Ask the experts
MPS medicolegal adviser Dr Sarah Townley answers common medicolegal queries from sessional GPs
Query 1
A 17-year-old female patient rang the out-of-hours (OOH) centre complaining that she had recurrent symptoms of a chest infection. A treatment centre visit was arranged, the diagnosis was confirmed by a GP and the patient was prescribed amoxicillin.
Unfortunately, the patient was allergic to penicillin and had an anaphylactic reaction requiring hospital treatment. The initial call to the OOH centre was recorded by the triage nurse and the patient volunteered the information that she was allergic to penicillin. In addition, the patient was clear that she told the GP that she was allergic to penicillin – an allergy history was not recorded in the OOH record. MPS member
One of the main difficulties of OOH sessional work is the lack of access to patient medical records. It is essential to remember that histories taken from patients seen in an OOH setting may need to include details that aren’t routine in a normal GP consultation.
Adverse reactions to medicines are particularly important as an alert will not routinely flash up if the information has not been previously recorded
Adverse reactions to medicines are particularly important as an alert will not routinely flash up if the information has not been previously recorded. In Good Practice in Prescribing Medicines, the GMC advises that you should be in possession of an adequate history from the patient, including any previous adverse reactions to medicines, current medical conditions, and concurrent or recent use of medicines, including non-prescription medicines, in order to prescribe responsibly.
This case also highlights the importance of reviewing all the OOH notes, including the triage notes, as they may hold essential information, particularly in the cases of patients who may struggle to give adequate information. In this case, a claim ensued and the GP was adamant that they had asked the patient about any allergies and none were reported.
However, given that no allergy history was recorded, together with the fact that the patient volunteered the information to the triage nurse, the GP accepted that the best way forward was to resolve the claim by way of an early negotiated settlement.
Query 2
I’ve started working in a new practice. Recently, one of the partners mentioned that she’d been given an expensive necklace by a patient, whom she has been treating for six months for a psychiatric illness. I’m not sure what to do with this information. MPS member
You must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit you
Accepting gifts from patients has both ethical and contractual considerations. Contractually, individual GPs and contractors must keep a register of gifts from patients that have a value of over £100. The PCT can request to see such registers. The register should record the name of the donor, nature of the gift and its approximate value. GPs should also consider whether they need to take financial advice regarding the tax implications of such gifts.
The GMC advises on the ethical considerations, stating: “You must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit you.” Essentially, you must remain transparent and accountable when receiving gifts from patients.
In this case, it is imperative to gain further information from the partner regarding the gift received and then perhaps offer helpful advice regarding a gift register within the practice. If you are concerned after this that there may be potential exploitation of a vulnerable patient, then it would be reasonable to raise the matter with a senior partner within the practice or, failing this, with the PCT.
Query 3
Recently, I saw a 13-year-old patient who had an ectopic pregnancy. She had been on the pill for the last few months.
One of the other GPs in the practice said that her parents are patients at the surgery too. Should I tell them about this? How can I determine if she is mature enough to give consent? MPS member
This is a complex case raising issues including confidentiality, consent and child protection. When assessing if a young person is mature enough to give consent, you have to decide if the patient understands the nature, purpose and consequences of the treatment you are proposing.
If you conclude that they can understand, retain and weigh up the information and then communicate their decision, then they would appear to have capacity to consent. Always remember that capacity is decision specific. Even if the child does have capacity, it is always good practice to encourage them to involve their parents or a trusted adult to help them in a difficult situation.
There are only a few circumstances where you can disclose information without [the patient's] consent
If the patient does not want her parents involved, there are only a few circumstances where you can disclose information without her consent. The GMC, in 0-18 Years: Guidance for all Doctors, advises that these situations include: when there is an overriding public interest; if the disclosure is in the best interests of the child who does not have the understanding to make a decision about disclosure; or when it is required by law.
If you consider the child to be at risk of sexual abuse or at risk of serious harm, then it would be reasonable to disclose such information. However, you should advise the child what you plan to disclose and explain why before disclosure, unless that would put the child at increased risk of harm.
If you are unsure whether disclosure is appropriate you should seek advice from a senior colleague, the local doctor for child protection or your medical defence organisation. If they do advise disclosure then you would have to justify a decision not to disclose.
In order to make this assessment it is important that you gain further information from the child. Worrying features in the history would include big differences in age between sexual partners, the sexual partner holding a position of trust, the use of force, drugs or alcohol, or involvement of any person known to the police or child protection agencies.
It is worth noting that sexual activity with a child under the age of 13 amounts to an offence of rape under section 5 (1) of the Sexual Offences Act (2003), hence consideration should always be given as to whether or not such cases should be brought to the attention of the relevant agencies.
These cases are fictional, but loosely based on cases in which MPS has been involved. If you would like to ask one of our medicolegal panel a question please contact sara.williams@mps.org.uk.