Multiple jeopardy

MPS is involved in hundreds of legal actions each year, and it can be a stressful and harrowing time for the unprepared. Sara Williams talks to GP Dr Paul Davis about his experiences and explores what help is available when things do go wrong

When a patient takes action against a doctor, the experience can be likened to a “death by 1,000 arrows”. This refers to the multiple pathways that are available for patients to seek redress and scrutinise their treatment.

From one single incident, doctors can be held accountable and have their professional conduct dissected in a number of ways – by their regulatory body, coroners, criminal and civil courts, healthcare regulators and the various bodies that handle complaints. This is also known as “multiple jeopardy”.

Last year, the Faculty of Forensic and Legal Medicine of the Royal College of Physicians held a conference, at which Ann Abraham, the UK Parliamentary Ombudsman and the Health Service Ombudsman for England, urged doctors not to view multiple jeopardy as intimidating, but as a mechanism of multiple benefit that is worthwhile. By this, one assumes, she means learning and reflecting when things go wrong.

In May 2005, Dr Paul Davis, a GP from Hertfordshire, experienced the process firsthand when:

• he was involved in an inquest
• he received a complaint
• he received a GMC referral
• he received a claim 
  – all from one case.

It taught him the importance of good record keeping and why appropriate indemnity is vital.

Dr Tom Lloyd has been an MPS medicolegal adviser for four and a half years, and in that time he has handled more than 1,500 cases. “It can be very hard for doctors to deal with all the different procedures involved, over what is often a significant length of time. Each stage has different processes that are aiming for a different outcome. Unfortunately, Dr Davis’ experience is not unique.

“The key to managing complaints and claims successfully is to seek help early on. If you do not know where to turn please contact MPS, as we are there to give advice and help you.”

Receiving a complaint

Complaints are an inevitable reality of busy and challenging clinical practice; however, this doesn’t make the experience any less unpleasant. Complaints are a challenge to a doctor’s professional practice, which can have a profound impact on their relationships with their patients.

But, if complaints are only viewed negatively, they can lead to demoralisation and increasingly defensive practice. It is important to view the complaints process constructively, as a way of seeking a patient’s input, and opportunity to learn and improve patient care. It also ensures that doctors are, as society expects, seen to be accountable.

When Dr Davis received the complaint about his practice four years ago, he was shocked and extremely upset. “I received a letter of complaint alleging clinical negligence six weeks after I’d seen a patient who later died. I had seen the man at his home. I diagnosed a viral infection and left contact numbers to use if he got worse.

“I had no further contact with the patient and he was found dead three days later. I was devastated. I began to doubt myself and, in particular, my clinical skills. What had I done wrong? I carried on working, but was struggling emotionally.”

Many doctors find it hard to admit that they are struggling or need to seek the necessary help. Often even the immediate family may be unaware of the case, in circumstances where the doctor has deliberately kept his ordeal from them.

Fortunately, Dr Davis realised that he needed to do something. When he received the complaint letter, he took sick leave and went to see his GP, who prescribed him antidepressants. He also accessed a counselling service provided by the local PCT. Through this service he saw a clinical psychologist, who identified signs of post-traumatic stress disorder, and provided treatment which proved beneficial.

Dr Davis became increasingly anxious about not being at work, so returned from sick leave after one week to perform light duties. “During the next few weeks the anxiety lessened as the antidepressants and counselling started to work, but I was still getting flashbacks and my thoughts were often preoccupied. My reaction was very similar to someone who had experienced bereavement. I constantly worried about my future.

“My colleagues were very supportive and understanding. I asked one of the partners to mentor me and oversee my work to ensure I was safe to practise. In due course he said that the practice had no concerns about my standard of work and decided that ongoing monitoring was not necessary. Also, seeing my GP weekly was very beneficial.”

Such a reaction is normal in response to an extremely abnormal event. According to Dr Lloyd there is a deep reluctance within the medical profession to admit that you are having difficulty coping. “If you are involved in a serious adverse event such as Dr Davis’ it is important to reflect on your own health without embarrassment. Speaking to your GP or occupational health physician can be enormously beneficial.

“It may be that a short period off work or a reorganisation of your working day is enough in the short-term to help you manage. For those not directly involved, but aware that a partner or colleague is involved in a case, it is important to be supportive and look out for signs that they need help. The fact that Dr Davis’ practice helped him and supported him through the case was of enormous benefit.”

GMC referral

The General Medical Council (GMC) began its investigation into Dr Davis’ fitness to practise in August 2005. Dr Davis met with MPS and an independent medicolegal report from a GP expert was commissioned. This report was favourable and concluded that none of the professional standards set by the GMC had been breached.

However, Dr Davis still felt ashamed that he was being investigated by the GMC and that he had let down his patients, colleagues and family. He often asked himself – was he a bad doctor?

Dr Lloyd says: “GMC investigations do strike fear into any doctor. Many worry that they are going to be struck off the register, although in fact this is an infrequent sanction. However, the GMC does have lesser sanctions that can restrict a doctor’s professional practice. Again it is important to discuss with MPS any letter received from the GMC so that we can provide advice and explain the processes and timescales involved.”

Inquest

The inquest was held five months after the patient’s death, and two months after the complaint to the GMC. (Doctors should be aware that timescales are very variable and it can take many months before an inquest is held.) The coroner attributed the cause of death to natural causes, and made no criticism of the patient’s care.

“At the inquest I found being cross-examined one of the most harrowing experiences of my career. When it was over I was relieved at the outcome, but I was also aware that the rest of the other processes could take a long time to be concluded. It was impossible to “move on” knowing that the GMC and litigation proceedings were ongoing.”

Dr Lloyd says: “Dr Davis’ description of giving evidence at an inquest is one experienced by many doctors. It is often the first time that a doctor has been directly questioned in an adversarial environment. Discussion with MPS about any forthcoming inquests is important so that we can try and minimise the stress of such an experience.”

Claim

After the inquest, the patient’s partner withdrew the health service complaint and concentrated on legal action. As a result the complaint against Dr Davis was never formally answered. The GMC concluded its investigations in June 2006, stating in a letter that the case was being closed after the initial enquiry stage because there had not been any breach of the Good Medical Practice guidelines and that no further action was needed. The letter was received 13 months after the death of the patient and 10 months after the GMC started its investigation.

A year later, in May 2007, both parties met. It was agreed to settle the claim, but for a third of the sum sought and without admission of liability. This reflected some weaknesses in the defence – and the inevitable risks and inherent unpredictability in litigation.

Dr Davis said: “I was relieved that we were not going to have to go to court and the case was reaching closure, but I did not find the denial of liability comforting – I still felt that I had been considered negligent. However, the GP expert, barrister and solicitor were all very supportive – one commented that it was the best set of case notes he had seen.

“MPS was fantastic in terms of the support and advice I received and really looked after me.”

Handling the media

Few doctors would welcome being approached by a reporter with questions about patients’ care – especially when it comes out of the blue. In July 2007, Dr Davis was approached by two newspapers for comments about the case. He contacted MPS and the press office gave him advice on how to handle the journalists’ queries and provided a statement.

Dr Davis said: “The press coverage that followed was unexpected and caused particular anguish; I wondered whether it was ever going to end. The one-sided reporting by a couple of the newspapers was particularly upsetting – I worried about what my friends and family would think. But as it turned out, I received few comments from patients, and most of those were supportive.”

“The MPS press office is staffed by professionals experienced in dealing with the media. If you find yourself in a similar situation, it is important that you know what to do. MPS has produced a guide to handling the media, which is available on the Publications section of the website,” says Dr Lloyd. “The press office will assess how best to manage your individual situation and let you know how they can help. The press office is available 24 hours a day, seven days a week, with an on-duty press officer contactable outside normal office hours.”

Conclusion

Dr Davis has spoken candidly on a personal level about the difficulties he faced during the years this case lasted. He obtained the support he needed that enabled him to overcome the litigation process and multiple jeopardy. It is helpful for doctors in a similar position to understand the lengthy timescales involved in litigation, the many other proceedings which can run in parallel, and the long periods of "no news".

Doctors are more used to experiencing the consequences of their decisions within a tight timeframe; they often find these lengthy and unpredictable timescales difficult, and require support from professional and personal sources throughout the process.

Ways to manage the stress of complaints and claims:

• Understand that one incident can lead to many lines of enquiry 
• Discuss your concerns with professional colleagues and family and seek their support
• Take advice at the earliest opportunity from MPS
• Recognise the potential for impact on your health, and consult your GP
• Learn positively from the event and make changes in your practice and personal life to reduce risks of similar complaints in the future
• Support colleagues who go through a similar process.

Help points

• MPS 
• GP 
• Occupational Health
• Partners and colleagues
• Doctors’ Support Line – 0870 7650001
• BMA Counselling Service – 08459 200169
• Practitioner Health Programme – 0203 049 4505 – www.php.nhs.uk