Patient Representative Encounter
NAME: /
General Practice
ADDRESS/LOCATION: /
General Practice
EMAIL: /
DATE EVENT IDENTIFIED: /
DATE REPORT COMPLETED: /
WHO CONTRIBUTED TO THE ANALYSIS?:
Practice Manager, Assistant Manager, Receptionist and 2 GPs
Please describe what happened
(Please outline in sufficient chronological detail including how it happened, who it happened to and the location of the event).
The surgeon and family of a patient with a severely ischaemic foot agreed that she was not strong enough to undergo amputation and she was discharged home to her care home for palliative care. She was on antibiotics for cellulites in her leg and oral morphine. When the Locum GP visited the Patient, he discussed her care with the family who wished only for her pain to be well controlled. This was documented in the patient’s records and the Key Information Summary was updated. At this time the patient was still on antibiotics that she was prescribed in hospital for cellulitis of the leg. She completed the course and two weeks later the Care Home staff reported that the cellulitis had improved. When reviewed thereafter the patient was struggling to take her medication and all but her pain relief and anxiolytics were stopped. 4 days later her ischaemic leg was red, hot swollen and gangrene was spreading. The On Call GP that day prescribed stronger analgesia and antibiotics and arranged to review her the next day.
At lunchtime, the same day, the relatives of the patient (not patients of the practice) presented at the front desk of the Health Centre demanding to speak immediately to the locum GP with whom they had previously discussed their Mother’s care. The Receptionist advised them that the locum was not available during this lunch time and she phoned the on-call GP who indicated that he would return to the Practice as soon as he could. The couple maintained they only wanted to see the locum GP as it was him with whom they had discussed their Mother. The son started to use domineering body language putting his hand to the Receptionists face and slamming his hand on the desk indicating they did not want to be ‘fobbed off’ A third GP who happened to pass, offered to speak to the couple but they declined and said that they would wait in the waiting room for as long as it took.
The Receptionist spoke to Locum GP who said he had a full surgery that day followed by mail and results to get through. It was his second last day working for the practice and for these reasons he was not willing to see the couple. This resulted in a heated confrontation involving the Receptionist and the Assistant manager and the couple were told that the On-Call GP would see them or they would be required to leave. By this time, they had been in the waiting room for two hours. Eventually after further debate with the Assistant Manager they agreed to see the On-Call GP.
The GP on call and the couple discussed that they wished for the Patient’s pain to be well controlled but that they were angry and upset that she was prescribed antibiotics as they felt it would prolong her life but would not save her leg. The GP on call emphasised that the consequences of stopping the antibiotics would allow infection to spread which would in all probability lead to sepsis and then death. The couple confirmed that they understood the consequences – “let her die but please give her good pain control”.
They subsequently lodged a formal complaint.
What was the impact or potential impact of the event?
(Please consider what may have been the emotional effect of the event on yourself and others, where appropriate, and the clinical, professional and organisational implications).
This has likely to have led to a loss of trust between the Patient representatives and the Practice.
This also impacted the relationship between Reception Staff and the GPs involved – Reception staff felt unsupported in this situation and felt that the GPs could have helped them instead of leaving them to deal with the situation. The Receptionist had felt threatened and inadequately skilled in dealing with the confrontation.
The reputation of the Practice was put at risk - other patients sitting in the waiting room were given a negative impression. Patients hearing such an exchange may share their concern with friends/family and in a small community this escalates and could lead to patients losing confidence in the practice and perhaps de-registering.
There was a potential for breach of confidentiality – sensitive clinical information was being discussed in the waiting room area in potential earshot of other patients.
The GP who had prescribed the antibiotics felt uncomfortable and guilty that he may have prescribed inappropriately for this patient
Please outline the different system factors that contributed to WHY the event occurred, taking into account how these different factors interacted with each other and led to the event happening.
(People Factors (e.g. severity or uncertainly associated with patient condition; social and personality factors; clinician and staff training,
skills, knowledge & competence; and physical and psychological characteristics such as fatigue, stress, motivation and needs).
Activity Factors (e.g. job task demands such as mental and physical workload, decision-making, time pressure, attention levels,
distractions and interruptions, volume and complexity of tasks; and interacting medical device, tools and technology issues such as their
availability and usability).
Combinds people, Activity and Environmental factors:
Although the GP on call had seen the Patient recently and was aware she was for palliative care, he prescribed antibiotics to relieve discomfort and to minimise the risk of sepsis from spreading infection. The MDDUS advises that it is at the GPs discretion whether or not they prescribe antibiotics.
A summary of the notes is printed out at the surgery for each home visit, however, there was no express mention in the summary of the family’s request that she not to be prescribed antibiotics and the care home were not told this either. Also the GP had been influenced by the patient having recently completed antibiotics.
According to MDDUS, the locum GP had no obligation to talk to the Patient’s relatives when they presented at the desk being neither patients of the Practice or a clinical emergency situation. Therefore, Locum Dr was within his rights to refuse to see them when they demanded to be seen.
The MDDUS advises that the matter should have been dealt with as per the practice complaints procedure – i.e, setting up a meeting at a time convenient to both parties to discuss the issue.
People act differently when under stress – the patient’s relatives and the busy practice staff were all under stress at the time of the incident. The Couple were anxious and upset about the care their Mother was receiving. They had not made clear to the Care home staff their express wishes.
The layout of the waiting room area and the position of the Relatives to the Receptionist made her feel intimidated and uncomfortable contributing further to her stress.
There was a breakdown in communication between receptionists, the Manager and the GPs and a time delay in the Assistant and Practice Manager being informed which had resulted in a longer wait for the Relatives.
Several doctors being involved in the care of one patient led to a discrepancy in the continuity of care – various entries in notes and communications with the care home staff may have contributed to different approaches.
The day and time at which the patient’s relatives visited the practice impacted on the situation unfolding as it did. The practice has been relying on GP locums for several months. Staff must get to grip with all their different personalities and the variation in responsiveness - some GPs are willing to help more in certain situations than others. The rota operates in such a way that GPs availability for home visits varies daily.
The on-call GP on the day of the incident is a palliative care specialist, had the receptionists known it was a palliative care issue and could have relayed this to the patient’s relatives, they may have agreed to see her.
The Assistant Manager is new to post and to date has had little experience of dealing with complaints. The discussion was conducted in the waiting room rather than moving to another room for more privacy. His attitude to them had also been clouded by the Receptionists account of their behaviour and knowledge of a previous incident in which their behaviour had resulted in causing a nurse in the care home to cry. The Assistant Manager lacked confidence and felt intimidated and that he did not possess the skills to diffuse the situation.
The Practice Manager was not working on this day – had she been, she would have dealt with the situation.
3. Lessons Learned
What lessons have been learned from the analysis of this event (as appropriate):
· At the individual level?
· At a care team level?
· At an organisational level?
· At the interface of primary and secondary health care?
· At the interface between health and social care?
Reception staff did not feel well supported by clinicians
Staff are uncomfortable in telling clinicians that they are struggling and need help.
The Assistant Manager has not yet received enough training to deal with complaints effectively
PM made aware that the Assistant Manager needs experience dealing with complaints.
A plan needs to be agreed and the timescale at which management should be contacted in an event such as
this made clear complaints should be dealt with in a private room.
There isn’t a clear “chain of command” when the Practice Manager is out of the Practice for dealing with complaints or difficult queries – clinicians need to be aware of their responsibility
This has identified a training need for new staff and update for other staff focused on dealing with aggressive patients and how to initially handle difficult queries and complaints
The GP’s decision to prescribe antibiotics could be justified
What action has been taken to-date to minimise the chances of this event happening again?
Once the family’s wishes were heard the clinical situation was reviewed and the antibiotics were stopped.
A practice meeting was held to discuss this event and it was made clear to staff that once an initial query such as this one has been looked in to and is unable to be resolved, the case should be passed to management immediately instead of being left to feel anxious about the situation with limited options.
The Assistant Manager will, with immediate effect, sit in with Practice Manager on all complaints and see complaints correspondence to better learn how to deal with them.
What further action do you plan?
(Outline your Action Plan for Improvement and how and when you will implement it together with the role and contribution of the wider care team where appropriate. Also, consider how you might share any interface issues or external factors that have contributed to this event but which you deem to be out with your control. Think again about taking a systems approach to improvement and consider the complex interactions between People, Activity and Environment already identified.
Practice staff will receive further training in dealing with anxious / upset / aggressive patients, this should be done at PLT within the next three months.
Ongoing learning in the Practice Manager Vocational Training Scheme course will also contribute to the Assistant Manger’s training in this.
The Practice Manager will review and update the Complaints Policy which will include clear instructions to ensure all discussions are conducted in the privacy of a side room
The GPs will review how palliative care information is made clear in the summary sheets for home visits
Who is responsible for ensuring that these actions are implemented and how will these be monitored and sustained in practice?
(Outline your role and contributions and those of the wider care team where appropriate).
At the next PLT day, all staff will work on a protocol for dealing with aggressive patients at the desk. The Practice Manager will lead this exercise and the Assistant Manager will type up and send to all staff – this will include a clear chain of command and responsibilities for each staff member in an event such as this.
Assistant Manager and the Practice Manager will work together on a learning plan for the Assistant Manager to better equip her to deal with difficult situations when the Practice Manager is out of the practice.
The GP who has a special interest in Palliative care will have responsibility for implementing the change to the patient summary
If you did not have the opportunity to analyse this event with colleagues, what were the barriers? (Please complete where applicable).
n/a