRATEGIES TO MINIMISE 

DEFENSIVE MEDICAL PRACTICES 

■ Communicate effectively with patients, 

explaining what you are doing and why 

■ Have robust systems for follow-up 

■ Be open about risk 

■ Offer an appropriate standard of care 

■ Only order tests based on a thorough clinical 

history and examination 

■ Discuss difficult cases with colleagues 

■ Keep clear and detailed documentation 

■ Know what it is you seek to exclude or confirm 

with a test to determine if it’s necessary 

■ Identify learning needs (find good mentor) 

■ Undertake courses or independent study.

Be open about error 

Dr Aidan O’Donnell is a consultant anaesthetist 

who has practised mostly in the UK, but 

has recently moved to New Zealand. He 

says that the departments he works in have 

enlightened systems, where it is recognised 

that adverse events will happen, and should 

be treated as learning opportunities. 

He said: “Adverse events are collated and 

presented anonymously at monthly meetings 

in a blame-free atmosphere – the focus is on 

improving systems. Both departments contain 

anaesthetists who are comfortable saying 

‘I made a mistake, I got that wrong’.” 

Be a good doctor 

Doctors should feel confident enough 

not to practise defensively if they practise 

safely with evidence-based medicine, and 

follow local guidelines and protocols. 

Dr O’Donnell adds: “I try to establish a therapeutic 

rapport with my patients, and I’m comfortable 

with informed consent, eg, ‘I estimate you will 

have a 5% chance of dying in the one month 

following your operation’. I usually temper such 

statements with reassurance: ‘Whatever happens 

we will do our absolute best to look after you.’ 

Therefore, if things go wrong as a result of the 

anaesthetic, I know that I did warn the patient of 

the risks involved, and have an approach that (I 

hope) conveys open honesty and sincere regret.” 

Moving forward 

Although defensive medicine will always exist in 

the modern world, over-investigation of “what 

if” scenarios will never guarantee medicolegal 

protection in the wake of a claim/complaint, nor 

improve patient care. As a doctor you cannot 

always be right and outcomes for patients will 

not always be the ones you strived for; however, 

if you can show that you’ve acted and managed 

your patient appropriately, based on the evidence 

you had at the time, litigation should not follow. 

Many doctors describe litigation as a 

dagger at their back. However, it is good 

evidence-based practice, not defensive 

practice, that will deflect the blade. 

REFERENCES 

1 Andrews W, Defensive Medicine: Cautious or Costly? CBS news 

(22 Oct 2007) 

2 Dove J et al, Medical Professional Liability and Health Care System 

Reform, Journal of the American College of Cardiology (2010) 

3 Keren-Paz T, Liability Regimes, Reputation Loss, and Defensive Medicine, 

Medical Law Review (2010) 

4 Hermer L et al, Defensive Medicine, Cost Containment, and Reform, 

J Gen Intern Med (2010) 

5 Studdert D et al, Defensive Medicine Among High-Risk Specialist 

Physicians in a Volatile Malpractice Environment, JAMA (2005) 

6 Tellefsen C, Lawyer Phobia, Journal of American Academy of Psychiatry 

and Law (2009) 

7 Kravitz R et al, Omission-Related Malpractice Claims and the Limits of 

Defensive Medicine, Med Care Res Rev (1997) 

8 Kessler DP et al, Do doctors practice defensive medicine? QJ Econ (1996) 

9 Savage W et al, British Consultants’ Attitudes to Caesareans, Journal of 

Obstetrics & Gynaecology (2007) 

10 Johnson C, Study: Overtesting in Late-Stage Cancer Patients, eWoss 

news (12 October 2010) 

11 Chawla A, Defensive Medicine, Acad Radiol (2008) 

12 Ibid 5 

13 Jones M, Medical Negligence, 4th ed: Sweet and Maxwell, London (2008) 

14 Budetti PP, Tort Reform and the Patient Safety Movement, JAMA (2005) 

Once bitten 

Sally was a 30-year-old single mother with two dependent children. 

She became concerned about a possible lump in her left breast. In 

March she attended her local surgery, and saw the practice nurse. 

Nurse M performed a breast examination but did not find any 

abnormality and reassured Sally. 

Over the next few months, Sally noticed changes in her breasts, 

but felt reassured that nothing was wrong, as Nurse M had said that 

everything was fine. 

In June, Sally attended the surgery again and saw Dr F, complaining 

primarily of persistent back pain. He looked back over Sally’s notes. 

Dr F was mindful that a few years ago he had been accused of 

inappropriately touching a patient during an examination. In light of 

this, and because the notes stated that Sally had recently undergone 

a breast examination with Nurse M, he relied on her diagnosis and 

did not repeat the breast examination. Sally was diagnosed with 

mechanical back pain. 

In November Sally returned to the practice, with an inverted nipple 

and skin discolouration. Sally saw Dr F again who performed a breast 

examination, and found a lump in the same place she had described 

to Nurse M in March. Dr F referred her for urgent investigation, which 

confirmed metastatic breast cancer. 

OUTCOME 

If the cancer had been discovered earlier, Sally’s prognosis would have 

been better. Nurse M’s breast examination technique was criticised by 

the experts involved in the case, as she had not been properly trained 

to perform such examinations. 

Dr F was also criticised because he missed an opportunity to make 

the diagnosis at the consultation in June, when he failed to undertake 

a breast examination, relying instead on the examination carried out by 

Nurse M. The claim was settled by MPS, on behalf of the practice, for 

a large sum. 

LEARNING POINTS 

Dr F’s defensive practice put his personal feelings before his 

professional opinion. A doctor should never allow his personal 

experiences or concerns to affect his clinical judgment. Dr F 

should either have conducted the examination in the presence 

of a chaperone or, if he felt unable to examine Sally, he should 

have referred her to a colleague. 

When a patient re-presents with progressive symptoms (in 

this case, further changes in the breast), particularly after a 

significant time interval, the doctor should not rely on the earlier 

assessment but should conduct a further examination. 

OtnaYdur/Shutterstock.com 

11 



12 

ARTICLE 


Sympathy in the surgery 

Doctors are encouraged to be open with patients when things go 

wrong, to show compassion when dealing with sensitive issues 

and to communicate effectively. Sarah Whitehouse asks whether 

there is room for empathy, or even emotion, in the clinical setting 

“ I 

remember telling a family that 

their father, who had been 

admitted only hours earlier, had 

died in theatre,” recounts Mr Tom 

Berry, a trainee general surgeon. 

“I prepared as I have been taught. I 

took a nurse with me. I left my pager 

with someone else. I ensured that we 

had somewhere private. I prepared to 

answer any expected questions and 

what I would say the next steps were. 

Despite all this, as I broke the news 

to his wife, I realised I had tears in my 

eyes. His wife asked if I was okay. I 

felt guilty, as if I was intruding on their 

grief or trying to elicit sympathy.” 

WHAT IS EMPATHY? 

Coined from the Greek roots em and 

pathos (feeling into), empathy is the 

ability to put yourself in another person’s – 

the patient’s – shoes. 1 It is understanding 

a person’s subjective experience by 

sharing it vicariously, but maintaining 

an observant stance. 2 The observant 

stance is perhaps the key to empathising 

effectively in medicine – as a doctor, you 

cannot afford to become so consumed 

by a situation that you do not have the 

capacity to treat. Emotion, though, is 

what makes us human – should it be 

seen as something to shy away from? 

EMOTIONAL INTELLIGENCE 

“I don’t think I would be able 

to do my job properly without 

being able to empathise with my 

patients,” says Dr Ayesha Rahim, 

former Deputy Chair of the UK’s 

BMA Junior Doctor Committee. 

As a junior doctor in psychiatry, she 

explains: “It’s a huge thing for patients 

to tell you something extremely 

personal about themselves. It’s 

important to be attuned to what they 

are saying, and how they are saying it, 

by looking out for non-verbal clues.” 

Traditionally, empathy in clinical 

practice was bound up with the vague 

term “bedside manner” – you either 

had it, or you didn’t. It couldn’t be 

taught or improved. Now, however, 

empathic communication can be 

seen more as a taught skill, and 

one that is essential in order to fully 

understand a patient’s condition. 

Clinical empathy is about 

understanding a patient’s symptoms 

and feelings, and communicating that 

fact to the patient. It is important to 

check back with the patient when 

taking a history to show you fully 

understand, for example, “Let me 

see if I have this right.” Verbalising 

their emotion, eg, “You seem 

anxious about your chest pains,” 

demonstrates active listening. 

Being blind to emotional cues can 

lead to longer consultations and 

increased frustration from patients. It 

might even make a patient more likely 

to pursue a clinical negligence claim or 

complaint, should something go wrong. 

Dr Ann McPherson is Medical 

Director of the DIPEx Health 

Experiences Research Group, which 

established www.healthtalkonline.org, 

documenting patients’ experiences 

of their treatment. She says: “It’s not 

easy to be empathic to vulnerable, 

needy people 100% of the time. Being 

able to do it is something healthcare 

practitioners have to learn – in the 

same way that they learn clinical skills. 

“Over ten years, researchers 

employed by Oxford University have 

carried out detailed interviews with 

more than 2,000 patients. Many of 

them express gratitude and respect 

for the practitioners who have cared 

for them, but you only have to click on 

the ‘communication with healthcare 

practitioners’ link to find examples 

of people who have been upset, 

embarrassed, or even damaged by 

a lack of empathy and compassion 

on the part of doctors and nurses.”

There is concern that 

“too much” feeling can 

cause burnout among 

already overworked 

healthcare professionals. 

Little is said about how 

distressing situations can 

affect doctors emotionally 

© Brand X Pictures 

STOP, LOOK AND LISTEN 

Empathy is difficult to express unless 

it is truly felt. Although there are stock 

phrases that doctors use to empathise 

with patients, it is important that these 

are not repeated by rote, with little regard 

for the individual situation. Empathy as a 

taught skill can soon become formulaic 

emotion – something patients do not buy. 

Dr Pauline Leonard, a consultant 

medical oncologist at London’s 

Whittington Hospital, is leading a national 

programme, Connected, teaching 

doctors how to break bad news. She 

says: “There should be templates 

around empathy, but doctors should 

be encouraged to move the template 

to fit the patient – that is the art. 

“Doctors like templates because they 

are nervous. Ultimately, doctors are 

scared that when they empathise really 

well, so much emotion is unlocked in 

the room that they don’t feel equipped 

to cope with the situation and put 

the patient back together again.” 

If you empathise well, however, all you 

need to be equipped to do is sit and listen. 

Patients need to know that you are there 

to answer any questions, that you are not 

frightened of strong emotions. A good 

rule might be: don’t just do something, 

stand there. Tempting though it may be to 

bring an awkward conversation to a quick 

end, try not to brush off fear, uncertainty 

or anger with “Don’t worry, everything will 

be okay,” or “I know how you must feel”. 

Pausing and listening is more important, 

and more empathic. 

IN SYMPATHY 

Empathy in medicine may have its place, 

but the jury is out on sympathy’s role. 

Sympathy, when a person experiences 

feelings as if they were the sufferer, 

involves emotional identification with 

a patient’s set of circumstances, eg, 

if your eyes fill up with tears when a 

patient recounts their illness, or you 

feel anger when a patient tells you 

of a preventable adverse incident. 

In complete sympathy, a doctor would 

be unable to help, as there cannot be 

complete equality or complete sharing. 4 If 

you fully grieved for the loss of a parent’s 

young child, you would be overcome by 

the loss of the situation and wouldn’t be 

able to offer support. You would need 

support yourself. Dr Rahim explains: “It 

is difficult for a patient who has come 

to you to help contain their anxiety 

and distress to see their own doctor in 

extreme distress.” The more a doctor’s 

anxiety and aggression are under control, 

the calmer the patient is likely to be. 5 

Dr Ming-Keng Teoh, MPS Head of 

Medical Services (Asia), warns that 

doctors can present a risk to themselves 

if they let their emotions get the better 

of them in the heat of the moment. He 

cites as an example a doctor who, 

when faced with a patient with a lifethreatening 

haemorrhage in an ED, 

was accused of assaulting a colleague 

while hurrying and pushing him to 

release the required drugs. A complaint 

was lodged against the doctor to the 

hospital and, later, the Medical Council, 

despite an apology. In emergencies, 

it is important to retain your cool. 

The Hippocratic dictum of “do no 

harm” cannot be met if a doctor is 

consumed with their own emotional 

reaction to a situation, perhaps putting 

distressed patients and their families 

under added stress. At worst, sympathy 

can descend into pity, a condescending 

emotion that would serve to undermine 

the doctor–patient relationship. 

There is concern that “too much” 

feeling can cause burnout among already 

overworked healthcare professionals. 

Little is said about how distressing 

situations can affect doctors emotionally. 

Mr Berry argues: “More needs to be 

done to help doctors with considering 

the aftermath. The event of discussing 

bad news is well documented, but then 

it’s back to work and no more said.” 

Distressing conversations can prey on 

a doctor’s mind and, before moving on 

to the next consultation, or the patient 

in the next bay, doctors must be able 

to discuss these feelings if they wish. 

Similarly, it is important to know when 

to step back from a situation. Dr Brian 

Charles, consultant for MPS based in 

Barbados, says: “A common situation 

in the Emergency Department is the 

deathly sick child. Frequently, these 

cases affect staff, especially when they 

have young children or siblings of a 

similar age. I always advise the staff 

that it’s okay to have empathy and 

sympathy for the patients, but if it’s likely 

to affect judgment and objectivity, then 

someone else should take over. The 

difficult part is realising ‘when I can’t 

cope’ and when to call for help.” 

MAINTAINING BOUNDARIES 

An excess of emotion can blur 

boundaries. MPS medicolegal adviser 

Dr Richard Dempster explains: “There is 

a wide range of opinions as to what is 

appropriate professionally. Advice can 

at best only be general, because of the 

huge number of differing reactions to 

a doctor’s behaviour by patients. How 

doctors react and support patients will 

depend on the previous relationship they 

have had, and the knowledge that a 

doctor has of the patient’s personality.” 

In the UK, the GMC stresses that to fulfil 

your role in the doctor–patient partnership 

13 

ARTICLE 


14 

ARTICLE 


STEPS TO 

EFFECTIVE EMPATHY 

■ Recognise strong feeling 

(eg, fear, disappointment, 

anger, grief) 

■ Pause to imagine how the 

patient might be feeling 

■ State how you see the 

patient’s feelings (eg, “It 

sounds like you’re upset 

about...”) 

■ Legitimise the feeling 

■ Respect the patient’s effort 

to cope 

■ Offer support (eg, “Let’s see 

what we can do together”). 12 

REFERENCES 

1. “Let Me See If I Have This Right…”: 

Words That Help Build Empathy, Ann 

Intern Med 135:3, 221-27 (2001) 

2. Zinn W, The Empathic Physician, Arch 

Intern Med 153(3):306-12 (1993) 

3. Ibid 1 

4. Wilmer H, The Doctor–Patient 

Relationship and the Issues of Pity, 

Sympathy and Empathy, Br.J.med. 

Psychol 41: 243-48 (1968) 

5. Ibid 

6. GMC, Good Medical Practice p15 

(2006) 

7. GMC, Maintaining Boundaries p1 

(2006) 

8. SMC, Ethical Code and Ethical 

Guidelines p3 

9. Finlay, I, Dallimore, D, Your Child is 

Dead, BMJ 302:1524-5 (1991) 

10. Ibid 4 

11. Alfred, Lord Tennyson, Tears, Idle 

Tears, The Princess (1847) 

12. Platt FW, Empathy: Can It Be Taught? 

Ann Intern Med 117(8):700 (1992) 

you must be polite, considerate and 

honest, treat patients with dignity and treat 

each patient as an individual, 6 but warns 

against establishing or pursuing “a sexual 

or improper emotional relationship with a 

patient”. 7 Similarly, the Singapore Medical 

Council advises: “A doctor is expected 

to be dedicated to providing competent, 

compassionate and appropriate medical 

care to patients.” 8 Doctors have to be 

careful not to abuse their position of power. 

In providing competent and 

compassionate care, emotion does 

sometimes creep in. Dr Charles 

reasons: “Doctors are humans as 

well, and though we would like to 

distance ourselves emotionally from 

our work so as to remain objective, 

inevitably there will be times when an 

emotionally charged situation arises.” 

DEALING WITH EMOTION 

Dr Leonard agrees. “Patients do value 

it if you look touched too. If you look 

like you are finding it tough to break 

the news, patients can see that there 

is a person beneath the professional.” 

A study, Your Child is Dead, asked 

a group of parents who had suddenly 

lost their child about how the news 

was broken. 9 Parents took comfort in 

the fact that the informant of the bad 

news was also upset, with one parent 

stating: “He cared so much he had 

tears in his eyes.” The horrific loss of 

their child had not gone unnoticed 

by a cold, detached professional, 

eager to move on to the next job. 

Indeed, doctors may try so hard to 

appear professional that they come 

across as uncaring. Dr Lawrence Ng, 

MPS medicolegal consultant based 

in Singapore, says: “Body language is 

important, but usually it is subconscious 

and not within voluntary control. One 

may appear stiff and aloof whilst trying 

to remain composed and professional.” 

Getting the balance right between 

professional detachment and apparent 

coolness is hard. Dr Ng explains: 

“Cultural differences play a role in whether 

some form of sympathetic touching is 

appropriate, eg, hand-holding or shoulder 

touching. Misunderstandings may arise, 

but not usually if the gesture is sincere.” 

Understanding, like charity, begins at 

home. 10 Sincerity to oneself is essential 

in order to reach out to others. Dr 

Rahim questions doctors who might 

seem devoid of emotion: “If you are 

not feeling any emotion at all, it might 

be a warning sign to yourself – am I 

able to connect with my patients?” 

Dr Leonard reveals: “Sometimes, I worry 

that I have shown too much emotion 

in a consultation. Sometimes, patients 

look at me and say: ‘Oh Dr Leonard, I 

wouldn’t want your job.’ Not that I seek it, 

but that is the ultimate sign that patients 

know that I understand their situation.” 

PURPOSEFUL EMOTION 

“Tears, idle tears, I know not what 

they mean,” wrote Tennyson. 11 The 

empathic doctor should not be 

willing to indulge idle emotion or selfabsorbed 

sympathy; empathy should 

be with a strong clinical purpose. 

Above all, empathy allows the patient 

to see the person behind the professional, 

and the doctor to see the person, and 

the suffering, behind the patient. 

sturti/iStockphoto.com

Introducing… 

Membership Governance 

Dr Peter Mackenzie, Head of Membership Governance at MPS, explains the 

services and support on offer to those members who face particularly tough times 

Medicine is an extremely 

demanding career. 

Consequently, it is easy to 

encounter difficulties, whether it be 

through ill health, stress, falling behind 

with clinical skills and knowledge, or 

problems with communication. Most 

doctors will experience difficulties from 

time to time, but there are a few whose 

experience is more frequent than their 

colleagues. It is those members that 

MPS aims to work with to reduce their 

likelihood of future claims or complaints. 

Only a tiny percentage of MPS 

members find themselves in this 

situation and MPS’s Membership 

Governance (MG) Programme has been 

developed to support and help them to 

identify and address the causes, and 

thereby reduce their medicolegal risk. 

We are aware that there may be many 

factors beyond a member’s control that 

can lead to complaints or claims, so an 

important objective of the programme 

is to carry out a careful assessment 

before deciding whether someone might 

benefit from this initiative. Assisting 

so many members gives us a unique 

perspective on the frequency and 

types of medicolegal difficulties that 

doctors in different specialties encounter 

during the course of their career. 

A review would be recommended 

where a member is experiencing 

more medicolegal difficulties than we 

would generally expect. Our main 

concern is to identify underlying 

problems, if they exist, and then to 

work with the member concerned in 

order to address the root causes. 

In creating the MG Programme, 

we applied the following principles: 

■ Fairness, openness and transparency 

■ Support and rehabilitation 

– not punishment 

■ Accuracy and objectivity. 

The programme is based around a 

thorough assessment, performed by 

an experienced medicolegal adviser, 

of all cases opened in a member’s 

name over a ten-year period. Members 

are kept fully informed throughout the 

process, and detailed communication 

about issues takes place at every 

stage. On agreement of the existence 

of risk factors, the MG team is able 

to assist these members (who pay 

an enhanced subscription) with 

individually tailored risk management 

programmes. These may include: 

■ Courses to improve clinical 

or interpersonal skills 

■ A clinical risk self-assessment 

■ Practice visits 

■ A medical assessment (if 

health is an issue). 

We always write to members before 

performing an assessment of their 

cases. At that stage, we provide a 

number of background information 

leaflets about the programme. If 

MG does contact you, please take 

the time to read all the information 

we provide and remember that: 

■ Our aim is to help you to reduce 

your future medicolegal risk 

■ You can speak to, or meet, one 

of the MG team at any stage 

■ We are keen to explain why 

we are writing to you 

■ We provide support and detailed 

information throughout the process. 

MPS understands that contact from 

MG may create anxiety. It is important 

to stress that the programme is 

designed to be fair, objective and 

transparent in assessing medicolegal 

risk and to be rehabilitative, rather 

than punitive, in outcome. 

The main MPS educational activities 

that we recommend for members are: 

■ Clinical Communication 

Programme (CCP) – a sixmonth 

intensive programme that 

centres on a three-day, weekend 

residential workshop focusing on 

communication and listening skills. 

Experienced facilitators (all with clinical 

backgrounds) offer personalised, 

constructive feedback on recorded 

consultations provided by each 

participant before and after the 

workshop, and provide mentoring 

support by telephone throughout 

the six months to reinforce the 

skills learned at the workshop. 

They will help you develop your 

personal goals for improvement, 

and work towards achieving them. 

■ Clinical Risk Self Assessment 

(CRSA) – a practice visit, undertaken 

by a clinical risk manager or 

educational consultants (who are 

GPs), providing an interactive 

assessment of practice protocols 

and activities intended to offer help, 

support and guidance to achieve a 

safer practice for patients and staff. 

■ Mastering Your Risk workshop 

– a workshop including short 

lectures, reflective exercises, small 

group-facilitated discussions, group 

activities and skills rehearsal. 

In the next few editions of 

Casebook, we will look at which 

risks arise in different specialties. 

Feedback from members in MG 

(who have been asked to undertake 

with interventions): 

■ “My practice would appreciate a 

visit by one of your advisers to seek 

knowledge from their experience 

and advice in relation to our general 

practice complaints.” 

■ “You rather perceptively noted that 

the letter might create some anxiety.” 

■ “This is a godsend. I have been 

looking for such a course (CCP) for 

ages. I’d be delighted to attend.” 

If you would like more information to help you to better understand 

the programme, you can request a leaflet from MPS. To contact 

the Membership Governance department, please telephone 

0845 605 4000 or email membership.governance@mps.org.uk 

iStockPhoto.com/peter anderson 

15 

ARTICLE 


16 

On the case 

Head of Medical Services (Edinburgh) Dr Rob 

Hendry introduces this issue’s ward round of 

case reports, which highlight the dangers in 

relying on decisions made by others 

When treating a patient who has 

been seen by other doctors, it 

is good practice to still take a 

history and, if appropriate, to examine 

the patient again, keeping an open mind 

regarding alternative diagnoses. 

Do not presume the last doctor was 

on the right track – they may not have 

taken a full history, or the patient’s 

symptoms may have changed. In 

“Missed opportunities” on page 17, the 

doctor who performed a TOP on Miss R 

did not take a full history or adequately 

check for STIs before the procedure took 

place. Failure to examine the patient in 

this case rendered the claim indefensible. 

Similarly, the three different GPs who 

saw Mrs S in “Cuts and bruises” on 

page 20 simply relied on each other’s 

opinion rather than seeking a new 

diagnosis. The GPs were criticised for 

failing to realise how ill Mrs S was – there 

was no documentation of her vital signs 

that could have illustrated the severity 

of her illness and, as such, a timely 

admission was not arranged. 

When repeat prescribing, as 

in “Repeat offender” on page 21, it 

CASE REPORT INDEX 

WHAT'S IT 

WORTH? 

is important to look carefully at a 

colleague’s decision – do not repeat 

the mistakes of others. Problems can 

arise between primary and secondary 

care, when GPs take on the prescribing 

started by consultants. If you sign 

a prescription, you are ultimately 

responsible for it, so make sure it is 

correct. If a drug is unfamiliar, and you 

lack sufficient knowledge or experience, 

don’t prescribe it, until you know what 

you need to know to do so safely. 

“Inappropriate delegation” on page 

22 serves as a pertinent reminder to 

never practise beyond your skills and 

expertise. This is also the case when 

undertaking tasks delegated by others. 

Junior doctors have a duty to refuse to 

undertake a procedure (or take consent 

for a procedure, as in this case) if it 

lies outside their field of competence, 

except in an emergency. Likewise, when 

delegating care or treatment as a senior 

colleague, you must be satisfied that 

the person to whom you are delegating 

has the appropriate experience, 

qualifications, knowledge and skills to 

provide the care required. 

PAGE TITLE SPECIALTY SUBJECT AREA 

17 Missed opportunities GENERAL PRACTICE NOTEKEEPING/INVESTIGATIONS 

18 Heart of the matter GENERAL PRACTICE DIAGNOSIS 

19 To operate or not to operate? ORTHOPAEDICS CONSENT/COMPETENCE 

20 Cuts and bruises GENERAL PRACTICE DIAGNOSIS/INTERVENTION AND MANAGEMENT 

21 Repeat offender GENERAL PRACTICE SYSTEMS 

Since precise settlement figures can be affected by issues that are not 

directly relevant to the learning points of the case (such as the claimant’s 

job or the number of children they have) this figure can sometimes 

be misleading. For case reports in Casebook, we simply give a broad 

indication of the settlement figure, based on the following scale: 

CASE REPORTS 

22 Inappropriate delegation ENT CONSENT/COMPETENCE 

23 A pain in the buttock GENERAL PRACTICE NOTEKEEPING 

Casebook publishes medicolegal 

reports as an educational aid to 

MPS members and to act as a risk 

management tool. The reports are 

based on issues arising in MPS cases 

from around the world. Facts have 

been altered to preserve confidentiality. 

High £1,000,000+ 

Substantial £100,000+ 

Moderate £10,000+ 

Low £1,000+ 

Negligible

Missed opportunities Daniel 

Miss R was a 23-yearold 

woman who 

came to see her GP 

worried about the possibility 

of an unplanned pregnancy. 

Her last period was seven 

weeks ago. She had had 

a previous termination at 

aged 16 and had found it 

a very stressful experience. 

Miss R was very upset 

and asked her GP if she 

could have a termination 

of pregnancy (TOP). Dr W 

took a medical history. Miss 

R tearfully explained that 

she had had a termination 

once before and had been 

to a GUM (genitourinary 

medicine) clinic when she 

was much younger. There 

was no record of this in Miss 

R’s notes. Dr W spent time 

talking through the process 

of a termination with Miss R 

and exploring her thoughts 

about the pregnancy. 

Miss R was certain that 

she wanted a termination 

and had discussed this 

with her partner. 

Dr W referred Miss R 

for a TOP. Not unusually, 

Dr W hadn’t received any 

letters from the GUM clinic 

and, as it had been more 

than five years ago, Dr 

W didn’t document this 

information in her own 

notes. She did not ask Miss 

R why she had attended 

the GUM clinic, or contact 

the GUM clinic with Miss 

R’s consent to find out the 

reason for her attendance. 

The TOP was performed 

a week later. Miss R 

wanted a long-acting form 

of contraception and so 

an intrauterine device was 

inserted. Miss R did not 

have an STI screening 

and the doctor did not 

flag the GUM attendance 

with the TOP doctor. 

Three weeks later, Miss 

R attended the GP surgery 

with discomfort passing urine 

and general lower abdominal 

discomfort. She was seen 

by Dr F, who reassured 

her that it was normal to 

have some discomfort after 

a termination and that it 

should pass. However, in 

the following month, Miss 

R attended surgery twice 

more, again with the same 

symptoms, and saw a 

different doctor each time. 

Both doctors performed 

urine analysis and MSSUs, 

but these proved negative. 

Each time Miss R 

saw a doctor, no record 

was made in the notes 

of her being examined. 

Later, Miss R confirmed 

that she had not been 

examined by any doctor. 

A few weeks later, 

Miss R continued to have 

worsening lower abdominal 

pain, despite regular 

painkillers, so once more 

she attended her GP. 

On this occasion she 

was seen by Dr W, who 

performed an internal 

examination and thought 

she could feel a pelvic mass. 

Dr W was worried about 

an ectopic pregnancy; 

however, a pregnancy 

test was negative. She 

suspected a complication of 

the termination procedure 

and discussed her findings 

with the on-call gynaecology 

registrar, who arranged 

a clinic appointment for 

early the next morning. 

Later that day, however, 

Miss R’s pain became 

much worse and she 

called an ambulance. In 

the emergency department 

she was diagnosed with 

possible pelvic inflammatory 

disease. Miss R was taken 

to the operating theatre. 

Extensive pelvic inflammatory 

disease was confirmed, with 

tubo-ovarian abscesses. 

The inflammation was 

extensive, surrounding 

all structures, and Miss R 

required a bilateral salpingooophorectomy. 

Chlamydia 

testing was positive. 


Miss R made a claim 

against all the GPs 

involved in her care for 

the delay in diagnosis and 

her resulting infertility. 

EXPERT OPINION 

Expert opinion agreed that 

Miss R’s diagnosis had been 

significantly delayed due to 

inadequate patient records 

and delayed examination. 

Earlier testing and treatment 

for sexually transmitted 

infection would have 

prevented the complication 

of pelvic inflammatory 

disease and subsequent 

removal of both the ovaries 

and fallopian tubes, which 

resulted in infertility. The 

claim was settled for 

a substantial sum. 

MR 

■ Documentation of relevant history is vital for good 

continuity of care, where a patient may not see the 

same doctor twice. In this case, attendance at a 

GUM clinic was significant and should have been 

explored further and recorded in the notes. 

■ When seeing a patient with persistent symptoms, it 

is important to make a complete reassessment and 

exclude serious underlying pathology. 

■ When seeing a patient who has seen other doctors 

before, it is good practice to take the history and/ 

or examine the patient again, to pick up new 

information and keep an open mind to alternative 

diagnoses. Do not presume the last doctor was 

necessarily on the right track. 

■ Most GUM clinics do not routinely inform doctors 

about patient attendance, so it is important that you 

take a full history from the patient. 

■ Failure to examine the patient will often render a 

claim indefensible. 

Kaesler/iStockphoto.com 

17 

CASE REPORTS GENERAL PRACTICE NOTEKEEPING/INVESTIGATIONS 


18 

CASE REPORTS GENERAL PRACTICE DIAGNOSIS UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk 

Heart of the matter 

Mr G was a 55-yearold 

art gallery owner, 

based in the city 

centre. Over a period of 

six weeks, he developed 

a tight, burning sensation 

in his chest after meals, 

which cleared when he 

belched. He took some 

over-the-counter preparations 

for heartburn, including 

antacids. When these failed 

to alleviate his symptoms, 

Mr G made an appointment 

to see Dr V, his GP. 

During the consultation 

with his doctor, Mr G’s blood 

pressure was recorded as 

164/92. Dr V made a note 

that this was likely to be 

“white coat hypertension,” 

and therefore not significant. 

He advised Mr G to return 

at his convenience for 

another BP check up with 

the nurse. The medical entry 

noted the patient as having 

“heartburn clearing after 

belching”, with no other 

details of the nature of the 

pain, or any exacerbating 

or relieving factors. There 

was no record of whether 

this was related to exertion. 

Mr G said himself that he 

thought it was “probably just 

some heartburn”. He said 

that his wife asked him to 

make the appointment when 

his self-treatment had failed. 

Mr G said that he was not 

really worried about it and 

thought he’d “just come 

and get it checked out”. 

Dr V diagnosed 

oesophageal reflux and 

prescribed a course of 

ranitidine for two weeks. 

As Mr G had been treated 

with some omeprazole 

four years previously for 

suspected reflux disease, 

Dr V recorded that this was 

most likely a recurrence of 

the problem, possibly caused 

by a lifestyle of frequent 

social engagements. 

Over the next three 

months, Mr G presented to Dr 

V’s two colleagues in practice, 

Drs K and B. At each 

attendance, sparse records 

were kept, but his blood 

pressure was recorded as 

166/98 and 170/90. Despite 

this, no further investigations 

or treatment were ordered. 

On reviewing the records 


it was clear the original 

diagnosis of oesophageal 

reflux was accepted and 

not reconsidered by either 

doctor (or if it was, no 

record was made in the 

notes to that effect). 

Three months after that 

initial consultation, at his 

last practice visit, Mr G 

reported to Dr V that he 

had experienced a terrible 

weekend. There was an 

opening of an exhibition at 

the gallery that he had to 

leave because of extreme 

dizziness and palpitations. He 

said it was embarrassing in 

front of the invited guests and 

that he had been sweating 

excessively. Dr V told him 

it was probably due to the 

stressful environment and 

that he had likely experienced 

a panic attack, prescribing 

him some propranolol. 

One week later, Mr G 

collapsed and died at 

home. The postmortem 

examination was reported 

as showing left ventricular 

hypertrophy secondary to 

hypertension and severe 

coronary artery disease. 


Experts concluded that there 

had been many occasions 

when the diagnosis could 

have been made and 

treatment commenced, and 

that Mr G’s was an avoidable 

death. Experts were also 

critical of the failure to 

manage Mr G’s blood 

pressure. The case was 

settled for a substantial sum. 

GMcK 

■ Be wary of being unduly influenced in your medical management by patients who 

self-diagnose. This can often be wrong and prompt an incorrect treatment pathway. 

The terminology used by a patient might not be an accurate representation of 

pathology and can be misleading. 

■ Remember that chest pain experienced after a meal, or associated with belching, 

can also be a sign of angina, rather than a sign of gastro-oesophageal disease. 

■ Do not be reluctant to challenge the diagnosis of a colleague, regardless of seniority. 

Symptoms evolve and change and, with careful history-taking, patients can often 

report different symptoms at subsequent visits, where new diagnostic clues can 

emerge. Re-examine a patient’s previous history, from the beginning if necessary, if 

there is a change in symptoms. 

■ Remember the importance of actively managing chronic diseases and acting on 

abnormal signs, eg, elevated blood pressure www.bhsoc.org/other_guidelines.stm 

■ Preventative medicine is a large part of primary care and failure to act can result in 

adverse outcomes. 

Spauln/iStockphoto.com

To operate or not to operate? 

Mr B, a 23-yearold 

professional 

rugby player, fell 

awkwardly onto his right 

knee during a training 

session. He was sent to 

see Mr O, a consultant 

orthopaedic surgeon, three 

days later, with a stiff, sore 

and swollen knee. Mr O 

performed an arthroscopy 

and found that there was a 

tear through half to threequarters 

of the width of the 

posterior cruciate ligament. 

There were no other 

documented abnormalities 

within the knee joint. 

Mr O did not record his 

preoperative clinical findings 

and the documentation of 

the arthroscopy procedure 

was very limited. 

Mr O elected to perform 

an arthroscopic graft 

reconstruction of the 

posterior cruciate ligament, 

utilising an autograft from 

the semitendinosus and 

gracilis muscles, secured by 

a screw. This was performed 

a week after Mr O’s initial 

assessment. Initially Mr B 

made a good recovery, but a 

week after surgery he began 

to experience acute pain, 

swelling and locking in the 

affected knee. Mr O sought 

the opinion of a consultant 

orthopaedic colleague, 

Ms F, who performed a 

further arthroscopy. 

Ms F found that the screw 

had been malpositioned 

and was impinging upon 

the surface of the medial 

femoral condyle, significantly 

damaging the gliding surface 

of the articular cartilage. Ms 

F conducted further surgical 

intervention, including a tibial 

osteotomy. Unfortunately, 

the damage to Mr B’s knee 

joint was such that he was 

never able to resume his 

professional sports career. 

Mr B began a legal claim 

against Mr O, alleging 

that he had performed the 

surgery inappropriately and 

incorrectly such that his 

knee joint was permanently 

and significantly damaged. 


An orthopaedic sports 

injury specialist was 

concerned by many 

aspects of the case. The 

failure to document the 

degree of instability and 

other clinical findings 

in the knee joint before 

arthroscopy meant that 

Mr B would have difficulty 

justifying the procedure 

he had carried out, rather 

than opting for other, less 

invasive, interventions. 

The expert was of the 

opinion that the likely 

chances of the recovery 

of the injury following 

either conservative 

management or direct 


ligamentous repair, with a 

graft, were around 95%. 

The consent process 

for the procedure did not 

take into account the risk 

of Mr B not being able to 

continue with his sport 

and livelihood, when more 

conservative therapy 

might lessen this risk. 

Furthermore it was felt 

that the initial operative 

error had indeed caused 

secondary damage to the 

knee joint, and led to Mr 

B’s inability to resume his 

sports career. The claim 

was settled for a high sum. 

SK 

■ When treating professional competitors, great care 

must be taken to inform them fully of the risks of 

adverse outcomes that may affect their ability to 

carry on with their profession. 

■ It is important not to “overtreat” an injury if there are 

attendant risks in doing so. 

■ Good clinical examination is the cornerstone of 

good clinical practice and documentation of clinical 

findings, including operating notes, is essential. 

Robert Scoverski/iStockphoto.com 

19 

CASE REPORTS ORTHOPAEDICS CONSENT/COMPETENCE 


20 

CASE REPORTS GENERAL PRACTICE DIAGNOSIS/INTERVENTION AND MANAGEMENT 


Cuts and bruises 

Mrs S was a 65-yearold 

lady who had 

been suffering with 

stress incontinence and the 

discomfort of prolapse. She 

had a busy life looking after 

her three grandchildren and 

was finding her symptoms 

were interfering with this. 

She was admitted by her 

gynaecologist, Mrs V, for 

a vaginal hysterectomy, 

anterior and posterior vaginal 

repair and a colpopexy. 

The procedure appeared 

uneventful and Mrs V 

explained to Mrs S that the 

surgery should relieve her of 

her symptoms successfully. 

The next day, one of the 

junior surgical team noticed 

that Mrs S had a large bruise 

on her right buttock. This 

was discussed with the 

team and it was thought 

that this was caused due 

to her position on the 

operating table. Mrs S was 

reassured by this explanation 

and was discharged from 

hospital five days later. 

Three days later, Mrs S 

began to feel unwell. She 

felt feverish and had rigors 

that frightened her. She 

also developed diarrhoea 

and some yellow vaginal 

discharge. She felt so 

unwell that she requested 

a home visit from Dr W, 

her GP. There was very 

minimal documentation in 

Dr W’s notes about this visit 

except that he started some 

antibiotics and that he had 

noticed a bruise extending 

from her buttock to her knee. 

In particular, there was no 

documentation of her vital 

signs such as temperature, 

pulse or blood pressure and 

no written evidence of an 

abdominal examination. 

Over the next two weeks, 

Mrs S became increasingly 

concerned. She remained 

feverish and was finding it 

harder to walk because of 

pain in her right buttock and 

abdomen and swelling in her 

right leg. By the second week 

she was hardly able to walk 

at all and felt very unwell. 

She was visited at home by 

three different GPs from her 

practice. Each of the GPs 

noted the bruise that seemed 

to be extending down her leg 

but, again, did not document 

much else about her 

examination. The antibiotics 

were changed three times. 

When the bruising and 

swelling in her leg continued 

to worsen, one of the GPs 

discussed her case with the 

on-call gynaecologist over 

the phone. The gynaecologist 

thought Mrs S may have a 

DVT and suggested she go 

to the emergency department 

(ED) rather than to the 

gynaecology ward. When 

Mrs S arrived, she went to 

the medical assessment unit. 

The medics assessed her, 

but the on-call gynaecologist 

did not. She spent two days 

in hospital and, although 

an ultrasound scan failed to 

show a DVT, she became 

increasingly unwell. 

On the second day her 

temperature was spiking, 

her pulse was raised and her 

BP was running low. She 

was referred to the surgical 

ward, where she underwent 

an urgent CT scan, 

followed by a laparotomy. 

An extensive necrotising 

infection between the sacrum 

and rectum, extending 

into the right ischiorectal 

fossa, and multiple abscess 

tracks were found. Mrs S 

spent three months on the 

surgical ward undergoing 

extensive surgical treatment, 

including a loop sigmoid 

colostomy and recurrent 

debridement of the leg. 

Mrs S was traumatised 

by her long stay in hospital, 

the discomfort of all the 

surgery and with having to 

come to terms with having a 

colostomy. She made a claim 

against Mrs V and the three 

GPs who visited her at home. 


Experts agreed that Mrs V 

did not take enough care, 

by performing a rectal 

examination, to ensure that 

the rectum had not been 

perforated by a suture 

during the posterior repair. 


The GPs were criticised 

on several points. Firstly, 

it was felt that they had 

failed to consider a 

serious bacterial infection 

relating to Mrs S’s recent 

surgery. There was no 

documentation of her 

vital signs to assess 

the fever and severity 

of her condition. 

Secondly, it was felt that 

they failed to adequately 

examine the bruising and 

swelling to the right buttock 

and leg. Lastly, it was felt 

that they had failed to 

arrange admission and 

investigation earlier. The 

on-call gynaecologist was 

also criticised for failing 

to assess the patient as 

requested and therefore 

delaying her care for 48 

hours. The claim was 

settled for a substantial 

sum, divided between the 

hospital and the GPs. 

AF 

■ A diagnosis made by colleagues can always be 

challenged in the face of continuing symptoms. The 

three different GPs who saw Mrs S simply relied 

on each other’s opinion rather than seeking a new 

diagnosis. 

■ The GPs were criticised not for failing to diagnose 

her, but for failing to realise how ill she was and 

organise a timely admission. There was no 

documentation of her vital signs that could have 

illustrated the severity of her illness. 

■ Recent past medical history is likely to be relevant. It 

should be documented and considered. 

■ When there are post-surgical complications, the 

standard of aftercare is extremely important. 

■ This case highlights the importance of acting when 

a patient is deteriorating or failing to improve despite 

the working diagnosis and treatment. 

DR P. MARAZZI / SCIENCE PHOTO LIBRARY

Repeat offender kastock/iStockphoto.com 

Mrs B was a 

49-year-old deputy 

headteacher who, 

for 18 months, had been 

increasingly troubled by 

heavy irregular menstrual 

bleeding. She was referred to 

a gynaecologist who carried 

out a pelvic US and an 

endomentrial biopsy. In her 

follow-up appointment with 

the gynaecologist, Mrs B was 

told that her investigations 

had been normal and 

hormone replacement 

therapy (HRT) was suggested 

to regulate her bleeding. The 

gynaecologist told Mrs B 

that he would be writing to 

her GP with his opinion and 

treatment recommendations. 

Mrs B was therefore advised 

to go and see her GP to get 

a prescription for HRT in two 

weeks, which was thought to 

be sufficient time for the clinic 

letter to reach the GP. In the 

meantime, the gynaecologist 

scribbled down the name 

of the recommended HRT 

and gave it to Mrs B. 

Two weeks later, Mrs B 

duly took the afternoon off 

work and went to see Dr M, 

a locum, at her GP surgery. 

Unfortunately no clinic letter 

was available to Dr M on the 

practice computer notes. 

Unfamiliar with the practice’s 


administration systems, Dr 

M attempted to find out if a 

paper copy of the letter might 

be available somewhere. Dr 

M asked reception staff and 

personally looked through the 

partners’ piles of post but the 

letter could not be found. 

By now Dr M was running 

late and was sensitive to Mrs 

B’s frustration at having taken 

time off work for “a waste of 

time”. Eager to help Mrs B, Dr 

M looked at the handwritten 

note the gynaecologist 

had given her. The writing 

was barely legible, but Dr 

M thought the medication 

looked most like unopposed 

oestrogen. Mrs B’s blood 

pressure was satisfactory 

and it was recorded that 

Dr M counselled her about 

risks of breast cancer and 

thromboembolic disease. 

Mrs B left with a prescription 

for unopposed oestrogen. 

Mrs B continued to be 

prescribed three-monthly 

prescriptions of the 

unopposed oestrogen. 

The GP who signed the 

repeat, Dr P, saw from Dr 

M’s consultation notes 

that Mrs B had been seen 

recently by a gynaecologist 

and the prescription had 

started as a result of this, 

and was therefore satisfied 

it was appropriate. 

At six months she was 

seen in surgery by Dr T for 

a review of her HRT. Dr T 

again noted her attendance 

at the gynaecology clinic and 

recorded that a course of 

unopposed oestrogen was 

started by the gynaecologist. 

Mrs B’s blood pressure was 

taken and it was recorded 

that she was regularly selfexamining 

her breasts. 

The prescriptions 

continued for a year, when 

Mrs B was again called for 

a HRT review at the surgery. 

At this point she surprised 

Dr T by saying that the HRT 

wasn’t helping her bleeding 

that had recurred and which 

was, in fact, heavier and 

more persistent than ever. 

Dr T realised that for many 

months Mrs B had been 

mistakenly prescribed an 

unopposed oestrogen and 

now had heavy bleeding. 

Dr T apologised to Mrs B 

and also explained that she 

needed to be quickly referred 

back to the gynaecologist 

for investigation. She 

was referred urgently and 

in view of her history of 

increasingly heavy bleeding 

and prolonged exposure to 

an unopposed oestrogen, 

a hysteroscopy was carried 

out. This led to a diagnosis 

of endometrial cancer. Mrs 

B had a hysterectomy and 

made a full recovery. She 

made a claim against all 

the doctors involved in her 

care at the GP practice. 

The gynaecologist’s original 

letter was eventually found 

in the patient’s notes. 


The incorrect prescription 

could not be defended 

– Dr M was responsible 

for her actions. An expert 

gynaecologist advised that 

the patient’s subsequent 

problems were probably 

a result of this (although 

there was a low probability 

that they may have 

occurred in any case). 

The practice was liable 

because there was no 

system in place to check 

the prescriptions and 

uncover Dr M’s mistake. 

The confusion could 

have been avoided if the 

consultant had issued the 

first prescription. In shared 

care situations there is a 

reduction in risk if the initial 

prescription is commenced 

by secondary care. 

The claim was settled 

for a moderate sum. 

SC 

■ GPs must take particular care when taking responsibility for prescribing treatment commenced in the hospital sector. If 

you sign the prescription, you are responsible for it, so make sure that it is correct. If a drug is unfamiliar, don’t prescribe 

it if you don’t have the knowledge/experience. 

■ Practices should have a system for ensuring all incoming mail is checked and acted upon. There was a lost opportunity 

to correct the error when the hospital letter was received. 

■ Repeat prescribing is particularly risky for locum GPs. Locums should consider whether there is anyone better placed 

to do it, such as another GP who is more familiar with the patients. See MPS’s factsheet on “Safe Prescribing” 

(www.medicalprotection.org/uk/factsheets/prescribing) and an article in Sessional GP 

(www.medicalprotection.org/uk/sessional-gp/issue-2/should-sessional-gps-repeat-prescribe). 

■ Any GP doing repeat prescribing must ensure that the prescription is still necessary/correct. 

■ This case highlights the importance of being open and honest if you make or discover a mistake. 

21 

CASE REPORTS GENERAL PRACTICE SYSTEMS 


22 

CASE REPORTS ENT CONSENT/COMPETENCE 


Inappropriate delegation 

Mrs R, a 42-yearold 

amateur 

opera singer, was 

admitted for an elective 

partial thyroidectomy under 

ENT consultant, Mr F. Mrs 

R was admitted by Dr A, 

a junior surgical doctor. 

He recorded that she 

was having the operation 

because she had declined 

radioactive iodine treatment 

of her hyperthyroidism. Once 

he finished the history and 

examination, Dr A informed 

Mrs R that a more senior 

doctor would go through 

the consent form with her 

at some point during the 

day. On this particular day, 

however, there was a very 

long and busy surgical list, 

and Mr F did not get the 

chance to complete the 

consent form with Mrs R. 

Neither did he go through 

the form on his brief review 

of Mrs R on the ward 

round the next morning. 

When Mrs R arrived in 

the anaesthetic room, Dr 

A went through her notes. 

Realising that the consent 

form was still missing, 

Dr A went through to the 

operating theatre to discuss 

the matter with Mr F. Mr F 

was in the middle of another 

procedure and told Dr A 

to take Mrs R’s consent 

for the thyroidectomy and 

file it in her notes. Feeling 

a bit intimidated, Dr A 

agreed and went back into 

the anaesthetic room. 

Anxious at Dr A’s 

hesitancy, Mrs R asked if 

anything was wrong. Dr 

A reassured Mrs R and 

explained that there had 

been a little confusion 

because a consent form for 

the operation had not yet 

been signed, and he asked 

if he could go through that 

process with her. Mrs R 

agreed and Dr A described 

what her operation would 

involve. A written information 

leaflet was not available 

but Dr A asked Mrs R if 

she had any questions 

about the procedure and 

Mrs R answered no. Both 

Mrs R and Dr A then 

signed the consent form. 

After the operation, Mrs R 

experienced typical postthyroidectomy 

side effects, 

including discomfort on 

swallowing, hoarseness, 

neck stiffness, bruising and 

swelling. The team assured 

her that this was a usual 

response and offered her 

appropriate analgesia. 


Two days after her 

operation, Mrs R’s pain 

and swelling had reduced 

and she was discharged 

home after being told 

that the post-surgical 

hoarseness should settle 

in the next few weeks. 

Four weeks later, Mrs R 

saw Mr F in his outpatient 

clinic for routine wound 

review and thyroid function 

test. Mrs R commented 

that although her neck was 

healing well, the hoarseness 

had not improved since the 

operation and, concerned 

about her singing voice, 

she asked him how long it 

would be before this was 

resolved. Mr F told her that 

permanent hoarseness 

is a rare complication of 

thyroidectomy and arranged 

to review her again in 

another four weeks. 

At that review, there 

was still no improvement 

and Mr F diagnosed 

permanent damage to the 

recurrent laryngeal nerve. 

Mrs R started a claim 

against both Mr F and 

Dr A for not warning her 

that this could happen. 


Expert ENT opinion 

was critical of Mr F’s 

delegation of the task to 

Dr A. Although he was 

not directly accountable 

for the decisions and 

actions of Dr A, he was still 

responsible for the overall 

management of the patient, 

and accountable for the 

decision to delegate. 

Mr F claimed that he had 

spoken to Mrs R about the 

procedure at a previous 

consultation, but there 

was no record of this. Dr 

A should have refused 

to take consent, on the 

basis that it was outside 

his field of competence. 


for a moderate amount. 

SM 

■ All doctors have a duty to ensure that they have the necessary understanding of a 

procedure to take consent. If not, ensure that consent is taken by someone who does. 

■ It is important not to practise beyond your skills and expertise. 

■ When delegating care or treatment, you must be satisfied that the person to whom 

you are delegating has the appropriate experience, qualifications, knowledge and 

skills to provide the care. 

■ Written consent is essential for surgical procedures – except emergencies – and 

patients need to be informed of relevant side effects and complications. 

■ Record any discussion of possible complications in the notes, even if this discussion 

takes place outside the formal consenting process. 

■ A patient information leaflet is a useful adjunct to have but does not replace the 

discussion about risks and side effects. 

Stepan Popov/iStockphoto.com

A pain in the buttock stefanolunardi/shutterstock 

Mr B, a 46-year-old 

taxi driver, rang the 

out-of-hours service 

complaining of pain in the 

rectum and constipation. He 

mentioned that he had had 

infected piles before and he 

was prescribed antibiotics 

for it. The out-of-hours GP, 

Dr K, was satisfied by the 

explanation of symptoms 

over the phone and wrote a 

prescription for laxatives and 

antibiotics to be collected by 

Mr B from a local pharmacy. 

He advised Mr B to see 

his GP after the weekend if 

the symptoms persisted. 

Two days later Mr B visited 

his GP, Dr L, complaining of 

worsening pain and feeling 

unwell. He reported profuse 

sweating and rigors. Mr B 

had passed a small amount 

of motion, but was still 

experiencing rectal pain. Dr L 

checked Mr B’s temperature 

and examined the abdomen, 

chest and ENT, which were 

all unremarkable. She chose 

not to undertake a PR as 

she presumed the out-ofhours 

service had done so. 

Dr L diagnosed resolving 

constipation and coincidental 

viral infection. She advised 

Mr B to continue the 

antibiotics. She thought 

that the sweating might be 

a side effect of the Prozac 

Mr B was also taking and 

changed his prescription. 

Dr L saw Mr B again the 

following day, this time as 

a home visit. She did not 

perform a rectal examination 

and advised him to continue 

treatment. As Dr L visited 

Mr B after evening surgery, 

she omitted to make an 

entry in the patient’s notes. 

The following evening, Mr 

B called the out-of-hours 

service again. A different 

GP, Dr A, made a home visit 

and quickly diagnosed a 

rectal abscess. Admission 

to hospital was organised 

and aggressive surgical 

treatment was required. 

Mr B subsequently 

launched a claim against 

Dr K and Dr L. 


The defence of the case 

was complicated by poor 

notekeeping. The notes of 

Dr L’s home visit to Mr B, for 

example, had been written 

up several days later, 

after Dr L heard what had 

happened to Mr B. Notes 

wherever possible should 

be contemporaneous; Dr 

L should have made an 

entry as soon as possible 

after seeing Mr B and, 

if there was a delay, 

indicated the reasons 

why it was added later. 

A GP expert was critical 


of Dr K for not arranging 

for Mr B to be seen, and 

of Dr L for her failure to 

examine Mr B properly. 

It was advised that a 

referral for Mr B should 

have occurred earlier, 

when treatment would 

have been less radical. 


for a substantial sum. 

ZS 

■ Be aware of the risks of telephone consultations and 

prescribing. Are you putting yourself in a position 

to make a sound clinical judgment before offering 

advice? If you are unable to do this, you should 

arrange for the patient to be seen. See Your Practice 

(Autumn 2009) “Do’s and don’ts of telephone 

conversations” – (www.medicalprotection.org/uk/ 

publications/your-practice-autumn-2009/dosand-donts-of-telephone-conversations) 

■ The interface between out-of-hours care and routine 

GP care requires careful management to ensure 

safe handover. 

■ Always review documentation and, if unclear, clarify 

with the patient. 

■ Good documentation is essential to safeguard 

your practice. 

■ Giving antibiotics without clinical indications and 

examination is likely to be indefensible. 

23 

CASE REPORTS GENERAL PRACTICE NOTEKEEPING 


24 

OVER TO YOU 


Over to you… We 

Fatal inaction 

The case report “Fatal 

inaction” (Casebook 18(3)) 

stimulated considerable 

correspondence, with 

wide-ranging views on 

possible interpretations 

of the clinical details. The 

focus of Casebook case 

reports is always on the 

learning points, which are 

taken from a medicolegal 

– rather than clinical 

– perspective. Clinical 

details are purposefully 

kept to a minimum 

and further changes to 

this detail are made to 

ensure full anonymity. 

Many thanks to all 

those who took the time 

to contact us regarding 

this case report. 

Support for the 

MPS way 

This letter was received 

in response to a covering 

letter from MPS Chief 

Executive, Tony Mason, 

which accompanied 

Casebook 18(3). 

I’m respondIng to your 

request for feedback in your 

recent letter to members – 

your news was a detailed 

yet succinct summary of the 

MPS position on “Discretion 

and Occurrence Cover”. 

I’m an intensivist/ 

anaesthetist, an associate 

postgraduate medical 

dean in the East Midlands 

and in my middle 50s. My 

wife is also a consultant 

anaesthetist and a similar 

age to me. For many years 

I took my indemnity with 

another company as a 

result of an un-researched 

spontaneous decision as 

a medical student. Then, 

many years later, I was 

enlightened by my wife that 

I should swap to MPS. 

I would like to offer our 

strongest support for the 

position you represented 

on behalf of MPS and its 

members in your letter. All 

of our efforts – whatever 

the detail of our daily 

endeavours and whatever 

our role in the health 

service or in supporting 

those in the health service 

– should always be aimed 

at promoting patent safety 

and patient wellbeing. 

The position MPS has 

taken for nearly 120 years is 

a great, if somewhat oblique, 

example of this principle. 

Charlie Cooper, Nottingham, UK 

Great expectations 

thank you once again for an 

interesting Casebook issue. 

I read every magazine with 

keen interest. But I must 

say that after reading every 

issue, although it motivates 

me to be continuously 

on my toes, I wonder 

sometimes if it would not be 

better for me to go fishing 

instead of being a doctor. 

I have read of so many 

cases in Casebook articles 

that could have happened 

to me. I am not talking of 

pure negligence or just bad 

doctoring, but just here or 

there a small symptom or 

sign overlooked, or “you 

have checked but not 

written down in detail” and 

welcome all contributions to Over to you. 

We reserve the right to edit submissions. Please 

address correspondence to: Casebook, MPS, 

Granary Wharf House, Leeds LS11 5PY, UK 

Email: casebook@mps.org.uk 

then suddenly you have 

no leg to stand on. I am 

saddened by cases where a 

doctor just tried to help out 

of the goodness of his heart 

and then gets sued or told 

he was acting outside the 

sphere of his competence 

– for example, Dr Q in the 

case report “Fatal inaction”. 

If Dr Q would have done, 

or said, nothing (or if he 

would have said “Sorry, this 

is outside my competence, 

I cannot give any advice 

or help”) what would the 

response have been then? 

I see many doctors get 

sued or many litigation 

cases, where plenty of 

doctors were consulted by 

one patient for the same 

problem. For example, 

Dr A on Monday, Dr B 

on Wednesday, Dr C on 

Friday, etc. In my opinion, 

I still think it is best if one 

doctor takes responsibility 

for his patients and keeps 

on seeing them regularly. 

I wonder sometimes 

what patients expect 

from a doctor. We cannot 

guarantee a fault free or 

problem free outcome – for 

example, in your case report 

“A recognised complication”. 

Could this be the reason 

that fewer doctors’ children 

want to become doctors? 

I think most doctors really 

try their best, bending 

over backwards to help a 

patient – I am just thinking 

of the average GP in 

South Africa and the vast 

amount that he/she does 

every day. And I am not 

complaining, I love what 

I do. It’s just sometimes 

that I think that the world 

should treat their doctors 

with a bit more grace. 

Dr Martin Cramer, South Africa 

An evolving situation 

I read wIth Interest your case report (“An evolving situation”) 

regarding bilateral subdural haematomas, missed repeatedly 

in a patient attending an ED (Casebook 18 (3)). I have empathy 

with the junior doctors involved in the case, given that the 

patients' initial head CT was normal. I am pleased to hear Mr M 

made a full recovery. 

May I suggest two additions to the learning points you highlight: 

1. Always discuss patients re-attending with the same 

complaint with the duty ED consultant. Most EDs with 

whom I am familiar have this as a rule, for evident risk 

management purposes. 

2. Always reconsider your clinical reasoning before issuing any 

ED patient with a diagnosis of “viral gastroenteritis”. In the 

case of Mr M, where was the evidence of any “enteritis”? 

Gavin Lloyd, Consultant Emergency Physician, Royal Devon and Exeter Hospital, UK 

Fit for purpose? 

Please note that this letter 

refers to an article that 

appeared in the UK edition of 

Casebook only – you can read 

it online here: 

www.medicalprotection.org/ 

uk/casebook-september-2010/ 

fit-notes-fit-for-purpose 

the Issue of “fit notes” 

saddens me that GPs 

appear to be the focus for 

missives and imposition of 

training because we are 

assumed to be the cause 

of the system failing. I 

have worked in the New 

Zealand ARCIC system, 

which is similar to the 

idea behind the changes 

here, but it worked well. 

I believe British GPs do 

© BananaStock

see the benefits of careful 

return to work, but our 

efforts to achieve this in 

the old system were often 

frustrated, and they still are. 

Employers often reject 

fit notes because the 

suggestions, whilst clinically 

appropriate, do not fit in with 

their administrative needs 

in relation to statutory sick 

pay – that they must have 

the employee completely 

off in order to get the 

money. It may also cost 

them more to make the 

necessary changes, and 

they cannot be bothered. 

I feel the government 

should look at changing 

the law, to make the 

acceptance of the doctor’s 

opinion compulsory, and 

make it up to the employer 

to decide whether to 

make the changes or put 

the employee off work, 

but not insist the doctor 

change their advice. This 

was the case in New 

Zealand. There needs 

to be change in the 

administrative rules about 

re-claiming statutory sick 

pay, etc, for the employer. 

The article also mentioned 

hospital doctors giving 

med3 forms. Many hospitals 

do not allow their medical 

staff to give these forms, 

insisting that only GPs 

can do this, and must do 

this even if they have not 

seen the patient and had 

no confirmation from the 

hospital of the cause. This 

makes us unacceptably 

reliant on the patient’s 

verbal communication of 

how long the consultant 

supposedly said they are 

entitled to be off work. 

Hospitals do not stock 

the required stationery, and 

juniors are given obsolete 

stationery and no training in 

how to use it. This will lead 

to the next generation of 

GPs having no training, thus 

making the system fail again. 

It leaves little scope to 

work within our competence 

if we are forced to opine in 

specialist cases because 

the consultant specialists 

refuse or are not enabled 

to provide fit notes, and we 

Too close to home 

In the learnIng points attached to the Stevens-Johnson case (p23 of Casebook 18(3)), 

you repeat the wise advice that “it is good practice not to treat people too close to you, 

either relatives or colleagues”. This of course includes self-treatment, and is in general 

wise commonsense – until someone interprets the words literally. 

A few years ago, passing through London on my way to the airport, I began feeling 

gout pains in my foot. I have had occasional attacks of gout over the years, fortunately 

rarely, so I did not bother taking prophylactic treatment but I recognised this pain and 

knew that it presaged extreme pain over the next few hours. No problem, I thought, I’ll 

just go to the local pharmacist and buy myself a few indomethacin capsules, that’ll stop it. 

The young pharmacist was horrified – “Oh no, 

I can’t give you tablets! It’s unethical for doctors 

to treat themselves!” No amount of persuasion, 

seniority or authority helped. She even rang the 

Pharmaceutical Council for advice, and their 

response was the same. By that time I had to rush 

for my plane and there was no time to contact my 

GP or anything else. 

For those who don’t know, the pain of gout 

is about the worst there is. I wouldn’t wish it on 

anyone. But please, those of you who formulate 

official guidance, choose your words carefully. 

David Freed, Manchester, UK 

are not given the necessary 

information by them. 

As to patients believing 

their doctor was not 

qualified to judge them fit for 

work, are we talking about 

patients who would not 

consider anyone qualified 

to judge them fit for work, 

having decided themselves 

that they don’t want to 

work, or are we actually 

talking about patients 

feeling their doctor has 

insufficient knowledge of 

what their work involves? 

David Church, GP, UK 

An unexpected, 

painful end 

we collectIvely wrIte in 

response to the outcome of 

this case (from Casebook 

18(2)) against Mr E. It would 

appear that the patient Mr 

Q had exemplary treatment 

while under the care of Mr 

E. It appears Mr Q sustained 

a unilateral left-sided 

undisplaced acetabular 

fracture without any loose 

bodies. It also appears 

that at follow-up clinic, 

the fracture had healed 

radiologically and clinically, 

with Mr Q walking painfree 

and without a limp. 

We feel that the prognosis 

that Mr E gave with regards 

to the development of 

unilateral hip osteoarthritis, 

taking into account the 

fact that the fracture was 

undisplaced and had 

healed radiologically and 

clinically by three months, 

is correct and is backed by 

the associated literature. 

There is a wealth of 

literature that indicates, 

particularly in undisplaced 

acetabular fractures, that 

the functional outcome and 

level of pain present at one 

year post-fracture would be 

the residual outcome level, 

and it is highly unlikely to 

deteriorate. It would also 

seem implausible that a 

unilateral acetabular fracture 

would cause symmetrical 

hip joint osteoarthritis 

bilaterally. Mr Q developed 

pain in both hips six years 

after the accident, indicating 

that the arthritis of both 

hips is highly unlikely to be 

related to his undisplaced 

acetabular fracture. 

Mr MJ Barakat, Specialist 

Registrar, Trauma & Orthopaedics, 

Southmead Hospital, Bristol, UK 

Miss J Torres-Grau, Junior 

Doctor, Trauma & Orthopaedics, 


Mr I Packham, Consultant, 

Trauma & Orthopaedics, 


Casebook and other 

publications from MPS are also 

available to download in digital 

format from our website at: 

www.medical protection.org 

25 

OVER TO YOU 


26 

REVIEWS 


Reviews 

Sick Notes - True Stories from 

the Front Lines of Medicine 

by Dr Tony Copperfield 

(£8.99, Monday Books, 2010) Reviewed by Sian Barton, 

freelance journalist and patient, Milton Keynes 

I must confess – I’m a patient. So 

after peering through the illustrious Dr 

Tony Copperfield’s window into the 

working life of a GP, my initial feelings 

were paranoia. Dr Copperfield 

outlines the worst aspects of his 

beloved patients and leaves the lay 

reader asking the following questions: 

am I a dreaded heartsink? Is taking in 

a list really so awful? Do all heartsink 

patients suffer the same fate as poor 

old Mr Nickelby – who repeatedly 

visits for a buzzing in his ear’ole and 

(finally) ends up with a diagnosis of 

terminal cancer? 

But then if I think being a patient 

is hard, I should try being a GP. In 

between wading through the worried 

well, antibiotics addicts and elderly sex 

Direct Red: A Surgeon’s Story 

by Gabriel Weston 

(£7.99, CCV Digital, 2009) Reviewed by Dr June 

Tay, junior doctor in anaesthetics, London 

Direct Red is a concise, easyto-read 

book that provides an 

insight into the life of a surgical 

trainee working in the UK. Gabriel 

Weston is an ENT surgeon who 

writes about the highs and lows 

of her career with brutal honesty, 

painting a realistic picture of 

her chosen profession. 

She divides her book into different 

themes, using semi-fictional events. 

The book begins with her 

experiences as a medical student – her 

first male catheterisation, the human 

skeleton she owned, the first cardiac 

arrest she witnessed. Later, she 

touches on her struggles as a registrar, 

honing in on how she found it tough 

making her mark in a competitive field 

dominated by male counterparts. 

Weston dissects the raw details 

of what goes on behind the 

doors of an operating theatre, 

revealing its gruesome nature to 

her audience. Surgery may be a 

noble profession, but it is far from 

flawless, as Weston describes 

maniacs desperate 

for free Viagra, 

GPs have to unpick 

some serious 

problems for their 

patients. 

As befitting 

a medical writer of the year, Dr 

Copperfield (who is actually the 

pseudo-real creation of two medical 

practitioners) offers a wry insight 

into the daily struggles GPs in the 

UK’s public health system face in an 

interesting and enlightening way. 

However, I learnt that patients are 

not the only obstacles GPs have to 

jump over in order to do their job. 

Dr Copperfield casts a sharp eye on 

the system itself. There are some 

horrible examples of health service 

bureaucracy going spectacularly 

wrong. The case of the seriously ill 

woman who is expected to wait five 

months to see a specialist is mind- 

when she discharged a patient that 

should have been admitted out 

of a desire to prove her worth. 

She uses descriptive words in 

a poetic manner, likening bowels 

to a “snaking mass, writhing” and 

“vermiculating in our joint embrace”. 

She does not spare any details, 

describing how after assisting 

in theatre, her underwear was 

“soaked with (a) woman’s blood”, 

or when she reduced a middleaged 

woman's haemorrhoids. 

My favourite excerpt from the 

book is the touching story about 

Ben, a ten-year-old boy who was 

admitted with a headache and later 

diagnosed with a brain tumour. 

Weston was called to see Ben in the 

middle of the night because he was 

in pain: she prescribed painkillers. 

A few days later, she found out that 

he passed away; it then dawned 

on her that the last thing a sick 

child who cries out at night wants 

is medication. He needed another 

person’s warmth and comfort. 

Although this story did not have 

a happy ending, I identified closely 

with her thoughts and actions. I was 

struck by how the routine demands 

boggling, especially when our dutiful 

doctor rings to complain and it is 

pushed forward by just 30 minutes. 

Thankfully it isn’t all doom and 

gloom – Dr Copperfield does help 

his patients. The book is human, very 

funny, wise and, in some instances, 

heart-warming, and it’s nice to see how 

it works using the eyes of an expert. 

It is good to read something in print 

with an insightful comedy take on the 

workings of the UK health system, 

and certainly beats some of the 

depressing and histrionic reports that 

pepper the papers. Because looking 

at Dr Copperfield’s assessment of the 

situation, if you didn’t laugh, then you 

would surely cry. 

of night calls can make one less 

compassionate and empathic, and 

more impatient and self-centered. 

This will serve as a constant 

reminder of why we should have 

patients’ best interests at heart in all 

situations. Her writing also opens an 

emotional window into a surgeon’s 

life: how despite our daily exposure 

to death, that we too have feelings. 

As a junior doctor, Weston's 

anecdotes resonate closely with 

my own experiences that surgery 

does not always end in success. 

One example is “Mr Cooke”, who 

comes in with a leaking aneurysm 

and dies on the operating table, 

denied his last moments of liberty. 

Often we think surgery is the best 

option, but a good surgeon knows 

when not to make the cut. 

I would have preferred the characters 

and plot to be better developed as, at 

times, both seem to take a backseat 

to the anecdotes. The last few 

chapters would perhaps benefit from 

further editing, as some sentences 

were lengthy and difficult to follow. 

On the whole, it is a delightful and 

valuable read for both medical and 

non-medical professionals alike.

MPS Risk Solutions 

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S.P. Rayner/iStockphoto.com 

MPS0898:11/10

MEDICAL PROTECTION SOCIETY 

PROFESSIONAL SUPPORT AND EXPERT ADVICE 

How to contact us 

THE MEDICAL PROTECTION SOCIETY 

33 Cavendish Square 

London, W1G 0PS 

United Kingdom 

www.mps.org.uk 

www.dentalprotection.org 

General enquiries (UK) 

Tel 0845 605 4000 

Fax 0113 241 0500 

Email info@mps.org.uk 

MPS EDUCATION AND RISK MANAGEMENT 

MPS Education and Risk Management is a dedicated division 

providing risk management education, training and consultancy. 

Tel 0113 241 0701 

Fax 0113 241 0710 

Email education@mps.org.uk 

Please direct all comments, questions or suggestions 

about MPS service, policy and operations to: 

Chief Executive 

Medical Protection Society 

33 Cavendish Square 

London W1G 0PS 

United Kingdom 

tony.mason@mps.org.uk 

In the interests of confidentiality please do not include information 

in any email that would allow a patient to be identified. 

The Medical Protection Society is the leading provider of comprehensive professional 

indemnity and expert advice to doctors, dentists and health professionals around the world. 

MPS is not an insurance company. All the benefits of membership of MPS 

are discretionary as set out in the Memorandum and Articles of Association. 

The Medical Protection Society Limited. A company limited by guarantee. 

Registered in England No. 36142 at 33 Cavendish Square, London, W1G 0PS 

UK medicolegal advice 

Tel 0845 605 4000 

Fax 0113 241 0500 

Email querydoc@mps.org.uk 

UK membership enquiries 

Tel 0845 718 7187 

Fax 0113 241 0500 

Email member.help@mps.org.uk 

UK student membership enquiries 

Tel 0845 900 0022 

Fax 0113 241 0500 

Email student@mps.org.uk 

UK GP Practice Package enquiries 

Tel 0845 456 7767 

Fax 0113 241 0500 

Email member.help@mps.org.uk 

VOLUME 19 | ISSUE 1 | JANUARY 2011 

UNITED KINGDOM

Dr Rob Hendry - Medical Protection Society

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