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Problems in clinical management

Negligence is a legal concept. It does not mean neglect or wilful misconduct, but a failure to attain a reasonable standard of care. In cases of negligence, 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.

Guidelines are supposed to be an aid to clinical judgment, not a substitute for them
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.” (Bolam v Friern Hospital Management Committee [1957] 2 All ER 118.)

Adopt accepted practice

Accepted practice can be easy to define in some areas – prescribing in accordance with the recommendations of the British National Formulary will usually be regarded as accepted practice. 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 evidence).

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 Such evidence-based guidelines aim to improve the quality and consistency of clinical decisions, help replace outdated practices, provide a focus for audit of clinical practice, and provide benchmarks for clinical governance.

Guidelines are supposed to be an aid to clinical judgment, not a substitute for them. In theory, then, you may exercise your judgment and decide not to follow a particular guideline. In practice, however, you should only deviate from the accepted practice embodied in the guidelines if you have very good reasons for doing so. If 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 respected clinical guidelines and base your decisions on evidence, you will be in a very strong position if a complaint is made against you
If you follow respected 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 except in a real emergency – 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 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.

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.

You must satisfy yourself that they are competent to take on the duties you are delegating to them

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 by the GMC 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.