During 2021 the MDU opened almost 4,000 complaint files and took over 3000 calls relating to patient complaints. In a survey of 612 GPs by the Medical Defence Union (MDU) and GPonline three quarters of GPs (77%) feared facing a complaint with over a third (38%) having received a complaint during the pandemic.
The last two years have thrown up some common trends for complaints about remote consultations, referral delays and infection control measures. How can GPs and practice staff try to resolve such issues? The following fictional scenarios offer some advice.
A recurring theme in complaints is that the telephone or video consultation didn’t allow for an adequate assessment of the patient leading to the clinician underestimating how ill the patient was and a delay in investigation, treatment or referral.
In one case, a locum GP contacted the MDU after receiving a letter from the GMC. It explained they were carrying out a provisional enquiry after receiving a complaint from the widow of a patient.
The patient had collapsed and died three days after a telephone consultation with the GP. The cause of death was identified as a myocardial infarction.
The consultation took place during a lockdown. The GP referred to the notes and saw that the patient, who had COPD, had developed a cough and breathlessness, was coughing up white sputum. They also had chest pain and constant discomfort around the sternum following a bad bout of coughing and had tested negative for COVID.
The GP agreed with the patient that it sounded like an infective exacerbation of his COPD with musculoskeletal pain from the coughing. The doctor prescribed antibiotics with advice to call back if there was no improvement. The patient spoke to two other GPs over the next two days complaining of a chest getting ‘tighter’, both of whom reassured him and suggested giving the antibiotics time to work.
The widow raised concerns about all three doctors to the GMC saying it would have been obvious how unwell her husband was if the appointment had been in person and an examination may have identified the cardiac issue earlier.
A few months later the GMC wrote to the GP and the MDU adviser to say they were closing the case into his role with no further action. This letter also stated the GMC recognised that the pandemic was a very challenging time for doctors and these exceptional circumstances had been taken into account when closing the case.
It is important to have strategies to maximise the safety and effectiveness of remote consultations. Detailed guidance can be found here but in broad terms it is helpful to ask yourself:
- Can I assess this patient remotely? For example, is the patient hard of hearing or is there a language barrier that will make consulting remotely difficult?
- Can I assess the patient’s suspected condition? Has the patient been assessed for the same condition via telephone consultation before and do they now need a physical assessment?
- Have I still followed basic principles of history taking and examination?
- Are there any red flags?
- Am I in a position to exclude a serious diagnosis?
- What is my differential diagnosis and have I recorded this?
- Does the patient understand the next steps and know how to seek further help if needed? Did I provide safety netting advice?
- Do I need to ask the patient to be seen at a face-to-face appointment within a suitable timescale to fully assess them?
A typical case relating to a referral delay involved a GP who contacted the MDU after receiving a letter from the Parliamentary and Health Service Ombudsman (PHSO) about a complaint. It related to an alleged delayed diagnosis of bowel cancer in a 45-year-old woman.
She had initially been seen at the practice during the first lockdown with a two-month history of constipation and abdominal pain. There was no history of weight loss or rectal bleeding. A trial of laxatives was advised and blood tests organised, which all came back as normal. The patient was told to contact the practice if things did not improve.
Two months later the patient contacted the practice as the laxatives had only given temporary relief and the constipation was now worse. In addition, the patient reported unintentional weight loss of around 2kg and three episodes of rectal bleeding. She was seen the same day at which point her abdominal and rectal examinations were unremarkable. Given the new symptoms the GP referred her under a two-week wait for suspected bowel cancer.
The patient called the practice three weeks later as she had not heard from the hospital so the GP followed this up to be told that no referral had been received. Another two-week wait referral was made, highlighting that the patient had already been waiting three weeks. The hospital confirmed receipt.
The patient was seen a number of weeks later and had a colonoscopy which identified a large tumour. The complaint detailed concerns that the delay between first being seen by the GP and the diagnosis had adversely affected the patient’s prognosis.
The PHSO report concluded that the GP’s role in the care was appropriate and the delay was caused by the backlog of secondary care referrals.
We have previously advised GPs on steps they can take to reduce the risk of harm to patients and their own medico-legal risk from such delays. These steps include:
- Ensure the patient understands why they are being referred and whether the referral is urgent or routine and the likely timescales involved.
- Provide safety netting advice to the patient so that they know what to do if their symptoms worsen and to contact you if they do not hear from secondary care in the expected timeframe.
- If appropriate, you may wish to seek their view on a private referral.
- Ensure the urgency of the referral is clear and include relevant clinical details to reduce the risk of it being downgraded to a routine referral.
- Include all relevant clinical details including the patient's history, medication, allergies, examination findings and details of any investigations.
- Report any deterioration, new investigation results, or new symptoms.
- You have a responsibility to raise concerns if you think that patient safety is or may be seriously compromised.
Mask wearing and infection control
Following the announcement of the government’s ‘Living with Covid’ plan, guidance throughout the UK states that staff, patients and visitors are still required to wear face masks in healthcare settings.
Unfortunately, some patients and relatives have misunderstood the change in guidance to mean that masks are not required anywhere including healthcare settings. In one case a practice manager called the MDU for advice after experiencing an increase in patients declining to wear a mask since the relaxation of restrictions.
The adviser directed them to the current government guidance.
Examples of reasons for mask wearing exemptions are listed in the guidance under the ‘If you are not able to wear a face covering’ section.
Practices may wish to display notices online and within the practice to clarify the current government guidance. As we have previously advised, if a patient who can wear a mask declines to do so then they may be persuaded to change their mind by an explanation of the current guidance and why it is important for the protection of others. In addition, those without a face covering could be offered a mask to wear.
There is no power to enforce face coverings and practices should be cautious about declining to provide necessary care to a patient on the basis of their decision not to wear a mask.
- Dr Ellie Mein is medico-legal adviser at the MDU
Find out more about complaints handling, including a step-by-step guide on writing a response to a complaint on the MDU’s website here.