Problems in clinical management

Any doctor can make an error of judgment. Some are legally defensible, others are not; what is important is whether the management can be defended by a responsible body of professional opinion

Negligence is a legal concept. It does not mean neglect or wilful misconduct, but a failure to attain a reasonable standard of care. Any doctor can make an error of judgment. Some are legally defensible, others are not; what is important is whether the management can be defended by a responsible body of professional opinion.

In cases of negligence, the only remedy available in law is financial compensation: damages are paid to restore claimants to the position they would have been in had the negligent act not occurred. Before damages are payable, however, the claimant must prove all three of the following:

• They were owed a duty of care.
• There was a breach of that duty of care.
• Damage was suffered as a result.

Clinical practice

The courts assess standards of clinical practice by the “Bolam test” (in England and Wales, though similar standards exist in Scotland and Northern Ireland). Bolam sustained fractures during electroconvulsive therapy carried out in the early 1950s.

In the subsequent court case, experts for the claimant and defendant could not agree on whether Mr Bolam should have been given a muscle relaxant. The judge set out the following test in his summing up to the jury:

“A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art … putting it the other way round, a doctor is not negligent if he is acting in accordance with such a practice, merely because there is a body of opinion that takes a contrary view.”⁶

Adopt accepted practice

Evidence-based guidelines improve the quality of clinical decisions and provide benchmarks for clinical governance

Accepted practice is easy to define in some areas – prescribing in accordance with the recommendations of the British National Formulary is an obvious example. Increasingly, proper practice has to be based on evidence (ie, determined by systematic methods based on literature review, critical appraisal, multidisciplinary consultation and grading of recommendations by strength of vidence). Evidence-based information concerning practical aspects of a wide range of conditions can be found on the internet (see Appendix 1).

Accepted methods of investigation and treatment are often described by clinical guidelines. Such evidence-based guidelines improve the quality of clinical decisions, help replace outdated practices, provide a focus for audit of clinical practice, and provide benchmarks for clinical governance.

Of course, guidelines are guidance, not instructions or commands. They should be regarded as aids to, not substitutes for, clinical judgment and must be interpreted sensibly and applied with discretion. If you decide not to follow the guidelines and your judgment is called into question, you will have to demonstrate why you were justified in not complying with the guidelines. Conversely, if you follow respectable clinical guidelines and base your decisions on evidence, you will be in a very strong position if a complaint is made against you.

Act within your limitations

Although doctors are not expected to be infallible, the law requires that they exercise a reasonable standard of skill and care at all times.

• Never undertake a task that is beyond your competence – when in doubt, seek help from a more experienced colleague.
• Ensure you have sufficient help and equipment available for any procedure you undertake, and for the management of all foreseeable complications. 
• Ensure that you are familiar with the equipment that you are using or expecting others to use and that it is in full working order before beginning any procedure.
• Always explain to the patient what you are intending to do and why (see section on consent).

Delegate appropriately

In the context of multidisciplinary and cross-agency teamwork, it can be difficult to distinguish between delegation and shared responsibility. The question is really one of accountability, and the GMC states quite clearly in Good Medical Practice (para 41) that “[w]orking in teams does not change your personal accountability for your professional conduct and the care you provide” and, furthermore, that you must “make sure that your patients and colleagues understand your role and responsibilities in the team, and who is responsible for each aspect of patient care”.

As a member of a clinical team, you will have ongoing responsibilities for the care of patients, some of which you might delegate to staff who do not belong to a registered professional organisation. In these circumstances you would be held accountable for the actions of those staff members, so you must satisfy yourself that they are competent to take on the duties you are delegating to them and supervise them if necessary.

The matter is a little different when you delegate to a professional colleague. You would not be held accountable for the actions of another registered professional; however, you would still be expected to delegate appropriately (ie, to a colleague with relevant training and skills) and to have provided them with sufficient information to carry out the task assigned to them.

Keep comprehensive up-to-date records

A good medical record should provide all the information a newcomer to the care team would need to know about a patient and their treatment plan

The medical record is an essential component of patient care. It should contain sufficient information to “identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among healthcare providers”.⁷ A good medical record, should, therefore, provide all the information a newcomer to the care team would need to know about a patient and their treatment plan.

If you need to alter the notes at a later date, make it clear that you are introducing a retrospective correction. Any alteration to paper records should be clearly dated and signed. Do not obliterate the original entry – just run a line through it. Never try to rewrite notes at a later date. Do not delete entries in computer records, but add annotations to them if necessary (and date and initial them if the software doesn’t do it automatically).

Do not write derogatory statements or criticisms about patients, colleagues or others; be as objective and factual as you can in making your notes. If you record any history provided by someone other than the patient, make sure you include the source – eg, “Has been ‘confused lately’ (daughter)”. Remember, patients have a legal right of access to their records, which can also be scrutinised by the courts.

Safeguards for procedures

Before carrying out a procedure, always check the patient’s identity and look at the casenotes to establish the nature and site of the procedure

Every hospital will have policies and procedures in place for checking drugs and dosages before they are administered, identifying the part of a body to be operated on, counting swabs and instruments, and so on. Even so, there are numerous patient safety incidents, complaints and negligence claims to show that these checks are far from foolproof; it is too easy to become complacent and assume that they have been carried out competently.

• Before carrying out a procedure, always check the patient’s identity and look at the casenotes to establish the nature and site of the procedure, even if someone else has already prepared or marked the site.
• Familiarise yourself with your hospital’s policy on ordering and administering blood products.
• Make sure that any specimens and accompanying forms or reports are accurately and fully labelled.
• See that all hazardous substances and waste are labelled with appropriate warnings.
• Be aware of health and safety legislation as it applies to your day-to-day work, eg, disposal of sharps, etc.