Dr Rob Hendry - Medical Protection Society

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22 CASE REPORTS ENT CONSENT/COMPETENCE UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk 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. LEARNING POINTS 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 OPINION 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. The claim was settled 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. EXPERT OPINION 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 LEARNING POINTS 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. The claim was settled 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 UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk
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Page 3 and 4: ON THE COVER 8 On the defensive Whe
Page 5 and 6: EVENT FOCUS: SOUTH AFRICA Doctors o
Page 7 and 8: Images courtesy of The National Arc
Page 9 and 10: WHAT IS IT? Defensive medicine is c
Page 11 and 12: Be open about error Dr Aidan O’Do
Page 13 and 14: There is concern that “too much
Page 15 and 16: Introducing… Membership Governanc
Page 17 and 18: Missed opportunities Daniel Miss R
Page 19 and 20: To operate or not to operate? Mr B,
Page 21: Repeat offender kastock/iStockphoto
Page 25 and 26: see the benefits of careful return
Page 27 and 28: MPS Risk Solutions Knowledge… Exp

Dr Rob Hendry - Medical Protection Society

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