The perils of saying "no" - medical case study

This fictional scenario based in part on a real case involves an encounter between a young GP and an angry and subsequently violent patient

BACKGROUND:

1: Mr G has been promised by GP partner, Dr A, that he will be given a prescription for Viagra following a face-to-face appointment to discuss the matter. The patient duly makes an appointment but is booked instead with a GP trainee, Dr T, without being told.

Mr G turns up for the appointment and explains his request to Dr T but as the consultation progresses the GP begins to doubt that the patient meets the criteria for a prescription of Viagra on the NHS. Dr T turns his back on the patient to search the internet for guidelines and does not notice from the patient’s facial expression and body language that he is becoming very annoyed.

Dr T finally finds the guidelines and proceeds to ask some very intimate questions which make the patient feel more uncomfortable and his embarrassment leads to rising feelings of anger. Sure now of his facts Dr T informs the patient that he does not qualify for an NHS prescription of Viagra.

2: Mr G explodes with anger shouting that "Dr A said I could get it". Dr T responds by holding up and waving his printed guidelines on Viagra prescribing to justify his argument. The patient stands up and pushes over his chair, partially blocking Dr T’s exit, but the GP manages to run past him into the corridor and shouts for help.

The patient then leaves the consulting room where he encounters the practice manager who is speaking with Dr T in the corridor. The patient offers an apology about his behaviour and asks if he can speak to another doctor about the matter. The practice manager informs the patient that his aggressive behaviour is completely unacceptable and if there is any repetition then the police will be called.

He is then asked to leave the premises and told that the practice will be considering removing him from their list in line with their new 'zero-tolerance' policy. Dr T then points to a 'zero tolerance poster' situated on the waiting room wall as the patient makes to leave.

3: Mr G turns suddenly and punches Dr T hard on the face several times, causing him to fall onto the floor banging his head. The patient then rips the poster from the wall and flings it at the practice manager before storming out the door.

Dr T is initially treated for facial injuries in the surgery but is later driven to A&E by a colleague and is found to have a broken jaw. The practice has to complete a RIDDOR report and the Health & Safety Executive later write asking the practice partners to respond with risk assessments and safe systems of work procedures.

4: The incident is reported to the police who arrest the patient. He appears at court from custody, pleads ‘not guilty’ and is released on bail pending a trial date being fixed. The next day the police call at the practice to take witness statements from the staff.

The patient is subsequently removed from the practice list and six months later, Dr T, the practice manager, four reception and admin staff, and three patients are called to give evidence at the trial. After two days of evidence and cross-examination, the defendant is found guilty and sentenced to 120 hours community service.

The Health & Safety Executive heavily criticise the practice’s health and safety at work management, and issue an ‘improvement notice’ requiring immediate changes to their safe systems of work. Dr T has not yet returned to patient-facing medicine completely and continues to be traumatised by the whole event.

ANALYSIS/OUTCOME: This scenario illustrates how a relatively simple disagreement over a clinical matter can escalate into a major incident with both tremendous personal cost and reputational damage for the practice concerned. There are failings and lessons to be learned before, during and after the event.

Pre-incident: There is communication failure within the practice between Dr A and Dr T over the initial consultation arrangements for the patient. Had Mr G been offered an explanation at the outset, he might not have reacted as adversely.

During the incident: Dr T may have acted with diligence but he failed to appreciate the effect of his decision on an already frustrated and emotional patient. By concentrating on his computer screen the GP also failed to observe and act upon the obvious non-verbal signs of the patient’s rising anger and hostility. A powerful trigger for his initial outburst occurred when Dr T began to wave his documentation around in front of the patient. This was certain to further inflame the situation.

The encounter in the corridor also shows a lack of awareness, with the practice manager and Dr T failing to appreciate the seriousness of the situation and instead proceeding to point out various aspects of policy and procedures. This culminates in the most obvious trigger to actual violence – Dr T pointing at a ‘zero-tolerance’ poster as the patient is already about to leave.

Post-incident: This period illustrates the potential pitfalls that any employer can face following a serious assault in the workplace, as well as the huge potential personal costs to individuals involved. The practice can be subjected to intense scrutiny in a multi-agency dimension, leaving them open to censure, claims and even prosecution. This is the time where practice policies, risk assessments and safe systems of work will be subjected to maximum scrutiny and criticism. It is important to have policies and procedures in place to cover such an eventuality. See page 6 in this issue for some further guidance on ensuring staff security.

Alan Frame is risk adviser with MDDUS Training & Consultancy