New dangers

Surviving the wards is one thing, but knowing the legal dangers could save your skin. Sara Williams discusses the top medicolegal risks for new doctors

Consent

Doctors who don’t understand the purpose of consent or how to take it properly, can be sued for negligence or battery. If your actions are scrutinised by the GMC you’ll need more than a signature on a consent form to fight your corner. Consent is a process and there are many things to consider. Valid consent is about respecting patients’ autonomy and ensuring that they have made an informed decision. As GK Chesterton said: “Do not free a camel of the burden of his hump; you may be freeing him from being a camel.” New doctors should not feel pressured to do anything beyond their knowledge, experience and competence, such as obtaining consent for a procedure that they are not familiar with. Always get a senior to explain or demonstrate it as part of training.

Survival tips:

  • Always act in your patient’s best interests.
  • Document conversations.
  • Ask questions to ensure that the patient is competent and a) understands the situation, b) agrees and believes what he/she is being told.
  • Use your common sense – each consent is individual and depends on the patient’s individual circumstances. If you were treating Wayne Rooney’s right foot it would be pertinent to discuss all the side effects and potential complications particularly relevant to him.
  • Patients are presumed competent to consent unless proved otherwise. Incompetent adults unable to give valid consent should be treated using the best interests doctrine.
  • Any competent adult in the UK can refuse treatment.
  • You do not need a parent’s consent if a Gillick-competent child consents to treatment.
  • Give details so that the patient can weigh up the pros and cons of treatment and make an informed decision.

Danger rating: 5/5

Record keeping

Legible notes must be kept primarily to assist the patient when receiving care. But, secondly, should there be any future litigation against you the notes will form the basis of your defence. Notes indicate the quality of care given so get into the habit of writing accurate notes now.

Survival tips:

  • Making good notes should become habitual.
  • Always date and sign your notes. Don’t change them. If you realise later that they are factually inaccurate, add an amendment. Any correction must be clearly shown as an alteration, complete with the date the amendment was made and your name.
  • Document decisions made, information given, relevant history, clinical findings, patient progress, investigations, results and consent and referrals.
  • Avoid writing offensive comments – “Patient was not the brightest of buttons”. Assume that all records will be seen by the patient. There are moves to give patients full access in the future.

Danger rating: 4/5

Being safe

When prescribing, the hazard warning lights in your brain should be flashing persistently. This is one of the most dangerous areas for all clinicians. From over-prescribing, transferring to new charts and prescribing for the wrong patient, to forged prescriptions and overdoses, prescribing is fraught with complications. It is imperative that you have a good knowledge of the pharmacology and the legislation surrounding drugs, and the trust protocols and controlled drug routines – if unsure, ask. Always document allergies and double-check brand names, doses and frequency. You should not feel pressured to do anything beyond your competence; always get a senior to do it. If you are unsure about a prescription, or mishear on a ward round, always seek clarification, never guess. Ask ward pharmacists, or the GP – they are more than willing to help.

Handovers are another tricky area. Teams must work together in the allotted time to ensure that the clinically unstable patients are identified, plans for further care are put in place and tasks not yet completed are clearly understood by seniors and juniors.

Survival tips:

  • Prescriptions should clearly identify the patient, the brand, the dose, frequency and start/finish dates, etc, be written clearly or typed, and be signed by the prescriber. Always be aware of prescribing a drug that a patient is allergic to.
  • Good handovers require good leadership and communication.
  • Refer to your BNF (your prescribing bible). It is available online if your copy goes walkabout.

Danger rating: 4/5

Confidentiality

There is no such thing as “can you keep a secret, doc?” It is part of a doctor’s job description to protect patient’s personal information. Confidentiality is the bedrock of a successful doctor-patient relationship, indeed the word “confidence” derives from the Latin con “with” and fidere “to trust”. The GMC is explicit that doctors who break a patient’s trust undermine the entire medical profession and they will be dealt with very seriously.

Survival tips:

  • Remember that confidential information includes the patient’s name. Competent children have the same rights to confidentiality as adults.
  • Doctors can breach confidentiality only when their duty to society overrides their duty to individual patients and it is deemed to be in the public interest. Think alcoholic astronaut.
  • Doctors are required to report a range of issues, including notifiable diseases, births, abortions and people suspected of terrorist activity, and this would be a justified breach of confidentiality.
  • The courts can require doctors to disclose information, although it would be a good idea to contact MPS if you find yourself presented with a court order.
  • High-risk areas where breaches can occur are lifts, canteens, computers, printers, wards, A&E departments, pubs and restaurants. Be careful not to leave memory sticks or handover sheets lying around.

Danger rating: 3/5

Documentation

In England, patients who succumb to their illness have their death certified by their current doctor, as long as he/she saw them during the 14 days before death (28 days in NI), or he/she has examined the body after death. A Medical Certificate of the Cause of Death (MCCD) is then sent to the local Registrar of Births, Deaths and Marriages. If the deceased is cremated the treating doctor must sign a cremation form, with a second completed by another doctor. (Read our Practical Problems feature for more information on how to write death certificates). If a patient’s death requires further investigation, eg, they died during an operation, a doctor should refer them to a coroner, who will investigate unnatural deaths to ascertain the medical cause.

The coroner will do this by organising a postmortem or holding an inquest (an inquiry into the facts surrounding the death). As a junior doctor if you refer something to the coroner, the process must be discussed with the family. You may encounter families who don’t want certain information visible on the death certificate (eg, HIV – a box is ticked to certify the patient had it), but doctors have a legal and professional obligation to complete the certificate truthfully.

Survival tips:

  • Patient confidentiality must be respected when helping a bereaved family come to terms with death.
  • If you are unsure of the cause of death, refer the case to the coroner.
  • Take steps to verify what you are saying. Never sign a form unless you are absolutely sure that what you are saying is true.

Danger rating: 2/5

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