Community surgery : staying out of trouble.

1. Community surgery : staying out of trouble. Miss Nicola Lennard : 12 June 2015:

2. Multiple jeopardy

3. Reducing your risk

4. Common themes in complaints and claims • Confidentiality • Clinical competence • Communication • Consent • Clinical records

5. Data from “Data on written complaints in the NHS 2013-14”, NHS Information Centre.

6. 1. Clinical competence - GMC guidance • You must be competent in all aspects of your work, including management, research and teaching. • You must keep your professional knowledge and skills up to date. • You must be familiar with guidelines and developments that affect your work. • You must keep up to date with, and follow, the law, our guidance and other regulations relevant to your work • You must take steps to monitor and improve the quality of your work ( Paras 7-13,Good Medical Practice)

7. GMC guidance to be aware of Good Medical Practice 2013 Explanatory Guidance Learning materials

8. 2. Consent Emphasises obligations on doctors to provide information

9. Valid consent • Voluntary • With capacity • Informed • Nature and purpose of examination/procedure/disclosure • “Material” or “significant” risk, even if small • Alternatives to proposed treatment • Risks of doing nothing • Supreme Court: Montgomery -v- Lanarkshire Health Board [2015] UKSC 11

10. Supreme Court: Montgomery -v- Lanarkshire Health Board The doctor is ….. under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments. The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.

11. Materiality of risk is not a matter of percentage possibility Other factors are likely to be important such as: • the nature of the risk • the effect that it would have on the life of the patient • the importance placed by the patient on achieving the benefits of the procedure • alternative treatments available, and the risks associated with those treatments. The assessment is therefore considered to be both fact-sensitive and sensitive to the characteristics of the particular patient

12. Doctor’s “advisory role” involves dialogue • To ensure that the patient understands the seriousness, anticipated benefits and risks, reasonable alternatives • Information must be comprehensible - not a mass of technical information • A signature on a consent form is not enough

13. GMC consent guidance “The amount of information about risk that you should share with patients will depend on the individual patient and what they want or need to know. Your discussions with patients should focus on their individual situation and the risk to them”. Consent: patients and doctors making decisions together (2008) (extract from paragraph 28)

14. GMC consent guidance “You must tell patients if an investigation or treatment might result in a serious adverse outcome, even if the likelihood is very small”. Consent: patients and doctors making decisions together (2008) (extract from paragraph 32)

15. What to do when trouble strikes

16. For the patient- your ethical duty • You must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress, you should: • a. put matters right (if that is possible) • b. offer an apology • c. explain fully and promptly what has happened and the likely short-term and long-term effects • GMC- Good Medical Practice, Para 55

17. For the patient- your legal duty • Statutory Duty of Candour • NHS bodies and Healthcare organisations registered with CQC • Includes GP’s and doctors working in independent practice • “Notifiable patient safety incident” • Full explanation and apology to patient in person and in writing • Higher threshold than ethical duty

18. For the doctor and organisation • Careful documentation of the incident • Personal reflection • Discuss with colleagues and document • Significant Event Analysis • Further learning • Complaints handling • Seek advice from defence organisation

19. Conclusion • Communication with patients is key • Document all patient interactions carefully • Familiarise yourself with local policies and national guidelines • If you are unsure, seek advice from colleagues and/or your Medical Defence Organisation