Perils of the twilight zone

There has been a significant rise in out-of-hours complaints and claims against GPs. Dr Rachel Birch and Dr Richard Stacey explore the risks of working in this environment, drawing on real cases

During the last few years there has been a distinct rise in complaints and claims arising from consultations in the out-of-hours (OOH) setting. Providing general practice care in the OOH setting carries both unique risks and vulnerabilities.

Telephone triage has its own unique risks

This is the result of several factors that can be summarised as follows:

  • In most OOH consultations GPs are dealing with patients who are completely unfamiliar to them, and it is recognised that such patients have a lower threshold for making a complaint or claim.
  • A consulting GP in OOH will not have access to the patient’s complete GP records.
  • The fact that a patient is calling OOH may reflect that they have a heightened degree of concern about their symptoms and/or feel it needs dealt with as a matter of urgency.
  • Patients may have an unrealistic expectation that they are entitled to a home visit and/or may be unhappy at having to travel to an OOH centre.
  • Telephone triage has its own unique risks.
  • While the vulnerabilities in the OOH setting differ to those in conventional general practice, the steps you can take to protect yourself are remarkably familiar.

Clearly communicate

Developing a good rapport with patients is a must. You will see from the scenario “Pushing on an open door”, that while Dr Smith did not explore the possibility of a potentially serious diagnosis, Mrs Jones did not pursue a complaint on the basis that she had developed a good rapport during the telephone triage consultation.

Developing a good rapport with patients is a must

Tips that may help you develop a good rapport with patients in the OOH setting are as follows:

  • Introduce yourself – It is important to introduce yourself clearly at the start of the consultation, as a failure to do so can set the consultation off to a bad start. Many complaints relating to OOH care often make reference to the fact that the doctor did not introduce themselves.
  • Explore the medical history – In addition to exploring the presenting complaint, given that you do not have access to the full general practice records, it is important to explore the relevant past medical history, current medication and treatment history, allergy history and, where relevant, social and family history.
  • Explain nature of examinations – It is important to explain carefully the nature and purpose of any examination you intend to undertake. Remember to offer a chaperone in circumstances where you are contemplating an intimate examination.
  • Explore the diagnosis – You should clearly explain the diagnosis, together with any proposed treatment.
  • Provide safety-netting advice – You should provide appropriate safety-netting advice, which should include how the patient can re-access the OOH service should they need to do so.

Justify your management

It is extremely important to put yourself in a position to justify your management decision

When patients contact OOH services it is not unusual for them to ask for a home visit, while in many cases their problem can be appropriately managed either through a telephone consultation or through a consultation at an OOH centre; if there is an adverse outcome, patients will often allege that their request for a home visit was refused.

It is therefore extremely important to put yourself in a position to justify your management decision. In the scenario “A disputed visit request” [below], Dr Dunn was confronted by Mrs Coates who was seeking a visit for her daughter Jennifer, and fell into the trap of entering into a dispute about the OOH visiting policy.

In circumstances where a patient is complaining of abdominal pain, it is almost inevitable that a doctor will be criticised if they have not undertaken an abdominal examination, hence if a patient is particularly insistent on a visit and there are reasonable reasons why they may not be able to attend, then the safest approach is to undertake the visit.

Record-keeping

Comprehensive record-keeping is fundamentally important in general practice; however, in OOH it is particularly important for the following reasons.

  • You are particularly vulnerable to complaints and claims in OOH and your records will form the basis for your defence should your practice be criticised.
  • Your records are not only important for you, but for others who may be involved in a patient’s care. In the OOH setting it is much more likely that your records will be viewed by a colleague who has no previous knowledge of the patient, and therefore it is particularly important that they accurately reflect your consultation. It is not uncommon for complaints to arise in circumstances where there have been several calls to the OOH service.
  • A copy of your records will be forwarded to the patient’s regular GP and it is important that they are made aware of the nature and outcome of the consultation.

Providing general practice care in the OOH setting presents difficult challenges. However, it can be extremely rewarding and while there is a higher risk of a complaint or claim, equally it is not uncommon for patients to write with letters of thanks for treatment they have received.

In order to protect yourself as an OOH GP, it is important to be aware of the pitfalls and to take all reasonable steps to minimise the perils of the twilight zone.

Case 1: Pushing on an open door

Dr Smith was doing a Friday evening base session for his local OOH provider. She was asked to triage a call from 30-year-old Mrs Jones and note that the OOH call operator had recorded the following entry on the computer record: Patient thinks she has a urine infection and is requesting a prescription for antibiotics.

Dr Smith agreed that a urinary tract infection was the likely cause of her symptoms

Dr Smith called Mrs Jones, who was most apologetic for calling OOH. She explained that she had been experiencing vague lower abdominal pains and slight dizziness and, for the last eight hours, she had been passing urine more frequently.

Mrs Jones explained that she had to attend her father’s 60th birthday party on the following Sunday and wanted to feel better in time for the celebrations. Mrs Jones also said that she had had a urine infection several years previously and that it had responded to Trimethoprim.

Dr Smith agreed that a urinary tract infection was the likely cause of her symptoms and arranged for a prescription to be “phoned through” to the local pharmacy that was open late. Dr Smith advised Mrs Jones that she should see her GP after the weekend and take along a urine sample if her symptoms did not settle.

Dr Smith made the following entry in the records:

Urinary frequency, low abdominal pains and dizziness. Patient thinks she has a UTI – Trimethoprim helped previously. Rx Trimethoprim 200mg bd (6) – phoned to late-opening pharmacy. Adv – r/v with own GP after w/e if symptoms do not improve (with an MSU).

In the early hours of the Saturday morning, Mrs Jones’ abdominal pains intensified and she collapsed. Mr Jones called an urgent ambulance, which took Mrs Jones to the local hospital where a diagnosis of a ruptured right tubal pregnancy was made. Mrs Jones had emergency surgery and made a good recovery.

Outcome

Mrs Jones reassured him that she had no intention of making a complaint, as she had found Dr Smith to be “most friendly and helpful” when she had called

Upon receipt of the OOH contact log, Mrs Jones’ regular GP contacted Dr Smith to update him on the unfortunate outcome. Dr Smith decided that he would write to Mrs Jones to pass on his sympathy and apologies (and to wish her well with her ongoing recovery).

Mrs Jones subsequently wrote back thanking Dr Smith for his ongoing interest in her case and reassured him that she had no intention of making a complaint, as she had found Dr Smith to be “most friendly and helpful” when she had called.

Learning points

  • Beware of pushing on what appears to be an open door… it might slam back in your face.
  • Beware of the pitfalls of telephone consultations: in this case an examination including pulse, blood pressure, abdominal assessment and urinalysis/pregnancy test may have assisted.
  • In the context of a telephone consultation it is important to fully explore and document the history. Unfortunately, Dr Smith did not explore the possibility that Mrs Jones may be pregnant.
  • In circumstances where a patient suspects they know the diagnosis and the required treatment, it is important to consider other diagnoses and treatment options.
  • If you see a fertile female with abdominal pains, ask the menstrual history.
  • In this case, Dr Smith fell into the trap of colluding with Mrs Jones’ self-diagnosis and treatment plan.
  • It is important to put yourself in a position to justify your management plan and, in this case, while a UTI formed part of the differential diagnosis, other potential diagnoses were not explored.
  • Dr Smith may also be vulnerable to criticism in relation to his safety-netting, in that he did not advise Mrs Jones to seek further advice if her symptoms deteriorated over the weekend, or what red flag symptoms to look out for.

  

Case 2: A common trap

Dr Hughes was doing a base session on a Saturday when Mrs Guy brought her four-year-old son Andrew to the OOH centre.

Mrs Guy explained that Andrew had been unwell for three days with symptoms of lethargy, fevers, irritability, earache and loss of appetite. Dr Hughes examined Andrew, identified that he had a red bulging left tympanic membrane, diagnosed a left otitis media and prescribed paracetamol and amoxicillin.

Dr Hughes explained the diagnosis to Mrs Guy and said that he hoped Andrew would start to improve in the next one to two days

Dr Hughes made the following entry in the records:

“Off it” for 3/7: lethargic, off food, irritable, feverish and c/o otalgia. o/e temp 39.6 oC (aural), Chest – NAD, CVS – NAD, Abdo – NAD. ENT – sl red throat, bulging red left TM Diagnosis: L OM Rx Paracetamol/amoxicillin.

Dr Hughes explained the diagnosis to Mrs Guy and said that he hoped Andrew would start to improve in the next one to two days.

In the early hours of Sunday morning, Andrew’s condition deteriorated and he developed a non-blanching rash. Mrs Guy was concerned about his condition and called an ambulance. At hospital a diagnosis of meningococcal septicaemia was made and the necessary treatment was instigated.

Unfortunately Andrew required an amputation of several of the digits on his left foot, and developed long-term hearing loss and learning difficulties as a consequence of the disease.

Outcome

Mr and Mrs Guy pursued a claim. The GP expert evidence concluded that when Dr Hughes assessed Andrew, there were several signs and symptoms that could have been early signs of a serious underlying illness. Further to that there was no evidence that such diagnoses had been considered.

Even if it appears that there is an obvious diagnosis, especially in children, it is important to consider other significant diagnoses

Reference was made to the fact that there was no evidence of “safety-netting”. A paediatric expert concluded that an earlier admission to hospital would have led to an improved outcome. The claim was resolved by way of an early negotiated settlement.

Learning points

  • Even if it appears that there is an obvious diagnosis, especially in children, it is important to consider other significant diagnoses.
  • Your records should reflect that serious diagnoses have been considered and reasonably excluded.
  • Given that a child’s condition can deteriorate quickly, you should give appropriate safety-netting advice and make reference to this in the records.
  • Make sure that you are aware of and follow the NICE guidance, Feverish Illness in Children.

  

Case 3: A disputed visit request

Mrs Coates rang the OOH service to discuss her 13-year-old daughter Jennifer who had woken in the night with abdominal pains and vomiting. During her call to the operator, she asked if a doctor would come out to visit Jennifer and it was explained that the base doctor would call her back.

Twenty minutes later, Dr Dunn called Mrs Coates. She explained that Jennifer had woken at about 2am with abdominal pain, had vomited once but now appeared more settled.

Dr Dunn explained that the OOH home visiting policy dictated that home visits would be reserved for terminally ill patients or those that were genuinely housebound

Dr Dunn explored other relevant aspects of the history and given that Jennifer was more settled, he suggested that she should take some paracetamol for the pain and see her own GP in the morning – with the caveat that Mrs Dunn should call again if the symptoms worsened in the interim.

Despite Dr Dunn’s reassurances, Mrs Coates remained worried and asked if a doctor would come out and see Jennifer. Dr Dunn asked Mrs Coates if she would be able to bring Jennifer to the OOH centre. Mrs Coates explained that her husband was away, her other children were asleep and it would be inappropriate to leave them alone.

Dr Dunn asked if Mrs Coates could ask a neighbour to sit with her other children while she brought Jennifer to the centre. Mrs Coates did not feel it would be fair to wake her neighbours at this time in the morning and felt unhappy at the thought of transporting Jennifer in the car, given that she was in pain.

Dr Dunn explained that the OOH home visiting policy dictated that home visits would be reserved for terminally ill patients or those that were genuinely housebound. At this point Mrs Coates became frustrated and rang off with the parting shot: “What do I have to do to get my daughter seen by a doctor nowadays?”

Over the next hour Jennifer’s symptoms worsened: Mrs Coates called an ambulance and, on admission to hospital, she was diagnosed as having appendicitis.

Outcome

Mrs Coates pursued a complaint alleging that Dr Dunn declined to visit Jennifer. Mrs Coates was not happy with the response of either Dr Dunn or the OOH provider at the conclusion of local resolution and pursued her concerns with the Parliamentary and Health Service Ombudsman (PHSO).

Mrs Coates was not happy with the response of either Dr Dunn or the OOH provider

The PHSO upheld the complaint and recommended that the OOH provider reviewed and amended their home visiting policy.

Learning points

  • “Failure to visit” is a frequent cause of complaints and claims.
  • You should put yourself in a position to justify your management plan and in the context of a patient with abdominal pain, it would be difficult to defend a claim if you have not undertaken an abdominal examination.
  • While it is not unreasonable to explore the possibility of attending the OOH centre, there may be understandable reasons why attendance may be difficult.
  • Avoid getting into detailed conversations about the home visiting policy.
  • If there is any doubt, the safest option is to visit, as in the long-term this may prevent a complaint or claim.

  

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