The MDDUS Risk Bites podcast series looks at the potential consequences that can arise from differing approaches to a typical adverse event occurring in a practice. Whilst the patient discussed in the series is fictitious, it is interesting to consider the evidence for whether a more proactive approach to adverse events can translate into different outcomes in real-life situations, and the way in which appraisal can play a helpful part in this process.
In Scotland, the SPSO (Scottish Public Service Ombudsman) can examine complaints that have not been resolved following attempts at local resolution. The Ombudsman’s findings are published as Decision Reports on the SPSO website. (Ombudsmans provide a similar service in other parts of the UK.)
Consider these published summaries from actual Decision Reports dealing with similar adverse clinical events.
Mrs C complained about the standard of medical care she received when she reported a cough to the medical practice. She said that she reported a persistent cough on two occasions but was not referred for a chest X-ray. At a third consultation, seven months after Mrs C first reported her cough, a locum GP referred her for a chest X-ray and, after further tests, Mrs C was diagnosed with lung cancer.
We took independent medical advice from one of our GP advisers. We found that the practice missed two opportunities to arrange for Mrs C to have a chest X-ray as part of their routine investigations into a persistent cough. We found that the practice failed to reasonably follow the national referral guidance for suspected cancer which all GPs should be aware of and which clarify the significance of a cough in the diagnosis of lung cancer and state that a time frame of three weeks should be considered for a persistent cough.
When Mrs C first reported the cough it had been present for eight weeks, and when she next mentioned the cough it had been present for 13 weeks. The criteria for referral for suspected cancer had been met on both occasions. We found that Mrs C should have been sent for a chest X-ray earlier than she was, so we upheld her complaint, and made a number of recommendations.
We recommended that the practice:
- apologise to Mrs C and her family for the distress caused by the late arrangement of investigations into the cause of her cough
- notify the board's clinical support group and ask them to consider whether to undertake a random review of patient consultation records for quality assurance purposes
- carry out a reflective significant event analysis with support from the board's clinical support group and provide us with a copy.
Mrs C complained about the care and treatment she received from her medical practice when she attended with clearly visible changes in her left breast. The GP told Mrs C that there was nothing wrong other than a blockage and suggested that she buy starflower oil. Mrs C's health deteriorated over the next few months and nine months later she was diagnosed with breast cancer.
After taking independent advice from our GP medical adviser and considering the records and Mrs C's comments, we found that the GP had failed to adequately examine her breast. In view of the visible changes, Mrs C's age and the fact that she had a family history of breast cancer, we also found it unreasonable that the GP did not immediately refer her to the breast clinic. Our adviser said that the delay in referring Mrs C there was likely to have had a significant impact on the extent of the tumour and the level of treatment Mrs C required. However, the practice had carried out a significant event review, had demonstrated that they had learned lessons from the complaint and had apologised to Mrs C. In view of this, we did not need to make any recommendations.
Comparing the Ombudsman’s reports
In both cases the clinical aspects of the complaints were upheld. However, contrast the list of recommendations made in the first case with ‘no recommendations’ made in the second.
The difference appears to lie in the steps taken by the practice prior to the Ombudsman’s investigation. In the second case the practice had ‘carried out a significant event review’, ‘demonstrated they learned lessons from the complaint’, and ‘had apologised to the patient.’
These reports show the Ombudsman is aware of the processes available to learn from adverse events, and will take into account the steps taken by practices to address matters prior to considering making recommendations.
Recommendations published in previous Decision Reports relating to similar complaints have included requirements for matters to ‘be discussed at annual appraisal’. It may then be useful to consider the appraisal summary as one mechanism to formally record the actions taken when adverse events occur.
Complaints, appraisal and revalidation
I have worked as a primary care appraiser for some years and I am aware of the concerns expressed by some doctors that by discussing and reviewing complaints at appraisal there will be a permanent record of adverse events in their appraisal summary records. A few appraisees have expressed anxiety that a cursory review of appraisal summaries could lead to problems with revalidation.
An alternative view would be that undertaking significant event reviews and proactively discussing complaints at appraisal helps to demonstrate a willingness to critically examine personal practice using a recognised tool to do so. This would be in keeping with GMC guidance that “you should review your practice and consider how the supporting information can demonstrate that you are continuing to meet the principles and values set out in Good Medical Practice.”iii
The risk of not reviewing a formal complaint at appraisal has the potential to lead to future recommendations to do so by Ombudsman services, and in the event of matters escalating to a fitness to practise hearing, failure to disclose complaints could lead to allegations that an individual had not acted in an honest and trustworthy manner.
Whilst appraisal summary records are routinely reviewed as part of the revalidation process, it is important to appreciate that the GMC’s Responsible Officers Protocol states: “recommendations about doctors’ revalidation are not a route for raising concerns about their fitness to practise with the GMC.” The expectation for appraisals is that doctors will discuss their practice and performance with their appraiser and use supporting information to demonstrate that they are continuing to meet the principles and values set out in Good Medical Practice.
I am now the lead appraisal adviser for two health boards and in these roles I routinely review appraisal summaries and provide support to the responsible officers to assist them in making their recommendations on revalidation to the GMC. My experience in this area is that, provided adverse events are being appropriately addressed (for example, by undertaking significant event reviews), then this in itself does not create any problems in a positive recommendation regarding revalidation being made.
On balance I would advocate a positive approach to addressing complaints and adverse incidents by undertaking significant event analyses, which is a beneficial tool for learning, and including these for review at appraisal. By doing so doctors are demonstrating compliance with regulatory guidance and this action may be looked upon favourably in the event of a future external review of how a complaint has been managed.
i - Case 1 - SPSO Decision Report Case: 201403815 – published Feb 2015
ii - Case 2 - SPSO Decision Report Case: 201305253 – published Aug 2014
iii - The Good Medical Practice Framework for appraisal and revalidation