Video: Two years of Multiple Jeopardy

This video demonstrates how a wide range of medical protection services such as support and medicolegal counselling proved invaluable to a member who was facing a potential criminal charge of gross negligence manslaughter.

Video transcription

[Dr. Davies] In the case we're about to look at now, a doctor needed to call on a range of Medical Protection services. Facing a potential criminal charge of gross negligence manslaughter, the support of medical legal experts and counseling proved invaluable. The GP in question was asked to review a positive sputum culture result for a GP colleague who was on leave.

The patient was a 48-year-old non-smoker, who had been coughing up green sputum. The GP colleague had advised waiting for the results before writing a prescription for antibiotics. With the results in hand, the GP decided to call the patient, and on hearing that the cough was still productive, suggested a prescription of amoxicillin three times a day.

Unfortunately, the computer system was down, so the GP wrote out a prescription and made himself a note to record that and the telephone conversation on the patient's records as soon as it was back online. The patient's wife collected the prescription, and later that afternoon, the system came back online. The GP saw that his patient was allergic to penicillin and called the patient to stop him from taking his first dose.

Unfortunately, it was too late. The patient had already taken his medication, which had prompted an anaphylactic reaction, and an ambulance crew were with him. Sadly, he passed away. The GP was invited to a police interview under caution to investigate a potential criminal charge of gross negligence manslaughter. -

[Dr. Stacey] I can think of nothing more distressing than for a doctor to be invited to an interview under caution by the police. In this case, the member contacted the Medical Protection help line and spoke to a medico-legal advisor. That's a doctor with legal training. The medico-legal advisor realized the impact that this would have on the doctor on a personal basis and provided details of the Medical Protection counseling service.

In addition, the medico-legal advisor urgently instructed a solicitor to represent the member at the police interview. The solicitor immediately made contact with the police officer and arranged for the police interview to take place at a mutually convenient time that allowed the solicitor and the medico-legal advisor to meet with the member in advance of the police interview.

This was extremely helpful because it allowed the solicitor and the medico-legal advisor to explain what the police interview would involve, and to prepare an anticipatory statement. The member attended the police interview under caution and was represented by the solicitor. After a somewhat prolonged police investigation, the police eventually decided not to pursue charges, which came as a great relief to the member.

The practice were advised to undertake a significant event analysis. The purpose of this was to identify what happened, why it happened, and to take any steps that were appropriate to prevent it happening again. In this case, the patient clearly received a wholly inappropriate antibiotic. However, there were significant mitigating circumstances, the primary one being that the computer system was down when the doctor generated the prescription.

It was identified that the doctor did take prompt and appropriate action when he identified the error, but sadly, this was too late. As a result of the significant event analysis, the practice introduced safeguards to prevent a wrong prescription being issued in the future.

However, the incident was yet to be resolved. Medical Protection supported the GP as the family made a complaint to the practice. We also instructed a barrister to represent the GP at the inquest and engaged our press office to help with any media attention. The inquest found that the patient had died as a result of taking the amoxicillin.

The coroner said she'd considered making recommendations to prevent further deaths, but had decided not to based on the remedial action taken by the GP and the practice. - [Dr. Perrott] Medical Protection runs a workshop called "Achieving Safer and Reliable Practice" that looks at these system issues and helps you move away from chaos towards a safer and reliable system in your practice. There are also educational resources on our online system, Prism, that can help you look at the management of your test results, for example, and ways that you might want to improve the efficiency of those systems.

The team involved in this patient's care also demonstrated that they were able to learn from what happened. We believe that this learning from events is also something that's extremely beneficial, both to doctors and to patients. Having those conversations and involving your wider team in the learning is something that, again, for some people, might not be first-nature.

For others of you, you may be very well-rehearsed in a significant event analysis. Whatever your level of learning, there are probably things that you can benefit from thinking about, so Medical Protection can help you with our "Learning from Events" workshop and our online module, which is similarly titled, as well as some extra issues around considering human factors and reflection that you can also find online if you're interested.

We have an online module, our Reflection module, which will guide you through those questions and the strategies in shaping your reflection so it can be most beneficial to you and to your team.

The case against the GP went on for two years. After the inquest concluded, the family referred the GP to the GMC. Medical Protection continued to support the GP during the GMC investigation, which was subsequently closed with no action. In closing the case, the GMC said this was an isolated incident and the speed of the GP's actions afterwards were key.

He had demonstrated insight and had taken the appropriate steps to put things right as soon as he could.