Dr Emma Green, Medicolegal Consultant at Medical Protection, looks at how we assisted locum Dr N with an NHS England investigation.

Dr N, a locum GP, contacted Medical Protection after receiving an email from a practice manager where she had done a locum shift ten months previously.

The email had been forwarded from NHS England (NHSE), requesting reflections from Dr N following a complaint that had been made by a patient she had seen during her locum session. The practice had responded to the initial complaint, which had then been passed to NHSE who had investigated and partially upheld the complaint. The clinical advisor had been critical of the care provided by Dr N.

Dr N advised Medical Protection that she had not been made aware of the complaint previously or provided any input into the response. The deadline for the response for NHSE was also less than one week away. The Medical Protection case handler suggested that Dr N made contact with NHSE to explain that they had not previously been aware of the complaint and to request an extension to the deadline. She was also advised to request copies of the complaint, the response and the medical records in order to respond fully to the concerns. NHSE agreed to the deadline extension, giving Dr N more time to review the case.

The complaint was from a 63-year-old patient seen by Dr N who had attended with shortness of breath. The patient had a history of diabetes, COPD and hypertension and was a relatively frequent attender at the surgery. They had recently been seen at the surgery for an ECG and it was recorded the patient had swollen legs and had been advised to make an appointment. The complaint focused on the diagnosis made by Dr N and issues with getting an appointment at the practice.

Dr N had seen the patient face to face and diagnosed an exacerbation of COPD. She had prescribed steroids and antibiotics alongside existing inhalers. The patient had been admitted to hospital the following day with a diagnosis of acute heart failure.

The practice response had made some generalised comments regarding the care provided by Dr N but it was not clear from the response that Dr N had not been consulted. The response was mainly focused on the systems issues highlighted by the patient.  

The NHSE advisor was concerned about the record keeping as there were limited observations recorded and no recorded leg examination, and they also felt it was unclear how the diagnosis had been made given the recent attendance with leg swelling.

Dr N provided Medical Protection with some initial reflections, which were brief and outlined issues with the locum they had undertaken at the practice. The reflections were negative towards the delay by the practice in providing the complaint and mentioned that Dr N had reviewed the NICE guidelines for heart failure as a result of the complaint.

Dr N’s advisor at Medical Protection suggested that the reflections may benefit from more detail to try and reassure the clinical advisor that the issues that had been highlighted were a one-off. The main issues related to record keeping (specifically observations) and failure to link associated symptoms, and it was suggested that Dr N may wish to undertake some more targeted CPD, consider how they apply this to subsequent consultations and consider whether they could undertake a review of recent patient interactions and evidence their record keeping through audit.

Dr N undertook a number of CPD modules and included key learning points from them in her reflections. She explained how she had applied this to patients since undertaking the learning and gave some examples. Dr N also reviewed her recent consultations with the support of practices where she had locumed and was able to show evidence that her normal practice was to record all observations, including examples of other systems examinations and where remote consultations had incorporated observations.

Dr N did reflect that when she locumed there were occasions when she had not reviewed previous consultations but made a clear plan of action to ensure this was addressed for future locum sessions.

Following submission of the reflections Dr N attended a meeting with NHSE, attended by Medical Protection for support. The advisor felt that the reflections showed clear evidence that their initial concerns had been addressed and were unlikely to recur. They also acknowledged that they had been unaware at the time of undertaking a review that Dr N had not provided input into the complaint response and would feed back to the practice regarding their systems.

Dr N was advised that the recommendation to refer them to the performance advisory group (PAG) had also been withdrawn following her submissions. Dr N was very emotional following the meeting with NHSE but grateful for the support, as she recognised that her initial submissions had deflected the problem rather than reflect.

Learning points

Practices should ensure that locum doctors are contacted in the event of a complaint or other incident in a timely fashion.

Complaint responses should always include, where possible, an account from the involved clinician.

It is helpful when providing reflections to NHSE that they are detailed reflections and where possible evidence how learning has impacted practice. This may include anonymised examples of subsequent patient care.

Reflections can include recognition of systems issues and how these have been addressed but should not negatively detract from reflective learning.