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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

A confidential issue?

May I comment on the article “On deadly ground” (Casebook 21(3)); the case “CONFIDENTIALITY”. I feel that Dr W was not at fault in divulging Miss B’s HIV status with the mother present. The mere fact that Miss B allowed the mother to be present at the consultation gives the doctor the right to discuss ALL problems and queries of the patient.

In my opinion Miss B had given permission by allowing her mother in at the consultation. I always inform my patients when they allow another person into the consulting room that whatever is discussed will be with the patient’s consent and that if they are not comfortable with that we must ask the other person to leave. It is very difficult to take a complete history and at the same time think twice on what questions should be posed to the patient.

Dr JW Van Vreede, South Africa 

Response

In this scenario, the GP had wrongly assumed that the patient was content for her daughter to know confidential information regarding her HIV status. The patient, in making her complaint, had not expected that information to be divulged, and the case illustrates the dangers of making assumptions. Fortunately, although the GP had to endure the stress of a complaint to the Medical Council, the case did not proceed to a hearing.

A weekend of back pain

›› Regarding the case, “A weekend of back pain”, Casebook September 2013. One of the learning points of this case was that the claimant runs a litigation risk when pursuing a claim.

The article mentions that the claimant’s legal costs were being paid for by public funds and this was withdrawn after surveillance showed she was clearly lying regarding her disabilities. Surely she was attempting fraud by entering a fictitious claim and should be dealt with accordingly – was there any prosecution for this offence? Has she also committed a fraud by receiving taxpayer funding for her legal action to gain money by deception?

MPS should push hard for prosecution in cases such as these to reduce and deter unwarranted compensation payouts

If legally possible, MPS should push hard for prosecution in cases such as these to reduce and deter unwarranted compensation payouts.

Dr Chris Fox, Consultant Physician, East Kent Hospitals NHS Trust

Response

In this case, the claimant had a valid claim, and was entitled to the amount of compensation which was ultimately paid to her. However, she pleaded exaggerated damages, which led MPS to investigate and establish that her injury was less severe than she was claiming. This would not have impacted on her entitlement to public funding of her claim at the outset, but led to withdrawal of this funding when it was possible to show that a reasonable offer had been made.

Given that her claim was, in fact, successful, it would be difficult to secure a conviction in this case. However, I hope that this case does demonstrate how rigorous MPS is in investigating claims, paying when and where it is right to do so, and at the same time safeguarding members’ funds. You may have also noted that in the cases "A catalogue of errors" and "A restoration problem", where we were successful in our defence, MPS has sought to retrieve our costs from the unsuccessful claimant. Please do not hesitate to let me know if you have any further queries about these, or other, cases.

Poor notes: why?

›› It is a recurring observation that poor record-keeping is one of the major obstacles for MPS in defending complaints of negligence. Yet writing patients’ notes is one of the chores drilled into all of us, especially when we are training as interns.

This practice seems to wane as we get more experience and the notes become shorter and shorter, to end in no notes at all sometimes! Is this because of too much confidence, laziness or sheer carelessness? I don’t think so.

It must be a combination of many factors. I wonder if MPS could design a study to investigate this matter, difficult as it may be. Thanks for a great journal.

Dr Gustav Mutesasira, GP, Grahamstown, South Africa

Response

You are quite correct that an otherwise potentially defensible claim is often rendered indefensible if the practitioner’s recollection of events is not reflected in the records. You raise an interesting point in trying to understand why this happens. I am not sure how we could study this in a scientifically robust way, but perhaps there are analogies from other daily activities.

What is important is to continually remind ourselves how important good records are

When learning to drive, we are meticulous in following our instructor’s directions; look in the mirror, indicate and so on, and concentrate on when to depress the clutch, change gear and accelerate. As we become more experienced, not only does the process become easier, and a subconscious skill, we also sometimes cut corners and don’t concentrate on following all the rules we were taught at the outset.

What is important is to continually remind ourselves how important good records are; for continuity of patient care, as an indicator of the standard of our practice, and ultimately to enable unmeritorious claims to be defended. So it is no surprise that this is the topic in so many of our articles, features and case reports, as well as workshops and seminars. If you have any ideas about more that MPS could do, I would welcome hearing from you.

Stumbling block

›› Thank you for highlighting the important case of a nerve injury following a femoral nerve block (“Stumbling block”, Casebook 21 (3)). However I would dispute your statement that use of ultrasound has revolutionised the safety and efficacy of regional anaesthesia.

Surely the key factors in this case were the use of an unsafe nerve block technique, as well as severe deficiencies in consent and communication

Published works show a rate of nerve injury whilst using ultrasound to be similar to traditional techniques.1 Surely the key factors in this case were the use of an unsafe nerve block technique, as well as severe deficiencies in consent and communication. From the details published the decision to use a regional block at all might seem questionable, regardless of technique. The presence of an ultrasound machine would not have made any difference to these factors.

Dr Ben Chandler, Consultant Anaesthetist, Scarborough Hospital, UK

References
  1. Fredickson MJ, Kilfoyle DH, Neurological complication analysis of 1,000 ultrasound guided peripheral nerve blocks for elective orthopaedic surgery: a prospective study, Anaesthesia 64:836- 44 (2009)

Response

You correctly identify the issues of unsafe technique, consent and communication as being the factors which made this claim indefensible; the comment about ultrasound, whilst making no difference to the outcome of this case, was a comment made by one of the experts in passing.

An unavoidable amputation

›› Re: “An unavoidable amputation”, Casebook 21 (3). Thank you for your interesting case reports, which I always read.

I was trying to gain a better understanding as to why the patient, Mrs N, did not make a claim against Dr B, the initial clinician, or at least claim against both doctors. It seemed her focus was on one doctor rather than the other. This is relevant to my locum GP work.

Dr Vishal Naidoo, Portfolio GP, UK

Response

One can only presume that the claimant was either herself satisfied with the consultations with Dr B, or that she was advised by her solicitors or their GP expert when examining the record, that Dr B had exercised a reasonable standard of care. Given that the care provided later by Dr G was also considered to be reasonable, it would seem to have been the right decision.

Hospital managers: support needed

›› Dr Rob Hendry makes a very valid point in his article (“Under the influence”) in the latest edition (Vol 21 No 3, September 2013) of Casebook about failing teams being at the root of much of the problems in failing hospitals.

He is not precise about which teams he has in mind but the point is valid in all contexts; perhaps in failing hospitals it is the management team that needs most help. There can be considerable antipathy, as well as inability to understand the other’s point of view when managers and doctors meet. This may not be all that surprising when each have very different goals. People who just cannot get on need outside help.

Changing our own approach might encourage change in “the opposition” and avoid the need for involving a third party

Dr Hendry might like to follow up his comments with a note about where one should turn. I felt this was a lack in the article. His concluding comment was too vague. One needs to be aware of which of one’s actions one needs to “take responsibility for”, and how to do that.

Behaviours that impact negatively are compounded by communication failures, and some may find it helpful to read something on the subject. I would recommend a book by three American authors, which of the hundreds available and several I have read is really outstanding. Though I have not read the latest edition of 2012 there is every reason to believe it will be as good as earlier ones. Changing our own approach might encourage change in “the opposition” and avoid the need for involving a third party.

Dr Howard Bluett (retired consultant paediatrician), Tewkesbury, UK

The book recommended by Dr Bluett is Interplay: The Process of Interpersonal Communication, by Adler et al, published by Oxford University Press, USA; 12 edition (13 Jan 2012) ISBN-10: 0199827427; 1SBN-13: 978-0199827428 It will be reviewed in a future edition of Casebook.

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