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Inappropriate delegation

01 January 2011

Mrs R, a 42-year old 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 post-thyroidectomy 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 could 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.

Learning points

  • 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.