Case study: Zero tolerance

Medical case study

  • Date: 09 June 2014

Day one

Mr P is 53-year-old arts administrator. He has been a patient at the surgery for five years and is a frequent attender with a reputation for being demanding and sometimes rude and abusive to staff when he does not get his way. He phones the surgery first thing in the morning and demands an emergency appointment.

Later that day

Mr P is seen by a young GP locum – Dr L – and enters the consulting room with a plastic folder bulging with printouts from the internet. Even before the doctor can ask what the problem is he says: “I need for you to arrange some blood tests to check my vitamin levels – in particular A, D, E and K.” He informs the GP that he has inflammatory bowel disease (IBD) which affects the absorption of fat soluble vitamins. Dr L checks the records and notes that Mr P has been investigated previously and diagnosed with irritable bowel syndrome. She explains that the two conditions are different – IBD being much more serious. Mr P replies “I’m not stupid” and stands up from his chair, thrusting a print-out into Dr L’s face. “Look at the symptoms. I’ve been misdiagnosed. The blood tests will confirm that!” Dr L calmly asks the patient to sit down. She explains that such tests are not routine and first she must take a history of the complaint and then do an examination. Only then can she order relevant tests. Mr P grows angry and accuses Dr L of being ignorant along with the rest of the staff – especially the female ones. He stands up and shakes a finger in her face ranting about how it’s just the NHS trying to save money. He then kicks over his chair and storms out the room.

Day three

The practice manager pulls Mr D’s medical files and finds the letter in question. Checking the reference number on the letter she discovers it refers to a different patient – Mr Jason O – who had suffered an injury at work. The report was requested in order to process the resulting insurance claim. The practice manager phones the insurance agent dealing with the case who confirms that the appended medical notes do indeed appear to be those of Jason D not Jason O. The practice manager phones Mr D back and admits that there does appear to have been an inappropriate disclosure of his medical records.

Day five

The practice receives an official letter of complaint from Mr D alleging breach of the Data Protection Act 1998. He demands an explanation of how this happened and exact details of the records sent. He also wants proof that the copy records held by the insurance company have been either returned or securely destroyed/removed from their computer system.



THE practice manager contacts MDDUS for advice on the complaint. Ms K drafts a reply and forwards it to an MDDUS medical adviser to review. Among other advice it is suggested that all staff members abused by Mr P provide an account of the experience including administrative and clinical details. Dr L should also provide a full account of the consultation on Day one.

Ms K is sent a copy of GMC explanatory guidance on Ending your professional relationship with a patient. She is also provided with a link to guidance by the Royal College of General Practitioners on the removal of patients from the practice list.

A week later Ms K posts a reply to Mr P’s letter stating that the practice has considered his comments. She restates the reasons behind the decision for removal, adding that there has been a breakdown in the doctorpatient relationship and it is clear that Mr P no longer has confidence in the GPs in the practice. She again advises the patient to register with another practice so that a transfer of records can be quickly facilitated.


  • Ensure practice leaflets include policies on removing patients and “zero tolerance” to violence/abuse.
  • A patient being removed from the practice list should have been given a written warning within the last 12 months.
  • Consult GMC, RCGP or BMA guidance on patient removal.


This page was correct at the time of publication. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

Read more from this issue of Practice Manager

Practice Manager is published twice yearly and distributed to MDDUS practice managers and others with management responsibility in dental and medical surgeries. It features articles on employment law, health and safety, risk as well as profiles of practices across the UK. Browse our current and back issues below.
In this issue

Related Content

Coroner's inquests

Complaints handling checklist

Safety culture in primary care

Save this article

Save this article to a list of favourite articles which members can access in their account.

Save to library

For registration, or any login issues, please visit our login page.