Raising concerns

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Case studies and vignettes

The below case studies are examples of good practice to offer as a useful benchmark for raising concerns. Case study one featured as part of a BMA online blog on 4 June 2012. Case Study two is taken from the Social Partnership Forum guidance. While they relate more specifically to non-doctors staff/environment, the situations described can translate into a secondary care setting. 

The vignettes are fictional stories that serve to illustrate steps that GPs, junior doctors and medical students may take in raising a concern.

  • Case study 1 - emergency medicine consultant

    An emergency medicine consultant who had worked in the NHS for over 20 years was well respected in his trust. His selfless commitment to the NHS was highly valued by both his patients and his clinical colleagues.

    However, he was not a man to suffer fools gladly. Chronic under-funding in the emergency department meant that nurses were forced to wash bedpans by hand. This was some years ago, but most hospitals had by this time brought in special cleaning machines years previously. This trust had resisted such expenditure.

     

    No drinking water

    There was also no drinking water on tap. Staff either had to boil water or go to other departments to get drinks for patients. News of these shortcomings had reached the patients’ representative organisation. As a result, a reporter from the local newspaper had rung up the consultant asking for his comment. The consultant told the journalist that it was ‘a disgrace’ and that he had had many requests for improvements turned down by trust managers over the years. He had even been forced to appeal for a donation to the Hospital League of Friends to buy some filing cabinets and had used his own DIY skills to put up shelves in the department.

    The next edition of the local weekly paper bore the headline: ‘Doctor slams trust where nurses still wash bedpans by hand.’

    The medical director wrote a letter to the consultant demanding an explanation for his actions in talking to the media in direct breach of the trust’s ‘communications with the media’ policy, which prohibited all staff making statements to journalists without the prior written authorisation of the trust chief executive.

     

    Consultant warned

    The consultant was warned that the trust considered his actions amounted to gross misconduct and was told that he was required to attend a disciplinary interview the following week at which he could be dismissed.

     

    BMA get involved

    The consultant contacted his local BMA industrial relations officer, helpfully enclosing a batch of recent newspaper cuttings. In preparing his defence for the consultant, the IRO was able to rely on paragraph 330 of the Hospital Terms and Conditions of Service, which provides that: ‘A practitioner shall be free, without prior consent of the [trust], to publish… articles… or speak, whether on matters arising out of his or her NHS service or not.’

    The IRO was aware from previous cases that this express provision in the terms and conditions of service protected consultants who spoke out on matters of patient safety and provided an express contractual exception to the normal duty of confidentiality that an employee owes to an employer.

     

    Charges dropped

    At the subsequent disciplinary hearing, armed with this vital information, the IRO was able to get all the disciplinary charges dropped against the consultant and an apology from the medical director about the heavy handed approach that had been taken.

    The icing on the cake was that the trust agreed to sort out the plumbing in the department and to provide fresh drinking water for staff and patients.

    The consultant was the hero of the hour for all the trade unions in the trust because he had stood up to a belligerent management on a point of principle. However, without the expert knowledge and advocacy skills of his BMA IRO, the outcome could have been very different indeed.

     

  • Case study 2 - senior care coordinator

    Derek was a senior care coordinator in a care home for the elderly. Derek was on duty one day when he found that the carers had forgotten to give some residents their medication, which included tablets for water retention, blood pressure and some heart medication. Derek immediately told the home’s manager what had happened. The home’s manager took the unused medication and flushed it down the toilet.

    Derek came across another incident where medication was missed and was unsure what to do. After considering his options, Derek decided to contact the head office to tell them what he had witnessed. The matter was investigated and the home’s manager was taken through a disciplinary process. Derek then contacted PCAW because he was worried about being revealed as the whistleblower.

    The adviser at PCAW worked through the situation with Derek. As Derek was the sole witness of the manager’s actions, it was more than likely the manager would work out that Derek was the source of the concern. PCAW reassured Derek that he could ring back if he had any questions or concerns. A couple of months later Derek advised PCAW that the concern had been resolved. He had followed the advice and when he spoke to head office, they had taken his worries about confidentiality seriously and found another way to deal with the situation. Derek was still at the same home. He was relieved that no-one had been fired; the manager was still in post but there has been a change in the medicine protocols and in the culture at the home.

  • Vignette 1 - GP

    A fictional story illustrating the steps that GPs can take in raising a concern.

    Dr Wood is a trainee GP in a large training practice. Her GP trainer, Dr Andrews, was a partner in the practice and is well loved by his patients. Dr Wood had been expecting regular debriefing sessions with Dr Andrews to review difficult consultations after her surgeries, but increasingly Dr Andrews was late for these meetings, or he failed to turn up at all without any explanation. She asked him about missing these meetings and, although he apologised, the situation did not change much as the weeks of training continued.

    During a consultation with Mrs Lamb, Dr Wood was told that Mrs Lamb had previously seen her usual GP Dr Andrews for her problem, but that he did not seem to be very well that day and she wondered whether he had got a bad cold and had been having a few whiskies to help with that. She smiled and asked Dr Wood whether that was available on prescription for her too.

    At the end of the surgery Dr Wood decided that she needed to speak to someone about this situation but did not feel able to speak to her trainer Dr Andrews directly. Instead she asked to meet with the practice manager and informed her of the suggestion made by Mrs Lamb and the fact that Dr Andrews' behaviour had been a little erratic recently. The practice manager thanked Dr Wood for raising this with her and said that she would speak to the senior partner straight away and asked if Dr Wood would like to join her.

    After discussion with the senior partner, Dr Patel, it was agreed that he would speak with Dr Andrews as soon as possible to ask him about his use of alcohol and whether this was having any impact on his medical practice. At that subsequent meeting Dr Andrews denied any problems, although he did acknowledge that he was struggling to keep to time in surgeries more often than he used to do.

    Dr Patel continued to have some concerns as he had also noticed some changes in his partner's behaviour and so, after speaking to the other partners in the practice, he rang the medical secretary of the Local Medical Committee (LMC) to ask for advice. He was told that he should raise these concerns with the medical director at the regional NHS England office, which he did. The LMC secretary also offered to visit the practice to talk to Dr Andrews.

    The medical director told Dr Patel that one of his medical advisors would visit the practice urgently to speak to Dr Andrews directly. He also arranged to discuss the case at the next Performance Advisory Group meeting, at which the LMC was also represented. This ultimately led to Dr Andrews being suspended from the national performers list and referred for an occupational health assessment.

  • Vignette 2 - junior doctor

    A fictional story illustrating the steps that junior doctors can take in raising a concern.

    Dr Smith is a Foundation Year 2 doctor on a four month surgical rotation. Her rota was understaffed and she often found herself alone on the ward and unable to get in contact with her seniors who were busy in theatre. This led to her making decisions about patient care alone while running errands and doing administrative work. She often had to turn to the nurses and healthcare assistants on the ward for guidance. She was concerned that her lack of adequate training and supervision might result in harm to a patient.

    Dr Smith also noticed that one of the fire exits on the ward had been blocked by old/broken furniture/equipment for the previous two weeks. She pointed this out to several of the ward staff, but they simply said: "There’s just nowhere else to put it."

    Unsure of the steps to take in order to raise a concern and fearful of the reaction of ward medical and nursing staff, Dr Smith contacted the BMA for support and was advised to discuss her training issues with her educational supervisor, and that, if necessary, she could raise them with the foundation programme director in the trust. The BMA also advised her to check the hospital's policy on raising concerns about patient safety, especially as the issue of the furniture/equipment was likely to be covered by basic safety policies. Fearing a genuine threat to patient safety, she decided to talk to the designated officer at the trust and ultimately raised her concerns directly with the medical director. The BMA advised her about what kind of response to expect from the hospital management when raising a concern of this kind and offered support in case the response she received was not appropriate. The medical director resolved the issue of the furniture/equipment swiftly as one of fire safety.

  • Vignette 3 - medical student

    A fictional story illustrating the steps that medical students can take in raising a concern.

    A fourth year medical student was nearing the end of his first week at a clinical placement in the north of England. He had been placed on the gynaecology ward of a large district general hospital. He noticed a number of incidents on the unit where patients were not receiving basic care and had to decide how to act.

    On his second day, as he was leaving the ward to get lunch, he witnessed that Mrs Smith, who had been transferred from A&E with an ectopic pregnancy almost two days before, had not touched her food or drink. He stopped to talk to her and found that she had not eaten since she came in. She did not feel like eating when she first arrived and was asleep when lunch was delivered so missed that.

    The next day he mentioned this to one of the junior doctors and was told that patients often miss meals but that, as they were generally not in the ward for long, they did not worry too much.

    The situation made the medical student very uncomfortable. He therefore raised it with his personal tutor, who he happened to be meeting the next day. The tutor suggested that the student speak to the nursing staff and pointed him to the relevant GMC guidance.

    The student was concerned to make sure that future patients were checked on their food and fluid intake. He was aware that in other wards this was recorded on patient's charts. He therefore thought he should mention the issue to a consultant as well.

    The issue was acted upon by the consultant who raised it at the next multidisciplinary team meeting and flagged it to nurses and doctors on the ward.

    The personal tutor also decided to follow up the issue when he met the medical director a few months later and was pleased to hear that checks had been put in place.

    Students are uniquely placed to drive improvements to the culture within the NHS. Their personal values and commitment to their patients have not been worn down by workload or habituation. They can be the eyes and ears of the NHS due to their unique role moving around a variety of healthcare settings.

    Personal tutors are an excellent pastoral resource. They are people who can provide support and advice as well as people in whom students can confide within a confidential setting. Moreover, if students raise concerns as a group, the process can seem less daunting.

    The student in this vignette identified a problem and was able to raise it for the benefit of future patients. It is important that students are supported in raising concerns and that they know with whom to raise them and have an avenue for validating them.

    Doctors of the future should be able to approach reporting issues of misconduct safe in the knowledge that they will not be victimised for speaking out. Providing a safe environment for staff, colleagues and patients can only help create a better health service for the people of the UK.

    If the student in this vignette had wanted the issue to be taken forward confidentially, the personal tutor should have been able to do this through the sub-dean or another channel.