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Over to you

We welcome all contributions to Over to you. We reserve the right to edit submissions.
Please address correspondence to: Casebook, MPS, Victoria House, 2 Victoria Place, Leeds LS11 5AE, UK. Email: casebook@mps.org.uk

Ignoring the guidelines

Re: The case report “Ignoring the guidelines”, Casebook 21(1), January 2013

›› I have some years’ experience with a medicolegal practice in obstetrics and gynaecology and as a trainer for the Inner Temple. I read this article with some degree of incredulity. Personally, I would find it very difficult to criticise many of the actions of the obstetrician involved and indeed to follow the guidelines in the particular case with a poor outcome could be considered to be negligent.

In many emergency cases it is entirely appropriate for the clinician concerned to act within their abilities. Even if the guidelines make particular recommendation, it would be unwise to adhere to it in an emergency situation if they have no experience of using a particular drug or a technique.

In the situation you describe it would not be appropriate for the individual to do anything other than what they are familiar with. At no point does anyone question the validity of the guideline.

I would be disappointed if this case was not robustly defended. In my own experience I have made the mistake of relying on RCOG (Royal College of Obstetricians and Gynaecologists) guidelines in the past, only to be demolished and humiliated by the opposing side when they have pointed out their inconsistencies.

In my own experience I have made the mistake of relying on guidelines in the past, only to be demolished and humiliated by the opposing side when they have pointed out their inconsistencies

I would draw your attention to the fact that guidelines are indeed just that and that they are not tramlines, and that in such a case any clinician should have the intellectual rigour to base any actions on their own knowledge, experience and abilities. Thankfully, in most cases guidelines are based on good evidence and there is little dispute.

However, I think it is an exceptionally worrying development if one merely judges a colleague’s actions by comparing it with a guideline checklist that has been produced by a committee. Often the most sensible opinion is based on experience, meticulous research of the literature and careful thought. Unfortunately there is a paucity of all three in many reports I see today.

Dr Mike Bowen, UK

Response

We would agree that strict adherence to guidelines is not mandatory, and that circumstances will arise where this strict adherence is not inevitably in the patient’s best interests. Guidelines are intended to represent pooled experience of best practice, and so if a decision is made to depart from them, the clinician doing so has the burden of being able to explain and justify why that decision was appropriate – and document the reasoning.

You will have noted that there were other criticisms in the case – failing to attempt less radical procedures before proceeding to hysterectomy and lack of documentation.

Ignoring the guidelines 2

›› I read with interest the report on “Ignoring the guidelines” in the January 2013 case of postpartum haemorrhage (Casebook 21(1)). Whilst I agree that the ultimate decision on the most appropriate surgical management of this patient lay with the obstetrician on-call, it is important to point out that the medical management of the patient up to that point (including maternal resuscitation, and the correct implementation of the local massive obstetric haemorrhage guidelines) was the joint responsibility of the obstetrician and the obstetric anaesthetist on-call covering the labour ward.

Generally, when a massive obstetric haemorrhage occurs, in most obstetric units, the anaesthetist should take the lead with the administration of intravenous syntocinon (+/- infusion), im/iv ergometrine, im carbaprost, intravenous fluid resuscitation and administering packed red cells/blood products, since they are most familiar with these drugs and in those specific aspects of maternal resuscitation; the obstetrician (assisted by the midwifery team) should take the lead with the usage of pr misoprostol and im syntometrine, external uterine massage and bimanual compression, since they are most accustomed to using these particular drugs/techniques.

Once the decision to go to theatre has been made (jointly), whilst the anaesthetist should mainly concern themselves with continued maternal resuscitation, they still have a duty to discuss/remind the obstetrician of their available surgical options (B-Lynch suture, internal iliac/uterine/ ovarian arterial ligation, packing of the abdomen as a holding measure or to enable angiography +/- embolisation, hysterectomy, cross clamping the aorta etc, depending on the clinical scenario and cardiovascular/haematological stability), particularly if there is perceived deviation from local/national guidelines.

It is important to point out that the medical management of the patient up to that point was the joint responsibility of the obstetrician and the obstetric anaesthetist on-call

Massive obstetric haemorrhage is an extremely stressful clinical situation, particularly for the obstetrician, therefore the anaesthetist plays a crucial role in ensuring that logical sensible decisions are still being made amidst the mayhem, which includes insisting that the obstetrician calls for further assistance/senior help/consultant advice/consultant to come in, if the clinical situation warrants it.

Maternal resuscitation in massive obstetric haemorrhage is most effective when the labour ward obstetricians, anaesthetists and midwives work together as a team, so that the guidelines are followed and the appropriate decisions are made at the appropriate times, to achieve the best maternal outcome (which may still unfortunately be a hysterectomy, but at least the appropriate steps to justify that decision will have been taken along the way).

Dr Patrick Ward, specialty trainee, anaesthetics, UK

Note from Casebook:

Effective teamworking is part of the training offered on behalf of MPS by Atrainability, an organisation that specialises in the roles human factors and situational awareness play in risk and patient safety. Visit www.atrainability.co.uk for more information.

Ignoring the guidelines 3

Re: The case report “Ignoring the guidelines”, Casebook 21(1), January 2013

›› I think MPS should push for clarity regarding what is meant by the term “guideline”, particularly in the context of “NICE guidelines”. Vociferous lawyers often pursue doctors for not following NICE guidelines (which they see as rules), yet we are taught as doctors to ‘think outside the box’ and beware exceptional/atypical patients.

Moreover there is very little evidence for many of the NICE guidelines (some are graded low level of evidence and often simply considered as good professional practice). My belief is true guidelines represent more generic guidance that apply to the majority of patients with that condition, and provide a fallback when you may be otherwise unclear how to treat a condition.

My belief is true guidelines represent more generic guidance that apply to the majority of patients with that condition, and provide a fallback when you may be otherwise unclear

In the case you presented there was a lack of adherence to basic common sense and it should have been called “Ignoring the protocol”. In fact in that article the author loosely switches between the terms “protocol” and “guideline”.

I am happy to be pursued by a lawyer for not following a protocol, but would expect to be supported by MPS for not following a guideline – could MPS explain the different terms to our legal friends and fight for tighter use of the correct terminology?

Dr John Hewertson, UK

Response

We agree with your comments; guidelines tend to be based on pooled experience and opinion of best practice and can be used to standardise care and improve quality of care. Healthcare providers should know about the guidelines relevant to their field of practice, and then be able to decide whether or not to follow them for an individual patient.

The weight attached to a guideline will be influenced by the authority of the issuing body; for example, it might be a challenge to successfully argue against following some regulatory guidance. Protocols are built on a set of rules which healthcare providers are expected to follow, and in some contexts are stricter than guidelines and so carry more legal weight.

In clinical practice the terms are often used interchangeably, as you have observed. The terminology used would be but one consideration of what constitutes practice that would be supported as reasonable by a responsible body of the profession working in that field. And MPS would be very clear in explaining that to a claimant lawyer, where it was necessary to do so, in the defence of a claim.

More on primary postoperative care

›› I found the letter from a consultant surgeon on this matter in the January 2013 Casebook (“Primary postoperative care”, Over to You) very interesting – but it does not complete the picture on the whole issue of secondary care discharges to primary care.

As a manager who has to deal increasingly with patient complaints in a general practice, the discharge process and continuity of care does give a great deal of disquiet.

I fully understand the pressures to discharge quickly from secondary care – as GPs take on the financial responsibility for the cost of referrals [in the UK] this is only going to increase. The problem I see is in the quality of discharge notifications and how timely they are. There is no common format for discharge information being provided and important facts are never highlighted in the same place in the variety of documents that drop into our inboxes from hospitals.

There is no common format for discharge information being provided and important facts are never highlighted in the same place in the variety of documents that drop into our inboxes from hospitals

This places the GP in danger of missing some important detail and joining both the GP and the consultant at risk of legal action. To round off the point, if a discharge is made “in haste”, then flagging up such issues as the need for the follow-up to take place in primary care and making sure the GP gets this information is even more important.

Alan Moore, Group Manager, Great Sutton Medical Centre, UK

Where the heart is

>> I read with interest the last issue’s compendium of mishaps. I would like to point out that in “Where the heart is”, the statement “Mr R’s symptoms were potentially life-threatening” is inaccurate. In fact, those symptoms can and often do represent life-threatening conditions, but they are not in themselves fatal.

My main gripe however is with the statement “...where a cardiologist would have diagnosed him and Mr R would have survived”. It certainly isn’t the case in my (A&E/ITU-bearing) hospital in rural West Wales that Mr R would have been guaranteed to be seen by the only cardiologist on staff. Nor could we have guaranteed that the large saddle embolus in his pulmonary artery would not have killed him. A small point perhaps, but definitely one to reflect on.

Dr Gavin Ross, Haverfordwest, Pembrokeshire, UK

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